Reliability and validity of the Finnish version of the Lower Extremity Functional Scale (LEFS)

Purpose: The present study aimed to assess the psychometric properties of the Finnish version of the Lower Extremity Functional Scale (LEFS) among foot and ankle patients.

Methods: The LEFS was translated and cross-culturally adapted to Finnish. We assessed the test–retest reliability, internal consistency, floor-ceiling effect, construct validity and criterion validity in patients who underwent surgery due to musculoskeletal pathology of the foot and ankle (N?=?166).

Results: The test–retest reliability was high (ICC = 0.93, 95% CI: 0.91–0.95). The standard error of measurement was 4.1 points. The Finnish LEFS showed high internal consistency (Cronbach’s α?=?0.96). A slight ceiling effect occurred as 17% achieved the maximum score. The LEFS correlation was strong with the 15D Mobility dimension (r?=?0.74) and overall HRQoL (r?=?0.66), pain during foot and ankle activity (r=??0.69) and stiffness (r=??0.62). LEFS correlated moderately with foot and ankle pain at rest (r=??0.50) and with physical activity (r?=?0.46).

Conclusions: The Finnish version of the LEFS showed reliability and validity comparable to those of the original version. This study indicates that the Finnish version of the LEFS serves both clinical and scientific purposes in assessing lower-limb function.

• Implications for Rehabilitation

• The Finnish version of the Lower Extremity Functional Scale (LEFS) is a reliable and valid tool for assessing lower-extremity musculoskeletal disability in Finnish-speaking population.

• Investigation of the psychometric properties of the Finnish version of the LEFS showed validity and reliability comparable to those of the original English version.

• The Finnish LEFS is easy to complete and suitable for clinical, rehabilitation and research purposes.

     

Comparative biomechanical analysis of gait in patients with central cord and Brown-Séquard syndrome

Abstract

Purpose: This is a pilot study with the aim to highlight the use of kinematic and kinetic analyses as an adjunct to the assessment of individual patients with central cord syndrome (CCS) and hemisection or Brown-Séquard syndrome (BSS) and to discuss their possible consequences for clinical management. Methods: The sample studied consisted of 17 patients with CCS, 13 with BSS and 20 control subjects (control group (CG)). Data were obtained using a three-dimensional motion analysis system and two force plates. Gait differences were compared between CCS, BSS walking at a self-selected speed and CG at both a self-selected and a similar speed to that of the patient groups. Results: The most relevant findings involved the knee and ankle, especially in the sagittal plane. In patients with CCS, knee flexion at initial contact was increased with respect to those in the BSS group (p?<?0.01). The ankle in the BSS group made initial contact with a small degree of plantar flexion. Conclusion: The use of gait biomechanical analysis to detect underlying impairments can help the physician to set a specific rehabilitation program in each CCS and BSS walking patient. In this group of patients, rehabilitation treatment should aim to improve gait control and optimise ankle positioning at initial contact.

• Implications for Rehabilitation

• In this study, gait differences between patients with CSS and BSS were evaluated with biomechanical equipment.

• The most remarkable differences were found in the knee and ankle sagittal plane due to ankle position at initial contact.

• In this group of patients, rehabilitation treatment should aim to improve gait control and to get a better ankle positioning at initial contact.

     

The use of Bioptron light (polarized,polychromatic, non-coherent) therapy for the treatment of acute ankle sprains

Purpose The purpose of this study was to investigate the efficacy of Bioptron light therapy for the treatment of acute ankle sprains. Method A parallel group, single-blind, controlled study was carried out in patients with grade II acute ankle sprains. Patients were randomly allocated into two treatment groups (n?=?25 for each). Both groups received cryotherapy, and the test group also received Bioptron light therapy. All treatments were performed daily for 5 d. Evaluations included self-reported pain via a visual analogue scale, degree of ankle edema, and ankle range of motion via goniometry carried out before the treatment and at the end of the treatment. Results The test group showed the largest magnitude of improvement for all evaluations at treatment five, and the between-group differences observed were statistically significant (p?Conclusions These data provide preliminary evidence of the efficacy of Bioptron light therapy supplemented with cryotherapy for the treatment of acute ankle sprains; however, larger studies are required to confirm these results.

• Implications for Rehabilitation

• Ankle sprains are common acute injuries among professional and recreational sports players but also among people in general.

• Cryotherapy is the first-standard treatment of acute ankle sprains.

• Phototherapy such as Bioptron light has been recommended supplement to cryotherapy to reduce the symptoms of ankle sprains.

• The results of the present trial showed that using BIOPTRON LIGHT and cryotherapy the rehabilitation period of acute ankle sprains can be reduced.

     

Risk of fall for people with diabetes

Abstract

Purpose: To examine the risk of fall for people with diabetes compared with healthy control subjects. Correlation between tactile sensation and postural control was examined for subjects with diabetes. Methods: Subjects with type 2 diabetes were classified into two groups: (i) diabetes without neuropathy (n?=?23) and (ii) diabetic peripheral neuropathy (DPN) (n?=?9). Age-matched healthy control subjects (n?=?32) were recruited. Tactile sensation, equilibrium scores (ES), strategy scores and sensory analysis scores from the Sensory Organization Test (SOT) were compared among the groups. Results: Subjects with diabetes without neuropathy demonstrated impaired postural control upon the disruption of somatosensory inputs. Subjects with DPN lost balance upon being deprived of visual inputs. A decrease in tactile sensation was associated with a decrease in the ESs in all subjects with diabetes (r?=??0.35 to ?0.77; p?<?0.05), and they tend to use more hip strategy for postural control upon being deprived of visual inputs. Conclusions: Different postural control strategies are adopted by various subgroups of subjects with diabetes. Subjects with DPN demonstrated a significant shift from ankle to hip strategies for balance tests when vision was deprived.

• Implications for Rehabilitation

• The severity of diabetic peripheral neuropathy (DPN) is associated with the risk of fall.

• Different compensatory strategies in balance control have been adopted by different subgroups of people with diabetes.

• In order to minimize the risk of fall, specific balance training program should be offered to different subgroups of people with diabetes.

• The balance training should emphasize on optimizing the competence of their existing compensatory postural control strategies.

     

Technical devices in children with motor disabilities: a review

Abstract

Purpose: To assess the effectiveness of technical devices used in children with motor disabilities. Method: A systematic search of CINAHL Plus, EMBASE, PEDro, Cochrane Library, Isi Web of Knowledge and Scifinder Web was carried out, covering the period between January 2000 and January 2012. The inclusion criteria were: (1) Studies involving a minimum of five children (randomized-clinical trials with control group and experimental group, clinical trials without control group and prospective cohort studies; (2) age range, 0 to 18 years. The methodological quality of the included studies was assessed by the two authors through the application of the PEDro scale. Results: Of the 59 articles identified by the search strategy, 27 articles were considered eligible. The most frequently evaluated devices were ankle and foot orthoses and the most studied pathology was cerebral palsy. The mean score on the PEDro scale was 6.8. Conclusions: The methodological quality of studies needs to be improved and more rigorous research designs should be followed that will allow the effectiveness and quality of movement to be assessed. The satisfaction of the patient and family with the devices should be analyzed in future studies.

• Implications for Rehabiliation

• The study adds an analysis of studies to determine the effectiveness of technical devices in children with motor disabilities and proposals for future studies to assess the long-term outcomes and improve the quality of interventions.

• Therefore, this review proposes to identify:

• The main technical device used in children with motor disability.

• Which types of pathology or motor disorders require technical devices to be used and what devices are available.

• The effects on the child of wearing technical devices.

• The measurements used to determine the effectiveness of technical aids.

     

A cross-sectional observational study comparing foot and ankle characteristics in people with stroke and healthy controls

Purpose: The purpose of this study was to explore and compare foot and ankle characteristics in people with stroke and healthy controls; and between stroke fallers and non-fallers.

Methods: Participants were recruited from community groups and completed standardized tests assessing sensation, foot posture, foot function, ankle dorsiflexion and first metatarsal phalangeal joint range of motion (1st MPJ ROM), hallux valgus presence and severity.

Results: Twenty-three stroke participants (mean age 75.09?±?7.57 years; 12 fallers) and 16 controls (mean age 73.44?±?8.35 years) took part. Within the stroke group, reduced 1st MPJ sensation (p?=?0.016) and 1st MPJ ROM (p?=?0.025) were observed in the affected foot in comparison to the non-affected foot; no other differences were apparent. Pooled data (for both feet) was used to explore between stroke/control (n?=?78 feet) and stroke faller/non-faller (n?=?46 feet) group differences. In comparison to the control group, stroke participants exhibited reduced sensation of the 1st MPJ (p?=?0.020), higher Foot Posture Index scores (indicating greater foot pronation, p?=?0.008) and reduced foot function (p?=?0.003). Stroke fallers exhibited significantly greater foot pronation in comparison to non-fallers (p?=?0.027).

Conclusions: Results indicated differences in foot and ankle characteristics post stroke in comparison to healthy controls. These changes may negatively impact functional ability and the ability to preserve balance. Further research is warranted to explore the influence of foot problems on balance ability and falls in people with stroke.

• Implications for Rehabilitation

• Foot problems are common post stroke.

• As foot problems have been linked to increased fall risk among the general population we recommend that it would be beneficial to include foot and ankle assessments or a referral to a podiatrist for people with stroke who report foot problems.

• Further research is needed to explore if we can improve functional performance post stroke and reduce fall risk if treatment or prevention of foot problems can be included in stroke rehabilitation.

     

Sociometric status and the attribution of intentions in a sample of adolescents with cerebral palsy

Purpose To examine how cerebral palsy (CP) and sociometric status at age 10 explain the development of a cognitive bias across two groups of adolescents aged 15.

Method Children with CP (N?=?60) and without CP (N?=?57) are part of a follow-up study. Three categories of sociometric status (popular, average, rejected) were obtained by conducting a class-wide interview in the class of the target children at age 10. At 15 years old, the same children (CP and non-CP) were asked to complete the Home Interview With Child questionnaire measuring a cognitive bias (hostile attribution of intentions (AI)).

Results Children with CP, especially girls, were significantly more rejected and less popular than controls at age 10. At age 15, among all participants, sociometric rejected and popular children tended to have a higher percentage of hostile AI than sociometric average children.

Conclusions There were no significant results for the combined effect of CP and sociometric status on the development of hostile AI at age 15. However, knowing the risk incurred by children with CP of being socially rejected, attention should be paid in the rehabilitation process to opportunities for social participation to facilitate the development of social competence.

• Implications for Rehabilitation

• Level I or II cerebral palsy (CP) is a condition that affects not only motor abilities but also social competence in children.

• Sociometric status in a group tends to affect the development of the ability to interprete intentions of others during adolescence.

• Sociometric measures in the class of children with CP could be a useful tool in the rehabilitation process in order to better define social participation opportunities.

• To improve social participation attempts, rehabilitation interventions should target social initiating skills, flexibility in interpreting peers’ behaviours, and ability to react effectively to negative peer treatment.

     

Foot and ankle impairments affect balance and mobility in stroke (FAiMiS): the views and experiences of people with stroke

Purpose: To explore the nature and impact of foot and ankle impairments on mobility and balance in community-dwelling, chronic stroke survivors. Methods: A qualitative research design using face to face semi-structured, audio recorded interviews. Thirteen community-dwelling stroke survivors, all of whom had self-reported foot and ankle impairments, were interviewed (female n?=?6, mean age?=?67 years, SD?=?12 years, mean time since stroke?=?4 years, SD?=?6 years, right stroke n?=?7, left stroke n?=?6). A framework analysis approach was used to analyse and interpret transcribed interviews. Results: Three themes emerged: (1) Impact. The influence of foot and ankle impairments on mobility and balance. (2) Standing out. How participants felt they “stood out” because of their impairments and wanted to be normal. (3) Help. The specific help and advice participants received in managing their problems. Conclusions: Foot and ankle impairments such as pain, altered somatosensory input and weakness significantly contribute to problems with community ambulation, balance and fear of falling in people with chronic stroke. Specific foot and ankle impairments may also negatively contribute to perceptions of physical appearance and self-esteem. Therapeutic management approaches within clinical practice appear to focus mostly on the gross performance of the lower limb with little emphasis on the specific assessment or treatment of the foot or ankle.

• Implications for Rehabilitation

• Foot pain, sensory impairments and muscle weakness in the foot and ankle can impact on community ambulation, balance and fear of falling following stroke.

• Foot and ankle function post-stroke should be routinely assessed and monitored.

• Clinicians should be aware of the potentially distressing negative perceptions associated with altered gait patterns, footwear and orthotic use.

     

The psychometric properties of the cervical nonorganic signs in patients with neck pain: an assessment of pain expression

Purpose: Neck pain is a common cause of disability. This study investigated the psychometric properties of the cervical nonorganic signs (CNOS), a tool for assessing abnormal illness behaviors in patients with neck pain.

Methods: The CNOS was administered on patients with neck pain. Reliability and validity analyses were used to evaluate the psychometric properties. Exploratory factor analysis was used to investigate the dimensionality. Correlations with the Short Form-36 were used to investigate the convergent validity.

Results: The results supported the reliability (inter-rater reliability intra-class correlation: 0.920), validity (correlated with body pain (|ρ|=0.31) and vitality (|ρ|?=0.30), and two-factor dimensionality (χ²=^?5.904, p=?0.66; χ²/df?=?0.738; RMSEAConclusion: The CNOS is a reliable and valid instrument for assessing pain and vitality problems. It helps patients to express severe pain and lack of vitality. The rehabilitation discipline could use the scale to understand pain expression and to design proper rehabilitation programs.

• Implications for Rehabilitation

• The cervical nonorganic signs has two domains (pain and vitality).

• The scale is reliable and valid for patients with neck pain.

• Patients with high scores on the pain domain have severe body pain that may interfere with normal social activities.

• Clinicians should understand their suffering and try to help them to alleviate the pain.

     

Preferences for technology versus human assistance and control over technology in the performance of kitchen and personal care tasks in baby boomers and older adults

Abstract

Purpose: Quality of Life technology (QoLT) stresses humans and technology as mutually dependent and aware, working together to improve task performance and quality of life. This study examines preferences for technology versus human assistance and control in the context of QoLT. Method: Data are from a nationally representative, cross-sectional web-based sample of 416 US baby boomers (45–64) and 114 older adults (65+) on preferences for technology versus human assistance and control in the performance of kitchen and personal care tasks. Multinomial logistic regression and ordinary least squares regression were used to determine predictors of these preferences. Results: Respondents were generally accepting of technology assistance but wanted to maintain control over its’ operation. Baby boomers were more likely to prefer technology than older adults, and those with fewer QoLT privacy concerns and who thought they were more likely to need future help were more likely to prefer technology over human assistance and more willing to relinquish control to technology. Conclusions: Results suggest the need for design of person- and context-aware QoLT systems that are responsive to user desires for level of control over operation of the technology. The predictors of these preferences suggest potentially receptive markets for the targeting of QoLT systems.

• Implications for Rehabilitation

• In anticipation of potential needs for help with instrumental activities of daily living (IADL) and activities of daily living (ADL), approximately half of US baby boomers and older adults are open to having intelligent, person-aware technology provide assistance. The remainder would prefer human assistance.

• US baby boomers and older adults are generally not in favor of relinquishing control to the technology when receiving IADL or ADL assistance.

• Preferences for technology versus human assistance and control over technology vary by socio-demographic, health-related, and technology attitude variables.

• Intelligent, person-aware quality of life technologies for rehabilitation must be designed to be sensitive to user characteristics and preferences for control over operation of the technology.

     

The effect of footwear adapted with a multi-curved rocker sole in conjunction with knee-ankle-foot orthoses on walking in poliomyelitis subjects: a pilot study

Background: Knee-ankle-foot orthoses (KAFOs) are used by people with poliomyelitis to ambulate. Whist advances in orthotic knee joint designs for use in KAFOs such the provision of stance control capability have proven efficacy, little attention has been paid to shoe adaptations which may also improve gait.

Aim: The aim of this study was to evaluate the alteration to the kinematics and temporal-spatial parameters of gait caused by the use of heel-to-toe rocker-soled footwear when ambulating with KAFOs.

Method: Nine adults with a history of poliomyelitis who routinely wore KAFOs participated in the study. A heel-to-toe rocker sole was added to footwear and worn on the affected side. A three-dimensional motion capture system was used to quantify the resulting alteration to specific gait parameters.

Results: Maximum hip joint extension was significantly increased (p?=?0.011), and hip abduction and adduction were both significantly reduced (p?=?0.011 and p?=?0.007, respectively) when walking with the rocker sole. A significant increase in stride length (p?=?0.035) was demonstrated but there were no significant increases in either walking speed or cadence.

Conclusions: A heel-to-toe rocker sole adaptation may be useful for walking in patients with poliomyelitis who use KAFOs.

• Implications for Rehabilitation

• The poor functionality and difficulty in walking when using an orthotic device such as a KAFO which keeps the knee locked during ambulation, plus the significant energy required to walk, are complications of orthoses using.

• Little evidence exists regarding the biomechanical effect of walking with a KAFO incorporating fixed knee joints, in conjunction with rocker-soled footwear.

• The main aim of walking with a heel-to-toe rocker sole is to facilitate forward progression of the tibia when used with an AFO or KAFO or to provide easier walking for patients who have undergone an ankle arthrodesis.

• In this study, a rocker sole profile adaptation produced no significant alteration to hip joint flexion, but hip joint maximum extension was significantly increased in subjects suffering from poliomyelitis, and maximum hip adduction and abduction were both significantly reduced.

• The most significant alterations were seen in stride length, and although there was a significant increase in this parameter, there was no statistically significant increase in walking velocity or cadence.

     

Ratings of pain and activity limitation on the visual analogue scale and global impression of change in multimodal rehabilitation of back pain – analyses at group and individual level

Purpose: To evaluate changes in pain intensity and activity limitation, at group and individual levels, and their associations with the global impression of change after multimodal rehabilitation in patients with back pain.

Method: Patients with long-term back pain (n?=?282) participated in a 4-week programme with a follow-up after 6 months. Visual analogue scales (VAS) were used to rate pain intensity and activity limitation. Global impression of change (GIC) was rated on a 7-category scale. The sign test, the Svensson method and the Spearman rank correlation were used for analyses.

Results: Significantly lower ratings in pain and activity limitation at follow-up were found at group level. However, a large individual variability was found by the Svensson method. The correlations between GIC and changes in pain and activity limitation were r_s??=_? 0.49 and r_s =?_?0.50, respectively. A rated GIC of at least “much better” on group level showed changes of ≥20?mm on the VAS.

Conclusions: At group level, lower VAS ratings were found in patients with back pain. However, a large individual variability in pain and activity limitation was also found resulting in low to moderate associations between GIC and the change in VAS ratings. The large individual variability might be due to the impreciseness in the ratings on the VAS. We have presented a critical discussion of statistical methods in connection with the VAS.

• Implications for Rehabilitation

• The use of VAS as a rating instrument may be questioned, especially for perceived pain intensity which is a too complex experience to be rated on a line without any visible categories.

• Single ratings of pain intensity should preferably be complemented with the ratings of activity limitation in patients with long-term back pain.

• Global impression of change is a suggested inclusive rating after rehabilitation.

• The improvement desired by the patient should preferably be determined before rehabilitation.

     

Using musculoskeletal modeling to evaluate the effect of ankle foot orthosis tuning on musculotendon dynamics: a case study

Purpose: This case study examines the influence of an ankle foot orthosis footwear combination (AFO-FC) on musculotendon lengths and gait kinematics and kinetics after right thrombotic stroke resulting in left hemiplegia. Methods: Gait analysis was performed over three visits where the subject walked with an AFO-FC with two shank-to-vertical angle (SVA) alignments, a posterior leaf spring AFO (PLS AFO), and shoes alone. Biomechanical and musculoskeletal modeling was used to evaluate musculotendon lengths, kinematics, and kinetics for each condition. Results: The AFO-FC improved walking speed and non-paretic kinematics compared to the PLS AFO and shoes alone. The operating length of the paretic gastrocnemius decreased with the AFO-FC improving knee kinematics in swing, but not stance. As the SVA of the AFO-FC was reduced from 15° to 12°, internal ankle plantar flexor moment increased. Conclusions: Musculoskeletal modeling demonstrated that the AFO-FC altered gastrocnemius operating length during post-stroke hemiplegic gait. Using these tools to evaluate muscle operating lengths can provide insight into underlying mechanisms that may improve gait and guide future AFO-FC design.

• Implications for Rehabilitation

• Modeling musculotendon operating lengths during movement has the potential to inform how ankle foot orthoses (AFO) affect tight muscles and improve mobility after stroke.

• Adjusting shank-to-vertical angle (SVA) of the AFO-footwear combination (AFO-FC) has the potential to improve gait kinematics by controlling length of the pathologic gastrocnemius and maximizing internal ankle plantar flexor moment of individuals with neuromuscular disorders.

     

Fatigue induced changes to kinematic and kinetic gait parameters following six minutes of walking in people with multiple sclerosis

Purpose: The aim of this study was to examine the effect of 6?min of walking on fatigue, exertion and spatiotemporal, kinematic and kinetic gait parameters in people with multiple sclerosis (MS). Methods: Thirty-four people with MS with moderate levels of disability completed measures of fatigue, exertion and instrumented gait analysis before and after 6-min trials of rest and walking (using a modified 6-min walk test, m6MWT). Ten age- and gender-matched healthy controls completed analysis before and after the m6MWT. Results: The MS group had a significant increase in self-reported fatigue following the m6MWT; however, there was no effect on spatiotemporal gait parameters. During stance on the more affected side ankle dorsiflexion at initial contact decreased, while knee and hip flexor moments and hip power absorption increased. On the less affected side ankle and knee power absorption, and hip extensor moment all increased. Healthy controls showed increases in joint kinetics likely due to increased walking speeds following m6MWT. Conclusion: For people with MS, ankle dorsiflexion angle reduces at initial contact following walking induced fatigue, while increased power absorption at the hip, knee and ankle indicate gait inefficiencies that may contribute to higher levels of fatigue and exertion.

• Implications for Rehabilitation

• The modified 6-min walk test (m6MWT) leads to significant increases in self-reported fatigue and exertion in people with MS.

• Following the m6MWT, there is significantly reduced ankle dorsiflexion angle at initial contact in the more affected leg in people with MS. This reveals an important walking-induced kinematic change that should be the target of future orthotic and strengthening interventions.

• In people with MS, increased power absorption primarily during the stance phase of gait following the m6MWT reveals important walking-induced muscle weakness that should also be monitored in future strengthening and gait retraining interventions.

     

Fractures diagnosed in primary care – a five-year retrospective observational study from a Norwegian rural municipality with a ski resort

Abstract

Objective: The aim of this study was to characterize fractures recorded at a Norwegian primary care centre near a ski resort.

Design: A retrospective five-year observational study in the period 2010–2014.

Setting: A primary care centre equipped with an x-ray machine and located near a ski resort in a small rural municipality of 931 inhabitants in Norway. The X-ray images are digitalized and instantly transferred for assessment of a radiologist and/or an orthopedic surgeon both before and after treatment.

Subjects: All patients with radiologically confirmed fractures.

Results: A total of 1154 X-ray examinations were done, out of which 480 (41.6%) were fractures verified by a radiologist. The most frequent fractures were in the wrist (30%), collarbone (15%), shin (11%), humerus (9%) and ankle (8%). 316 (66%) of the fractures were in males and of these 225 were in age group 10–19?years. Males dominated among fractures in collarbone (92% males), finger (80% males), and foot (85% males). Women with fractures of the wrist, ankle, humerus and metacarpal bones, had a higher median age than men with similar fractures. Nonsurgical treatment with cast or braces was initially offered in 371 (77%) of the fracture-cases at the primary care level.

Conclusion: Young men acquired most of the fractures, predominantly in the wrist, and mostly during the winter sport season. Nearly eight of ten fractures were treated locally in primary care centre.

• Key points

• A large seasonal variation was found in number of patients with fractures.

• More than 60% had fractures in the wrist, collarbone, shin or ankle.

• More than half of the patients with a fracture were males and below 20 years old.

• Most fractures were ski-related.

     

Application and outcomes of therapy combining transcranial direct current stimulation and virtual reality: a systematic review

Purpose: To evaluate the methods and major outcomes of transcranial direct current stimulation (tDCS) combined with virtual reality (VR) therapy in randomized controlled trials.

Method: A systematic review was performed following PRISMA guidelines using PubMed, PubMed Central, Web of Science and CAPES periodic databases, with no time restriction. The studies were screened for the following inclusion criteria: human subjects, combination of VR and tDCS methods, and randomized controlled study design. All potentially relevant articles were independently reviewed by two researchers, who reached a consensus on which articles met the inclusion criteria. The PEDro scale was used to evaluate the studies.

Results: Eleven studies were included, all of which utilized a variety of tDCS and VR application methods. The main outcomes were found to be beneficial in intervention groups of different populations, including improvements in body sway, gait, stroke recovery, pain management and vegetative reactions.

Conclusions: The use of tDCS combined with VR showed positive results in both healthy and impaired patients. Future studies with larger sample sizes and homogeneous participants are required to confirm the benefits of tDCS and VR.

• Implications for Rehabilitation

• tDCS with VR intervention can be an alternative to traditional rehabilitation programs.

• tDCS with VR is a promising type of intervention with a variety of positive effects.

• Application of tDCS with VR is appropriated to both healthy and impaired patients.

• There is no consensus of tDCS with VR application.

     

Assessing subacute mild traumatic brain injury with a portable virtual reality balance device

Purpose: Balance impairment is a common sensorimotor symptom in mild traumatic brain injury (mTBI). We designed an affordable, portable virtual reality (VR)-based balance screening device (Virtual Environment TBI Screen [VETS]), which will be validated relative to the Neurocom Sensory Organization Test (SOT) to determine if it can replace commonly used postural assessments.

Methods: This preliminary study examines healthy adults (n?=?56) and adults with mTBI (n?=?11). Participants performed six upright postural tasks on the VETS and the SOT. Analysis of variance was used to determine between-group differences. Pearson’s correlations were used to establish construct validity. Known-groups approach was used to establish classification accuracy.

Results: The mTBI cohort performed significantly worse than the healthy cohort on the new device (p?=?0.001). The new device has 91.0% accuracy and an ROC curve with a significant area-under-the-curve (AUC?=?0.865, p?p?=?0.034).

Conclusions: The new VR-based device is a valid measure for detecting balance impairment following mTBI and can potentially replace more expensive and cumbersome equipment. Assessments that test visual-vestibular processing, such as VETS, increase sensitivity to mTBI-related balance deficits, which can be used to guide rehabilitation.

• Implications for rehabilitation

• Emerging technology using virtual reality can be economically integrated into the clinical setting for easy testing of postural control in neurologically impaired populations.

• Tailoring postural assessments to include tasks that rely on visual and vestibular integration will increase the accuracy of detecting balance impairment following mild traumatic brain injury.

     

Ankle positions potentially facilitating greater maximal contraction of pelvic floor muscles: a systematic review and meta-analysis

Abstract

Objectives: To evaluate the effect of ankle positions on pelvic floor muscles in women.

Methods: Multiple databases were searched from inception-July 2017. Study quality was rated using the grading of recommendations, assessment, development, and evaluation system and the “threats to validity tool”.

Results: Four studies were eligible for inclusion. Meta-analysis revealed significantly greater resting activity of pelvic floor muscles in neutral ankle position (?1.36 (95% CI ?2.30, ?0.42) p?= 0.004) and induced 15° dorsiflexion (?1.65 (95% CI ?2.49, ?0.81) p?= 0.0001) compared to induced 15° plantar flexion. Significantly greater maximal voluntary contraction of pelvic floor was found in dorsiflexion compared to plantar flexion (?2.28 (95% CI ?3.96, ?0.60) p?= 0.008). Meta-analyses revealed no significant differences between the neutral ankle position and 15° dorsiflexion for either resting activity (0.30 (95% CI ?0.75, 1.35) p?= 0.57) or maximal voluntary contraction (0.97 (95% CI ?0.77, 2.72) p?= 0.27).

Conclusion: Pelvic floor muscle-training for women with urinary incontinence could be performed in standing with ankles in a neutral position or dorsiflexion to facilitate greater maximal pelvic floor muscle contraction. As urethral support requires resting contraction of pelvic floor muscles, decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with urinary incontinence might potentially experience more leakage during exertion in a standing position.

• Implications for rehabilitation

• Pooled analyses revealed that maximal voluntary contraction of pelvic floor muscle is greater in induced ankle dorsiflexion than induced plantar flexion.

• As pelvic floor muscle strengthening involves achieving a greater maximal voluntary contraction, pelvic floor muscle training for women with stress urinary incontinence could be performed in standing either with ankles in a neutral position or dorsiflexion.

• Decreased resting activity in plantar flexion identified in the meta-analysis indicates that high-heel wearers with stress urinary incontinence might potentially experience more leakage during exertion in a standing position.

• Women with stress urinary incontinence should be advised to wear flat shoes instead of high-heels and should be cautioned about body posture and ankle positions assumed during exercise and daily activities.