Effects of Home-Based Locomotor Treadmill Training on Gross Motor Function in Young Children With Cerebral Palsy: A Quasi-Randomized Controlled Trial

Objective

To examine the effects of an intensive home-based program of treadmill training on motor skills related to walking in preambulatory children with cerebral palsy (CP).

Design

Quasi-randomized controlled trial.

Setting

Homes of the participants.

Participants

Children with CP (N=12) with Gross Motor Function Classification System levels I and II were assigned to the intervention group (n=6; mean age ± SD, 21.76±6.50mo) and control group (n=6; 21.25±6.07mo). All children were tested preintervention, postintervention, at a 1-month follow-up, and at a 4-month follow-up.

Interventions

All children received their weekly scheduled physical therapy sessions at their homes. In addition, children in the intervention group walked on a portable treadmill in their homes 6 times per week, twice daily for 10- to 20-minute sessions, for 6 weeks. The intervention was carried out by the children's parents with weekly supervision by a physical therapist.

Main Outcome Measures

Gross Motor Function Measure-66 Dimensions D/E, Peabody Developmental Motor Scales-2 (PDMS-2), Pediatric Evaluation of Disability Inventory (PEDI), timed 10-m walk test (10MWT), and Functional Mobility Scale (FMS). The Friedman test and Mann-Whitney U test were conducted for within-group and between-group differences, respectively.

Results

There was a significant between-group treatment effect for the PDMS-2 at posttest (P=.01) and 1-month postintervention follow-up (P=.09), as well as for the PEDI at posttest (P=.01), the 1-month postintervention follow-up (P=.009), and the 4-month postintervention follow-up (P=.04). The FMS was significant at the posttest (P=.04).

Conclusions

Home-based treadmill training accelerates the attainment of walking skills and decreases the amount of support used for walking in young children with CP.     

Relationship Between Communication Skills and Gross Motor Function in Preschool-Aged Children With Cerebral Palsy

Objectives

To explore the communication skills of children with cerebral palsy (CP) at 24 months' corrected age with reference to typically developing children, and to determine the relationship between communication ability, gross motor function, and other comorbidities associated with CP.

Design

Prospective, cross-sectional, population-based cohort study.

Setting

General community.

Participants

Children with CP (N=124; mean age, 24mo; functional severity on Gross Motor Function Classification System [GMFCS]: I=47, II=14, III=22, IV=19, V=22).

Interventions

Not applicable.

Main Outcome Measures

Parents reported communication skills on the Communication and Symbolic Behavior Scales Developmental Profile (CSBS-DP) Infant-Toddler Checklist. Two independent physiotherapists classified motor type, distribution, and GMFCS. Data on comorbidities were obtained from parent interviews and medical records.

Results

Children with mild CP (GMFCS I/II) had mean CSBS-DP scores that were 0.5 to 0.6 SD below the mean for typically developing peers, while those with moderate-severe impairment (GMFCS III–V) were 1.4 to 2.6 SD below the mean. GMFCS was significantly associated with performance on the CSBS-DP (F=18.55, P<.001), with gross motor ability accounting for 38% of the variation in communication. Poorer communication was strongly associated with gross motor function and full-term birth.

Conclusions

Preschool-aged children with CP, with more severe gross motor impairment, showed delayed communication, while children with mild motor impairment were less vulnerable. Term-born children had significantly poorer communication than those born prematurely. Because a portion of each gross motor functional severity level is at risk, this study reinforces the need for early monitoring of communication development for all children with CP.     

Changes in Gross Motor Function and Health-Related Quality of Life in Adults With Cerebral Palsy: An 8-Year Follow-Up Study

Objective

To describe changes in gross motor function and health-related quality of life (HRQOL) in adults with cerebral palsy (CP).

Design

An 8-year follow-up survey.

Setting

Participants who completed the baseline survey in 2003 were invited.

Participants

The sample of adults with CP (N=54; response rate=37%) included a “younger group” (group 1; n=31; age, 23–27y; 15 women) and an “older group” (group 2; n=23; age, 33–42y; 10 women).

Interventions

Not applicable.

Main Outcome Measures

The Gross Motor Function Classification System (GMFCS), Self-Rated Health (SRH), the Health Utility Index Mark III (HUI₃), and the Assessment of Quality of Life (AQoL).

Results

Eight years after the initial survey, 27% of the participants in the combined group had deteriorations on the GMFCS, 52% on the SRH, 44% on the HUI₃, and 25% on the AQoL. Members of group 1 reported stable scores as they made the transition to adulthood, while many of the group 2 members experienced declines, with relative risk of 1.47 (95% confidence interval [CI], 0.16–2.24) on the GMFCS, 1.36 (95% CI, 0.83–2.23) on the SRH, 1.19 (95% CI, 0.66–2.15) on the HUI₃, and 3.17 (95% CI, 1.12–9.00) on the AQoL.

Conclusions

Although much attention has focused on the transitions of persons with CP during their late teens and early 20s, this research found that deteriorations in the GMFCS levels and the HRQOL were most evident in adults in their late 20s and 30s. More detailed longitudinal studies are required to evaluate the longer-term health outcomes among persons with CP into their 30s and beyond.     

Effects of Repetitive Peripheral Magnetic Stimulation on Upper-Limb Spasticity and Impairment in Patients With Spastic Hemiparesis: A Randomized,Double-Blind,Sham-Controlled Study

Objective

To investigate short-term and long-term effects of repetitive peripheral magnetic stimulation (rpMS) on spasticity and motor function.

Design

Monocentric, randomized, double-blind, sham-controlled trial.

Setting

Neurologic rehabilitation hospital.

Participants

Patients (N=66) with severe hemiparesis and mild to moderate spasticity resulting from a stroke or a traumatic brain injury. The average time ± SD since injury for the intervention groups was 26±71 weeks or 37±82 weeks.

Interventions

rpMS for 20 minutes or sham stimulation with subsequent occupational therapy for 20 minutes, 2 times a day, over a 2-week period.

Main Outcome Measures

Modified Tardieu Scale and Fugl-Meyer Assessment (arm score), assessed before therapy, at the end of the 2-week treatment period, and 2 weeks after study treatment. Additionally, the Tardieu Scale was assessed after the first and before the third therapy session to determine any short-term effects.

Results

Spasticity (Tardieu >0) was present in 83% of wrist flexors, 62% of elbow flexors, 44% of elbow extensors, and 10% of wrist extensors. Compared with the sham stimulation group, the rpMS group showed short-term effects on spasticity for wrist flexors (P=.048), and long-term effects for elbow extensors (P<.045). Arm motor function (rpMS group: median 5 [4–27]; sham group: median 4 [4–9]) did not significantly change over the study period in either group, whereas rpMS had a positive effect on sensory function.

Conclusions

Therapy with rpMS increases sensory function in patients with severe limb paresis. The magnetic stimulation, however, has limited effect on spasticity and no effect on motor function.     

Evaluation of an Activity Monitor for the Objective Measurement of Free-Living Physical Activity in Children With Cerebral Palsy

Objective

To explore the use of an activity monitor (AM) to objectively characterize free-living physical activity (F-LPA) in children with mobility impairment resulting from cerebral palsy (CP).

Design

First, a validation study compared outcomes from the AM with video evidence. Second, multiday F-LPA was characterized. Relationships between laboratory measures and F-LPA were explored.

Setting

The evaluation study was conducted in a laboratory environment. F-LPA monitoring was conducted in the participants' free-living environment.

Participants

Convenience sample of ambulatory children (N=15; 11 boys, 4 girls) aged 5 to 17 years with CP undergoing gait analysis.

Interventions

Not applicable.

Main Outcome Measures

Accuracy of the AM for sitting/lying time, upright time, stepping time, and strides taken. Daily volumes of F-LPA of children with CP.

Results

AM outcomes in comparison with video-based analysis were (mean ± SD) 97.4%±2.7%, 101.1%±1.5%, 99.5%±6.6%, 105.6%±15.8%, and 103.8%±10.1% for sitting/lying time, upright time, standing time, stepping time, and stride count, respectively. Participants' daily F-LPA demonstrated considerable variation: mean standing time ± SD, 2.33±.96h/d; mean stepping time ± SD, 1.68±.86h/d; mean steps per day ± SD, 8477±4528; and mean sit-to-stand transitions per day ± SD, 76±49. Laboratory-measured cadence and mobility level were related to F-LPA, but not directly.

Conclusions

The AM demonstrated excellent ability to determine sitting/lying and upright times in children with CP. Stepping time and stride count had lower levels of agreement with video-based analysis but were comparable to findings in previous studies. Crouch gait and toe walking had an adverse effect on outcomes. The F-LPA data provided additional information on children's performance not related to laboratory measures, demonstrating the added value of using this objective measurement technique.     

Waist Circumference Provides an Indication of Numerous Cardiometabolic Risk Factors in Adults With Cerebral Palsy

Objective

To report the prevalence of cardiometabolic risk factors in a cohort of adults with cerebral palsy (CP) and to investigate the ability of anthropometric measures to predict these factors.

Design

Cross-sectional study.

Setting

Testing took place in a laboratory setting.

Participants

Adults with CP (N=55; mean age, 37.5±13.3y; Gross Motor Function Classification System levels, I–V) participated in this study.

Interventions

Not applicable.

Main Outcome Measures

Total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, glucose, insulin, and C-reactive protein levels were measured from a fasting venous blood sample. Insulin resistance was calculated using the Homeostasis Model Assessment (HOMA-IR) index. Blood pressure, body mass index (BMI), waist circumference (WC), waist-hip ratio, and waist-height ratio were also measured. The metabolic syndrome (MetS) was defined according to the 2009 Joint Interim Statement.

Results

The prevalence of the MetS was 20.5% in ambulatory adults and 28.6% in nonambulatory adults. BMI was associated with HOMA-IR only (β=.451; P<.01). WC was associated with HOMA-IR (β=.480; P<.01), triglycerides (β=.450; P<.01), and systolic blood pressure (β=.352; P<.05). Receiver operating characteristic curve analysis revealed that WC provided the best indication of hypertensive blood pressure, dyslipidemia, HOMA-IR, and the presence of multiple risk factors (area under the curve, .713–.763).

Conclusions

A high prevalence of the MetS was observed in this relatively young sample of adults with CP. WC was a better indicator of a number of risk factors than was BMI and presents as a clinically useful method of screening for cardiometabolic risk among adults with CP.     

Systematic Review of High-Intensity Progressive Resistance Strength Training of the Lower Limb Compared With Other Intensities of Strength Training in Older Adults

Objective

To examine the effect of high-intensity progressive resistance strength training (HIPRST) on strength, function, mood, quality of life, and adverse events compared with other intensities in older adults.

Data Sources

Online databases were searched from their inception to July 2012.

Study Selection

Randomized controlled trials of HIPRST of the lower limb compared with other intensities of progressive resistance strength training (PRST) in older adults (mean age ≥65y) were identified.

Data Extraction

Two reviewers independently completed quality assessment using the Physiotherapy Evidence Database (PEDro) scale and data extraction using a prepared checklist.

Data Synthesis

Twenty-one trials were included. Study quality was fair to moderate (PEDro scale range, 3–7). Studies had small sample sizes (18–84), and participants were generally healthy. Meta-analyses revealed HIPRST improved lower-limb strength greater than moderate- and low-intensity PRST (standardized mean difference [SMD]=.79; 95% confidence interval [CI], .40 to 1.17 and SMD=.83; 95% CI, −.02 to 1.68, respectively). Studies where groups performed equivalent training volumes resulted in similar improvements in leg strength, regardless of training intensity. Similar improvements were found across intensities for functional performance and disability. The effect of intensity of PRST on mood was inconsistent across studies. Adverse events were poorly reported, however, no correlation was found between training intensity and severity of adverse events.

Conclusions

HIPRST improves lower-limb strength more than lesser training intensities, although it may not be required to improve functional performance. Training volume is also an important variable. HIPRST appears to be a safe mode of exercise in older adults. Further research into its effects on older adults with chronic health conditions across the care continuum is required.     

Improvement of Upper Extremity Motor Control and Function After Home-Based Constraint Induced Therapy in Children With Unilateral Cerebral Palsy: Immediate and Long-Term Effects

Objective

To investigate the long-term effects of home-based constraint induced therapy (CIT) on motor control underlying functional change in children with unilateral cerebral palsy (CP).

Design

Randomized controlled trial.

Setting

Home based.

Participants

Children with unilateral CP (N=45; aged 6–12y) were randomly assigned to receive home-based CIT (n=23) or traditional rehabilitation (TR) (n=22).

Interventions

Both groups received a 4-week therapist-based intervention at home. The home-based CIT involved intensive functional training of the more affected upper extremity during which the less affected one was restrained. The TR involved functional unimanual and bimanual training.

Main Outcome Measures

All children underwent kinematic and clinical assessments at baseline, 4 weeks (posttreatment), and 3 and 6 months (follow-up). The reach-to-grasp kinematics were reaction time (RT), normalized movement time, normalized movement unit, peak velocity (PV), maximum grip aperture (MGA), and percentage of movement where MGA occurs. The clinical measures were the Peabody Developmental Motor Scales, Second Edition (PDMS-2), Bruininks-Oseretsky Test of Motor Proficiency (BOTMP), and Functional Independence Measure for children (WeeFIM).

Results

The home-based CIT group showed a shorter RT (P<.05) and normalized movement time (P<.01), smaller MGA (P=.006), and fewer normalized movement units (P=.014) in the reach-to-grasp movements at posttreatment and follow-up than the TR group. The home-based CIT group improved more on the PDMS-2 (P<.001) and WeeFIM (P<.01) in all posttreatment tests and on the BOTMP (P<.01) at follow-up than the TR group.

Conclusions

The home-based CIT induced better spatial and temporal efficiency (smoother movement, more efficient grasping, better movement preplanning and execution) for functional improvement up to 6 months after treatment than TR.     

Electrically Induced Resistance Training in Individuals With Motor Complete Spinal Cord Injury

Objective

To examine the effects of 16 weeks of electrically induced resistance training on insulin resistance and glucose tolerance, and changes in muscle size, composition, and metabolism in paralyzed muscle.

Design

Pre-post intervention.

Setting

University-based trial.

Participants

Participants (N=14; 11 men and 3 women) with chronic (>2y post spinal cord injury), motor complete spinal cord injury.

Intervention

Home-based electrically induced resistance exercise training twice weekly for 16 weeks.

Main Outcome Measures

Plasma glucose and insulin throughout a standard clinical oral glucose tolerance test, thigh muscle and fat mass via dual-energy x-ray absorptiometry, quadriceps and hamstrings muscle size and composition via magnetic resonance imaging, and muscle oxidative metabolism using phosphorus magnetic resonance spectroscopy.

Results

Muscle mass increased in all participants (mean ± SD, 39%±27%; range, 5%–84%). The mean change ± SD in intramuscular fat was 3%±22%. Phosphocreatine mean recovery time constants ± SD were 102±24 and 77±18 seconds before and after electrical stimulation-induced resistance training, respectively (P<.05). There was no improvement in fasting blood glucose levels, homeostatic model assessment calculated insulin resistance, 2-hour insulin, or 2-hour glucose.

Conclusions

Sixteen weeks of electrical stimulation-induced resistance training increased muscle mass, but did not reduce intramuscular fat. Similarly, factors associated with insulin resistance or glucose tolerance did not improve with training. We did find a 25% improvement in mitochondrial function, as measured by phosphocreatine recovery rates. Larger improvements in mitochondrial function may translate into improved glucose tolerance and insulin resistance.     

Effects of Cervical Spine Manual Therapy on Range of Motion,Head Repositioning,and Balance in Participants With Cervicogenic Dizziness: A Randomized Controlled Trial

Objective

To evaluate and compare the effects of 2 manual therapy interventions on cervical spine range of motion (ROM), head repositioning accuracy, and balance in patients with chronic cervicogenic dizziness.

Design

Randomized controlled trial with 12-week follow-up using blinded outcome assessment.

Setting

University School of Health Sciences.

Participants

Participants (N=86; mean age ± SD, 62.0±12.7y; 50% women) with chronic cervicogenic dizziness.

Interventions

Participants were randomly assigned to 1 of 3 groups: sustained natural apophyseal glides (SNAGs) with self-SNAG exercises, passive joint mobilization (PJM) with ROM exercises, or a placebo. Participants each received 2 to 6 treatments over 6 weeks.

Main Outcome Measures

Cervical ROM, head repositioning accuracy, and balance.

Results

SNAG therapy resulted in improved (P≤.05) cervical spine ROM in all 6 physiological cervical spine movement directions immediately posttreatment and at 12 weeks. Treatment with PJM resulted in improvement in 1 of the 6 cervical movement directions posttreatment and 1 movement direction at 12 weeks. There was a greater improvement (P<.01) after SNAGs than PJM in extension (mean difference, −7.5°; 95% confidence interval [CI], −13° to −2.0°) and right rotation (mean difference, −6.8°; 95% CI, −11.5° to −2.1°) posttreatment. Manual therapy had no effect on balance or head repositioning accuracy.

Conclusions

SNAG treatment improved cervical ROM, and the effects were maintained for 12 weeks after treatment. PJM had very limited impact on cervical ROM. There was no conclusive effect of SNAGs or PJMs on joint repositioning accuracy or balance in people with cervicogenic dizziness.     

Aerobic Capacity,Orthostatic Tolerance,and Exercise Perceptions at Discharge From Inpatient Spinal Cord Injury Rehabilitation

Objective

To describe physical capacity, autonomic function, and perceptions of exercise among adults with subacute spinal cord injury (SCI).

Design

Cross-sectional.

Setting

Two inpatient SCI rehabilitation programs in Canada.

Participants

Participants (N=41; mean age ± SD, 38.9±13.7y) with tetraplegia (TP; n=19), high paraplegia (HP; n=8), or low paraplegia (LP; n=14) completing inpatient SCI rehabilitation (mean ± SD, 112.9±52.5d postinjury).

Interventions

Not applicable.

Main Outcome Measures

Peak exercise capacity was determined by an arm ergometry test. As a measure of autonomic function, orthostatic tolerance was assessed by a passive sit-up test. Self-efficacy for exercise postdischarge was evaluated by a questionnaire.

Results

There was a significant difference in peak oxygen consumption and heart rate between participants with TP (11.2±3.4;mL·kg⁻¹·min⁻¹ 113.9±19.7beats/min) and LP (17.1±7.5mL·kg⁻¹·min⁻¹; 142.8±22.7beats/min). Peak power output was also significantly lower in the TP group (30.0±6.9W) compared with the HP (55.5±7.56W) and LP groups (62.5±12.2W). Systolic blood pressure responses to the postural challenge varied significantly between groups (−3.0±33.5mmHg in TP, 17.8±14.7mmHg in HP, 21.6±18.7mmHg in LP). Orthostatic hypotension was most prevalent among participants with motor complete TP (73%). Results from the questionnaire revealed that although participants value exercise and see benefits to regular participation, they have low confidence in their abilities to perform the task of either aerobic or strengthening exercise.

Conclusions

Exercise is well tolerated in adults with subacute SCI. Exercise interventions at this stage should focus on improving task-specific self-efficacy, and attention should be made to blood pressure regulation, particularly in individuals with motor complete TP.     

English Cross-Cultural Translation and Validation of the Neuromuscular Score: A System for Motor Function Classification in Patients With Neuromuscular Diseases

Objective

To develop and validate an English version of the Neuromuscular (NM)-Score, a classification for patients with NM diseases in each of the 3 motor function domains: D1, standing and transfers; D2, axial and proximal motor function; and D3, distal motor function.

Design

Validation survey.

Setting

Patients seen at a medical research center between June and September 2013.

Participants

Consecutive patients (N=42) aged 5 to 19 years with a confirmed or suspected diagnosis of congenital muscular dystrophy.

Interventions

Not applicable.

Main Outcome Measures

An English version of the NM-Score was developed by a 9-person expert panel that assessed its content validity and semantic equivalence. Its concurrent validity was tested against criterion standards (Brooke Scale, Motor Function Measure [MFM], activity limitations for patients with upper and/or lower limb impairments [ACTIVLIM], Jebsen Test, and myometry measurements). Informant agreement between patient/caregiver (P/C)-reported and medical doctor (MD)-reported NM scores was measured by weighted kappa.

Results

Significant correlation coefficients were found between NM scores and criterion standards. The highest correlations were found between NM-score D1 and MFM score D1 (ρ=−.944, P<.0001), ACTIVLIM (ρ=−.895, P<.0001), and hip abduction strength by myometry (ρ=−.811, P<.0001). Informant agreement between P/C-reported and MD-reported NM scores was high for D1 (κ=.801; 95% confidence interval [CI], .701–.914) but moderate for D2 (κ=.592; 95% CI, .412–.773) and D3 (κ=.485; 95% CI, .290–.680). Correlation coefficients between the NM scores and the criterion standards did not significantly differ between P/C-reported and MD-reported NM scores.

Conclusions

Patients and physicians completed the English NM-Score easily and accurately. The English version is a reliable and valid instrument that can be used in clinical practice and research to describe the functional abilities of patients with NM diseases.     

The Effects of Constraint-Induced Therapy on Kinematic Outcomes and Compensatory Movement Patterns: An Exploratory Study

Massie C, Malcolm MP, Greene D, Thaut M. The effects of constraint-induced therapy on kinematic outcomes and compensatory movement patterns: an exploratory study.

Objective

To determine changes in kinematic variables and compensatory movement patterns of survivors of stroke completing constraint-induced therapy (CIT).

Design

Pre-post, case series.

Setting

Clinical rehabilitation research laboratory.

Participants

Men (n=7) and women (n=3) with unilateral stroke occurring at least 9 months prior to study entry with moderate, stable motor deficits.

Intervention

Participants completed 10 consecutive weekdays of CIT for 6 hours a day comprised of trainer-supervised, functionally based activities using massed practice.

Main Outcome Measures

Kinematic measures included movement time, average velocity, trajectory stability, shoulder abduction, and segmental contribution. Functional measures included Wolf Motor Function Test (WMFT) performance time and functional ability scores and Motor Activity Log (MAL) “how-well” scores. All measures were administered before and after the 2-week CIT intervention.

Results

Movement time, average velocity, and trajectory stability significantly improved after CIT. Participants used more shoulder flexion to reach after CIT, but also demonstrated increased compensatory shoulder abduction. Functional scores also significantly improved, including WMFT performance time and functional ability and MAL scores. There was no change in trunk movement or amount of elbow extension.

Conclusions

CIT improved motor capacities in the hemiparetic arm as reflected in the functional outcomes and in some kinematic measures. Participants' reliance on common compensatory movements was not beneficially affected by CIT. The results of this study demonstrate that while functional capacity and some movement strategies in the hemiparetic arm improve after CIT, participants may not overcome their reliance on common compensatory movement patterns. Based on these findings, this study suggests that CIT may encourage subjects to generate movement through compensatory and/or synergy-dominated movement rather than promote the normalization of motor control. This outcome highlights the need to develop CIT further as an intervention that improves functional capacity and more normative movement strategies.     

Successful Discharge of Children with Gastroenteritis Requiring Intravenous Rehydration

Background

Emergency Department (ED) revisits are very common in children with gastroenteritis administered intravenous rehydration.

Study Objectives

To determine if bicarbonate values are associated with ED revisits in children with gastroenteritis.

Methods

We conducted a secondary analysis of prospectively collected data, which included children >3 months of age with gastroenteritis treated with intravenous rehydration. Regression analysis was employed to determine whether, among discharged children, bicarbonate independently predicts revisits within 7 days (primary outcome) and successful discharge (secondary outcome). The latter composite outcome measure was defined as discharge at the index visit and the absence of a revisit requiring intravenous rehydration.

Results

Of 226 potentially eligible children, 174 were discharged and were included in the primary outcome analysis. Of the eligible children, 18% (30/174) had a revisit that was predicted by a higher baseline bicarbonate (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0–1.3; p = 0.03), absence of a primary care provider (OR 7.8; 95% CI 1.2–51.0; p = 0.03), and ondansetron administration (OR 2.4; 95% CI 1.0–5.5; p = 0.05). Bicarbonate was not associated with successful discharge. Negatively associated independent predictors of successful discharge were volume of intravenous fluids administered (OR 0.84/10 mL/kg increase; 95% CI 0.76–0.93; p < 0.001), and baseline clinical dehydration score (OR 0.75/unit increase; 95% CI 0.58–0.97; p < 0.001). Revisits requiring intravenous rehydration and hospitalization were associated with higher bicarbonate values (21.2 ± 4.6 mEq, p = 0.001, and 22.3 ± 5.0 mEq/L, p < 0.001, respectively).

Conclusion

Lower serum bicarbonate values at the time of intravenous rehydration are not associated with unfavorable outcomes after discharge.     

Relationship Between Quality of Life and Dysarthria in Patients With Multiple Sclerosis

Objective

To evaluate dysarthria and dysarthria-related quality of life (QOL) and analyze its relations with duration of disease, severity, and general QOL in patients with multiple sclerosis (MS).

Design

Cross-sectional observational study.

Setting

Rehabilitation center.

Participants

Consecutive patients with MS (N=163) were recruited (mean age, 52±10.4y; mean MS duration, 19±10.4y).

Interventions

Not applicable.

Main Outcome Measures

Presence of dysarthria; dysarthria characteristics; MS severity and duration; and dysarthria-related and generic QOL were evaluated by means of the therapy outcome measure scale; Robertson profile; Expanded Disability Status Scale (EDSS), years of disease; QOL of the dysarthric speaker questionnaire; and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), respectively.

Results

The mean EDSS score was 6.5±1.3. Dysarthria affected 57 (35%) of the 163 patients. Dysarthria severity was mild in most of the 57 patients with dysarthria. Median Robertson profile scores were slightly but significantly higher in the nondysarthric group compared with the dysarthric group (P=.001). The QOL for the dysarthric speaker questionnaire was significantly more compromised in patients with dysarthria (P=.001). No difference on the SF-36 scores between patients with and without dysarthria was found, with the exception of the physical activity and physical pain subscales. The QOL for the dysarthric speaker questionnaire showed no correlation with MS duration and a weak correlation with EDSS score (r=.25). Correlations between the SF-36 and QOL for the dysarthric speaker scores were few and weak, with the exception of the role limitations because of emotions (r=−.428) and mental health subscales (r=−.383).

Conclusions

Dysarthria-related QOL is compromised in patients with MS and dysarthria and might be used as a supplementary measure in clinical practice and research for patients who have MS.     

Scales to Assess Gross Motor Function in Stroke Patients: A Systematic Review

Objective

To assess the clinical and psychometric properties of stroke motor assessment scales.

Data Sources

The databases consulted for the literature research were MEDLINE, PEDro, ISI Web of Knowledge, and Cumulative Index to Nursing and Allied Health (CINAHL). The search was carried out between March 2011 and January 2014.

Study Selection

Studies that describe and validate a measurement scale designed to assess gross motor function in stroke. The articles were classified according to the levels of evidence and grades of recommendation for diagnosis studies of the Oxford Center for Evidence-Based Medicine.

Data Extraction

General characteristics of the studies, including number of patients, motor function assessment scales analyzed, and their psychometric properties, were collected.

Data Synthesis

After the literature search, 19 articles were included in this review; 32 articles were excluded for not meeting the inclusion criteria. Four of the 19 articles studied the Motor Assessment Scale, 5 the Fugl-Meyer Assessment, 3 investigated the Sodring Motor Evaluation for Stroke Patients, 4 the Stroke Rehabilitation Assessment of Movement, 2 were about the Motricity Index, and 2 about the Rivermead Motor Assessment. All of them were classified as level 2b according to the levels of evidence and grades of recommendation.

Conclusions

All the scales compiled in this review have been shown to be useful both in clinical practice and in terms of research. The most suitable scales to be used in the clinical field would be the short versions of the Fugl-Meyer Assessment and the Stroke Rehabilitation Assessment of Movement. A real consensus about the measurement of gross motor function in patients with stroke is not available in the recent literature.     

Walking Ability and Quality of Life in Subjects With Transfemoral Amputation: A Comparison of Osseointegration With Socket Prostheses

Objective

To investigate walking ability and quality of life of osseointegrated leg prostheses compared with socket prostheses.

Design

Prospective case-control study.

Setting

University medical center.

Participants

Subjects (N=22) with transfemoral amputation (1 bilateral) referred to our center because of socket-related skin and residual limb problems resulting in limited prosthesis use. Their mean age was 46.5 years (range, 23–67y) and mean time since amputation was 16.4 years (range, 2–45y). Causes of amputation were trauma (n=20) and tumor (n=2).

Intervention

Implantation of an osseointegration prosthesis (OIP).

Main Outcome Measures

Global score of the Questionnaire for Persons With a Transfemoral Amputation (Q-TFA), prosthesis use, 6-minute walk test (6MWT), Timed Up & Go (TUG) test, and oxygen consumption during treadmill walking.

Results

With the socket prosthesis, the mean ± SD Q-TFA global score, prosthesis use, 6MWT, TUG, and oxygen consumption were 39±4.7 points, 56±7.9h/wk, 321±28m, 15.1±2.1 seconds, and 1330±310mL/min, respectively, and significantly improved with OIP to 63±5.3 points, 101±2.4h/wk, 423±21m, 8.1±0.7 seconds, and 1093±361mL/min, respectively.

Conclusions

Osseointegration is a suitable intervention for persons whose prosthesis use is reduced because of socket-related problems. Subjects with OIP significantly increased their walking ability and prosthesis-related quality of life.     

Cognition in Patients With Burn Injury in the Inpatient Rehabilitation Population

Objective

To analyze potential cognitive impairment in patients with burn injury in the inpatient rehabilitation population.

Design

Rehabilitation patients with burn injury were compared with the following impairment groups: spinal cord injury, amputation, polytrauma and multiple fractures, and hip replacement. Differences between the groups were calculated for each cognitive subscale item and total cognitive FIM. Patients with burn injury were compared with the other groups using a bivariate linear regression model. A multivariable linear regression model was used to determine whether differences in cognition existed after adjusting for covariates (eg, sociodemographic factors, facility factors, medical complications) based on previous studies.

Setting

Inpatient rehabilitation facilities.

Participants

Data from Uniform Data System for Medical Rehabilitation from 2002 to 2011 for adults with burn injury (N=5347) were compared with other rehabilitation populations (N=668,816).

Interventions

Not applicable.

Main Outcome Measures

Comparison of total cognitive FIM scores and subscales (memory, verbal comprehension, verbal expression, social interaction, problem solving) for patients with burn injury versus other rehabilitation populations.

Results

Adults with burn injuries had an average total cognitive FIM score ± SD of 26.8±7.0 compared with an average FIM score ± SD of 28.7±6.0 for the other groups combined (P<.001). The subscale with the greatest difference between those with burn injury and the other groups was memory (5.1±1.7 compared with 5.6±1.5, P<.001). These differences persisted after adjustment for covariates.

Conclusions

Adults with burn injury have worse cognitive FIM scores than other rehabilitation populations. Future research is needed to determine the impact of this comorbidity on patient outcomes and potential interventions for these deficits.     

Intra- and Interrater Reliability of the Modified Tardieu Scale for the Assessment of Lower Limb Spasticity in Adults With Neurologic Injuries

Objective

To examine the intra- and interrater reliability of the Modified Tardieu Scale (MTS) for lower limb assessment of adults with chronic neurologic injuries.

Design

Single-center intra- and interrater reliability study.

Setting

Outpatient neurorehabilitation unit.

Participants

Adults (N=30; mean age ± SD, 54.1±12.5y) with various chronic neurologic injuries and lower limb spasticity.

Interventions

Two experienced physiotherapists performed slow (R2) and fast (R1) passive movements for lower limb muscles half an hour apart on the same day (interrater reliability), while a third physiotherapist took goniometric measurements only. One physiotherapist repeated the assessment 1 to 3 days earlier or later (intrarater reliability). Assessors qualitatively rated the resistance to fast passive movements.

Main Outcome Measures

Intraclass correlation coefficients (ICCs) and limits of agreement (LOA) were calculated for R1, R2, and R2–R1. Kappa coefficients were calculated for tibialis range of movement and qualitative spasticity ratings.

Results

Intra- and interrater R1 and R2 measurements showed moderate to high reliability for the affected hamstrings, rectus femoris, gastrocnemius, soleus (mean ICC ± SD, .79±.08), and tibialis anterior (mean κ ± SD, .58±.10). Only intrarater measurements of the affected tibialis posterior were moderately reliable (R1=.57, R2=.77). Seven of 16 spasticity angle measurements of the affected muscles were moderately reliable. LOA were mostly unacceptably wide. Qualitative spasticity ratings were moderately reliable for affected hamstrings, gastrocnemius, and tibialis muscles (mean κ ± SD, .52±.10).

Conclusions

The MTS is reliable for assessing spasticity in most lower limb muscles of adults with chronic neurologic injuries. Repeated MTS measurements of spasticity are best based on R1 measurements rather than spasticity angle or qualitative ratings of spasticity. Optimally, MTS measurements should be undertaken by the same clinician.     

Effect of Chemodenervation of the Rectus Femoris Muscle in Adults With a Stiff Knee Gait Due to Spastic Paresis: A Systematic Review With a Meta-Analysis in Patients With Stroke

Objective

To determine the effect of motor branch block (MBB) or neuromuscular block (NMB) of the rectus femoris on knee kinematics during swing, functional outcome, and energy cost in adults with spastic paresis presenting a stiff knee gait.

Data Sources

PubMed, Embase, CINAHL, and Cochrane Library were searched. Studies were collected up to February 26, 2013. Reference lists were additionally scrutinized.

Study Selection

No restrictions were applied regarding study design. Patients were adults suffering from a central neurological disorder. Interventions had to include MBB or NMB. Outcome measures had to include knee kinematics during the swing phase. Study selection was independently performed by 2 reviewers.

Data Extraction

Two reviewers independently assessed the methodological quality of included studies. Data on kinematics, functional outcome, and energy cost from patients with stroke were extracted from the total population and when possible pooled.

Data Synthesis

A total of 9 articles describing 12 different studies were included. Knee kinematics (peak knee flexion or knee range) during swing improved significantly in all the included studies. The average increase in peak knee flexion varied from 1.9° to 15.4°. Data pooling of peak knee flexion in patients with stroke showed a significant improvement of 7.37° (P=.000) in NMB studies and of 9.35° (P=.002) in MBB studies. Data pooling of knee velocity at toe-off showed a significant improvement of 53.01°/s in NMB studies. In MBB studies, this improvement was not significant. Data pooling of knee range of motion, functional outcomes, and energy cost showed no significant difference.

Conclusions

According to this review, chemodenervation of the rectus femoris shows a significant improvement in peak knee flexion during swing. The effect on functional outcomes and energy cost is still unclear.