Survivors of chronic stroke – participant evaluations of commercial gaming for rehabilitation

Purpose: There has been an increase in research on the effect that virtual reality (VR) can have on physical rehabilitation following stroke. However, research exploring participant perceptions of VR for post-stroke rehabilitation has been limited.

Method: Semi-structured interviews were conducted with 10 chronic stroke participants (10 males, mean age?=?72.1, mean time since injury?=?38.6 mos.) who had recently completed an upper extremity VR stroke rehabilitation programme.

Results: Four main themes emerged: ‘the VR experience,’ ‘functional outcomes,’ ‘instruction,’ and the ‘future of VR in stroke rehabilitation,’ along with nine sub-themes. Participants illustrated the positive impact that VR training had on their functional abilities as well as their confidence towards completing activities of daily living (ADL). Participants also expressed the need for increased rehabilitation opportunities within the community.

Conclusion: Overall, participants were optimistic about their experience with VR training and all reported that they had perceived functional gain. VR is an enjoyable rehabilitation tool that can increase a stroke survivor’s confidence towards completing ADL.

• Implications for Rehabilitation

• Although there is an increase in rehabilitation programmes geared towards those with chronic stroke, we must also consider the participants’ perception of those programmes.

• Incorporating participant feedback may increase enjoyment and adherence to the rehabilitation programmes.

• The VR experience, as well as provision of feedback and instruction, are important aspects to consider when developing a VR programme for stroke survivors.

• VR for rehabilitation may be a feasible tool for increasing the survivors’ confidence in completing ADL post-stroke.

     

Rehabilitation robotics for the upper extremity: review with new directions for orthopaedic disorders

The focus of research using technological innovations such as robotic devices has been on interventions to improve upper extremity function in neurologic populations, particularly patients with stroke. There is a growing body of evidence describing rehabilitation programs using various types of supportive/assistive and/or resistive robotic and virtual reality-enhanced devices to improve outcomes for patients with neurologic disorders. The most promising approaches are task-oriented, based on current concepts of motor control/learning and practice-induced neuroplasticity. Based on this evidence, we describe application and feasibility of virtual reality-enhanced robotics integrated with current concepts in orthopaedic rehabilitation shifting from an impairment-based focus to inclusion of more intense, task-specific training for patients with upper extremity disorders, specifically emphasizing the wrist and hand. The purpose of this paper is to describe virtual reality-enhanced rehabilitation robotic devices, review evidence of application in patients with upper extremity deficits related to neurologic disorders, and suggest how this technology and task-oriented rehabilitation approach can also benefit patients with orthopaedic disorders of the wrist and hand. We will also discuss areas for further research and development using a task-oriented approach and a commercially available haptic robotic device to focus on training of grasp and manipulation tasks.

• Implications for Rehabilitation

• There is a growing body of evidence describing rehabilitation programs using various types of supportive/assistive and/or resistive robotic and virtual reality-enhanced devices to improve outcomes for patients with neurologic disorders.

• The most promising approaches using rehabilitation robotics are task-oriented, based on current concepts of motor control/learning and practice-induced neuroplasticity.

• Based on the evidence in neurologic populations, virtual reality-enhanced robotics may be integrated with current concepts in orthopaedic rehabilitation shifting from an impairment-based focus to inclusion of more intense, task-specific training for patients with UE disorders, specifically emphasizing the wrist and hand.

• Clinical application of a task-oriented approach may be accomplished using commercially available haptic robotic device to focus on training of grasp and manipulation tasks.

     

Prosthesis use in adult acquired major upper-limb amputees: patterns of wear,prosthetic skills and the actual use of prostheses in activities of daily life

Purpose: To describe patterns of prosthesis wear and perceived prosthetic usefulness in adult acquired upper-limb amputees (ULAs). To describe prosthetic skills in activities of daily life (ADL) and the actual use of prostheses in the performance of ADL tasks. To estimate the influence of prosthetic skills on actual prosthesis use and the influence of background factors on prosthetic skills and actual prosthesis use. Method: Cross-sectional study analysing population-based questionnaire data (n?=?224) and data from interviews and clinical testing in a referred/convenience sample of prosthesis-wearing ULAs (n?=?50). Effects were analysed using linear regression. Results: 80.8% wore prostheses. 90.3% reported their most worn prosthesis as useful. Prosthetic usefulness profiles varied with prosthetic type. Despite demonstrating good prosthetic skills, the amputees reported actual prosthesis use in only about half of the ADL tasks performed in everyday life. In unilateral amputees, increased actual use was associated with sufficient prosthetic training and with the use of myoelectric vs cosmetic prostheses, regardless of amputation level. Prosthetic skills did not affect actual prosthesis use. No background factors showed significant effect on prosthetic skills. Conclusions: Most major ULAs wear prostheses. Individualised prosthetic training and fitting of myoelectric rather than passive prostheses may increase actual prosthesis use in ADL.

Implications for Rehabilitation

• Arm prostheses are important functional aids for adult acquired major upper-limb amputees (ULAs).

• Despite being mainly satisfied with their prostheses, reporting their prostheses as useful and showing good prosthetic skills, prosthesis-wearing major ULAs do not use their prostheses for more than about half of the activities of daily life (ADL) tasks carried out in everyday life.

• In unilateral ULAs, individualised and targeted prosthetic training may increase optimal, active prosthesis use in ADL.

• Fitting the amputee with myoelectric rather than passive prostheses may increase prosthesis use in ADL, regardless of amputation level.

     

Cognitive training on stroke patients via virtual reality-based serious games

Purpose: Use of virtual reality environments in cognitive rehabilitation offers cost benefits and other advantages. In order to test the effectiveness of a virtual reality application for neuropsychological rehabilitation, a cognitive training program using virtual reality was applied to stroke patients. Methods: A virtual reality-based serious games application for cognitive training was developed, with attention and memory tasks consisting of daily life activities. Twenty stroke patients were randomly assigned to two conditions: exposure to the intervention, and waiting list control. Results: The results showed significant improvements in attention and memory functions in the intervention group, but not in the controls. Conclusions: Overall findings provide further support for the use of VR cognitive training applications in neuropsychological rehabilitation.

• Implications for Rehabilitation

• Improvements in memory and attention functions following a virtual reality-based serious games intervention.

• Training of daily-life activities using a virtual reality application.

• Accessibility to training contents.

     

Understanding nursing practice in stroke units: a Q-methodological study

Abstract

Purpose: Nurses represent the largest professional group working with stroke-survivors, but there is limited evidence regarding nurses’ involvement in post-stroke rehabilitation. The purpose of this study was to identify and explore the perspectives of nurses and other multidisciplinary stroke team members on nurses’ practice in stroke rehabilitation. Method: Q-methodological study with 63 multidisciplinary stroke unit team members and semi-structured interviews with 27 stroke unit team members. Results: Irrespective of their professional backgrounds, participants shared the view that nurses can make an active contribution to stroke rehabilitation and integrate rehabilitation principles in routine practice. Training in stroke rehabilitation skills was viewed as fundamental to effective stroke care, but nurses do not routinely receive such training. The view that integrating rehabilitation techniques can only occur when nursing staffing levels were high was rejected. There was also little support for the view that nurses are uniquely placed to co-ordinate care, or that nurses have an independent rehabilitation role. Conclusions: The contribution that nurses with stroke rehabilitation skills can make to effective stroke care was understood. However, realising the potential of nurses as full partners in stroke rehabilitation is unlikely to occur without introduction of structured competency-based multidisciplinary training in rehabilitation skills.

• Implications for Rehabilitation

• Multidisciplinary rehabilitation in stroke units is a cornerstone of effective stroke care.

• Views of stroke unit team members on nurses’ involvement in rehabilitation have not been reported previously.

• Nurses can routinely incorporate rehabilitation principles in their care.

• Specialist competency-based stroke rehabilitation training needs to be provided for nurses as well as for allied health professionals.

     

Improving manual skills in persons with disabilities (PWD) through a multimodal assistance system

Abstract

In this research work, we present a Multimodal Guidance System (MGS) whose aim is to provide dynamic assistance to persons with disabilities (PWD) while performing manual activities such as drawing, coloring in and foam-cutting tasks. The MGS provides robotic assistance in the execution of 2D tasks through haptic and sound interactions. Haptic technology provides the virtual path of 2D shapes through the point-based approach, while sound technology provides audio feedback inputs related to the hand’s velocity while sketching and filling or cutting operations. By combining this Multimodal System with the haptic assistance, we have created a new approach with possible applications to such diverse fields as physical rehabilitation, scientific investigation of sensorimotor learning and assessment of hand movements in PWD. The MGS has been tested by people with specific disorders affecting coordination, such as Down syndrome and developmental disabilities, under the supervision of their teachers and care assistants inside their learning environment. A Graphic User Interface has been designed for teachers and care assistants in order to provide training during the test sessions. Our results provide conclusive evidence that the effect of using the MGS increases the accuracy in the tasks operations.

• Implications for Rehabilitation

• The Multimodal Guidance System (MGS) is an interface that offers haptic and sound feedback while performing manual tasks.

• Several studies demonstrated that the haptic guidance systems can help people in recovering cognitive function at different levels of complexity and impairment.

• The applications supported by our device could also have an important role in supporting physical therapist and cognitive psychologist in helping patients to recover motor and visuo-spatial abilities.

     

Three-dimensional,virtual reality vestibular rehabilitation for chronic imbalance problem caused by Ménière’s disease: a pilot study*

Purposes: The purpose of this study was to evaluate a three-dimensional, virtual reality system for vestibular rehabilitation in patients with intractable Ménière’s disease and chronic vestibular dysfunction.

Methods: We included 70 patients (36 for study, 34 as control) with a chronic imbalance problem caused by uncompensated Ménière’s disease. The virtual reality vestibular rehabilitation comprised four training tasks (modified Cawthorne–Cooksey exercises: eye, head, extension, and coordination exercises) performed in six training sessions (in 4 weeks). Measurements of the task scores and balance parameters obtained at the baseline and after final training sessions were compared.

Results: A significant improvement was observed in extension and coordination scores. Patients in the early stages of Ménière’s disease had a significantly greater improvement in the center of gravity sway and trajectory excursion in the mediolateral direction than did patients in the late stages of Ménière’s disease. Mild functional disability attributable to Ménière’s disease was a predictor of improvement in the statokinesigram and maximum trajectory excursion in the anteroposterior direction after rehabilitation. The control group showed no significant improvement in almost all parameters.

Conclusion: Virtual reality vestibular rehabilitation may be useful in patients with Ménière’s disease, particular those in the early stages or having mild functional disability.

• Implication for rehabilitation

• Chronic imbalance caused by uncompensated Ménière’s disease is an indication for vestibular rehabilitation.

• The interactive virtual reality video game, when integrated into vestibular rehabilitation exercise protocol, may assist patients who have mild disability Ménière’s disease and who cannot benefit from treatment with drugs or surgery.

• The initial data from this study support the applicability of three-dimensional virtual reality technology in vestibular rehabilitation programs. The technology gives professionals a new tool to guide patients for vestibular rehabilitation exercises through three-dimensional virtual reality video game playing.

• The virtual reality vestibular exercise game can provide patients a step-wise, interactive, dynamic, three-dimensional, and interesting rehabilitation environment.

     

Reaction time for processing visual stimulus in a computer-assisted rehabilitation environment

Purpose: To examine the reaction time when human subjects process information presented in the visual channel under both a direct vision and a virtual rehabilitation environment when walking was performed.

Method: Visual stimulus included eight math problems displayed on the peripheral vision to seven healthy human subjects in a virtual rehabilitation training (computer-assisted rehabilitation environment (CAREN)) and a direct vision environment. Subjects were required to verbally report the results of these math calculations in a short period of time. Reaction time measured by Tobii Eye tracker and calculation accuracy were recorded and compared between the direct vision and virtual rehabilitation environment.

Results: Performance outcomes measured for both groups included reaction time, reading time, answering time and the verbal answer score. A significant difference between the groups was only found for the reaction time (p?=?.004). Participants had more difficulty recognizing the first equation of the virtual environment.

Conclusions: Participants reaction time was faster in the direct vision environment. This reaction time delay should be kept in mind when designing skill training scenarios in virtual environments. This was a pilot project to a series of studies assessing cognition ability of stroke patients who are undertaking a rehabilitation program with a virtual training environment.

• Implications for rehabilitation

• Eye tracking is a reliable tool that can be employed in rehabilitation virtual environments.

• Reaction time changes between direct vision and virtual environment.

     

Training wheelchair navigation in immersive virtual environments for patients with spinal cord injury – end-user input to design an effective system

Purpose: A user-centred design was used to develop and test the feasibility of an immersive 3D virtual reality wheelchair training tool for people with spinal cord injury (SCI).

Method: A Wheelchair Training System was designed and modelled using the Oculus Rift headset and a Dynamic Control wheelchair joystick. The system was tested by clinicians and expert wheelchair users with SCI. Data from focus groups and individual interviews were analysed using a general inductive approach to thematic analysis.

Results: Four themes emerged: Realistic System, which described the advantages of a realistic virtual environment; a Wheelchair Training System, which described participants’ thoughts on the wheelchair training applications; Overcoming Resistance to Technology, the obstacles to introducing technology within the clinical setting; and Working outside the Rehabilitation Bubble which described the protective hospital environment.

Conclusions: The Oculus Rift Wheelchair Training System has the potential to provide a virtual rehabilitation setting which could allow wheelchair users to learn valuable community wheelchair use in a safe environment. Nausea appears to be a side effect of the system, which will need to be resolved before this can be a viable clinical tool.

• Implications for Rehabilitation

• Immersive virtual reality shows promising benefit for wheelchair training in a rehabilitation setting.

• Early engagement with consumers can improve product development.

     

A review of technological and clinical aspects of robot-aided rehabilitation of upper-extremity after stroke

Cerebrovascular accident (CVA) or stroke is one of the leading causes of disability and loss of motor function. Millions of people around the world are effected by it each year. Stroke results in disabled arm function. Restoration of arm function is essential to regaining activities of daily living (ADL). Along with traditional rehabilitation methods, robot-aided therapy has emerged in recent years. Robot-aided rehabilitation is more intensive, of longer duration and more repetitive. Using robots, repetitive dull exercises can turn into a more challenging and motivating tasks such as games. Besides, robots can provide a quantitative measure of the rehabilitation progress. This article overviews the terms used in robot-aided upper-limb rehabilitation. It continues by investigating the requirements for rehabilitation robots. Then the most outstanding works in robot-aided upper-limb rehabilitation and their control schemes have been investigated. The clinical outcomes of the built robots are also given that demonstrates the usability of these robots in real-life applications and their acceptance. This article summarizes a review done along with a research on the design, simulation and control of a robot for use in upper-limb rehabilitation after stroke.

• Implications for Rehabilitation

• Reviewing common terms in rehabilitation of upper limb using robots

• Reviewing rehabilitation robots built up to date

• Reviewing clinical outcomes of the mentioned rehabilitation robots

     

Motor skill changes and neurophysiologic adaptation to recovery-oriented virtual rehabilitation of hand function in a person with subacute stroke: a case study

Purpose: The complexity of upper extremity (UE) behavior requires recovery of near normal neuromuscular function to minimize residual disability following a stroke. This requirement places a premium on spontaneous recovery and neuroplastic adaptation to rehabilitation by the lesioned hemisphere. Motor skill learning is frequently cited as a requirement for neuroplasticity. Studies examining the links between training, motor learning, neuroplasticity, and improvements in hand motor function are indicated.

Methods: This case study describes a patient with slow recovering hand and finger movement (Total Upper Extremity Fugl–Meyer examination score?=?25/66, Wrist and Hand items?=?2/24 on poststroke day 37) following a stroke. The patient received an intensive eight-session intervention utilizing simulated activities that focused on the recovery of finger extension, finger individuation, and pinch-grasp force modulation.

Results: Over the eight sessions, the patient demonstrated improvements on untrained transfer tasks, which suggest that motor learning had occurred, as well a dramatic increase in hand function and corresponding expansion of the cortical motor map area representing several key muscles of the paretic hand. Recovery of hand function and motor map expansion continued after discharge through the three-month retention testing.

Conclusion: This case study describes a neuroplasticity based intervention for UE hemiparesis and a model for examining the relationship between training, motor skill acquisition, neuroplasticity, and motor function changes.

• Implications for rehabilitation

• Intensive hand and finger rehabilitation activities can be added to an in-patient rehabilitation program for persons with subacute stroke.

• Targeted training of the thumb may have an impact on activity level function in persons with upper extremity hemiparesis.

• Untrained transfer tasks can be utilized to confirm that training tasks have elicited motor learning.

• Changes in cortical motor maps can be used to document changes in brain function which can be used to evaluate changes in motor behavior persons with subacute stroke.

     

Exercise gaming – a motivational approach for older adults with vestibular dysfunction

Purpose The purpose of the study was to identify possible reasons for a modest level of exercise compliance during computer-assisted training for vestibular rehabilitation. Method Qualitative design and analysis of 14 semi-structured interviews with seven participants before and after a period with computer-assisted home training. The interviews evolved around themes, such as the elderly participants' self-efficacy, motivation and acceptance of the technology. Results Age was not an excuse for the modest exercise compliance. The participants were basically self-efficient and accepted the technology, but their knowledge and understanding of the training programme were insufficient. The participants asked for a greater variation in the exercises and asked for closer contact with the physiotherapist. When Mitii is used for vestibular rehabilitation, the system has some limitations. Conclusions The modest level of exercise compliance can be explained by (1) missing variety of exercise speed and duration and lack of introducing new exercises, (2) insufficient interaction with the physiotherapist regarding the participants’ performance and lack of social contact with other patients and (3) desire for a deeper understanding of the training programme with supplying information on the parts of the vestibular system addressed by the training.

• Implications for Rehabilitation

• Computer-assisted technologies should generate feedback on the quality of user performance and inform the patient of the relevance of the exercise.

• The technology should support social contact among patients with the same diagnosis and establish contact with the physiotherapist at the hospital advice and feedback.

• Varity and adjustments to exercises are necessary to maintain motivation and exercise compliance.

     

Sexuality after stroke: an exploration of current professional approaches,barriers to providing support and future directions

Purpose Sexual difficulties post-stroke are common, yet frequently neglected within rehabilitation. This study aimed to explore the process by which healthcare professionals approach and work with the topic of sexuality within stroke rehabilitation. Method Ten participants were recruited from 5 community and inpatient multi-disciplinary stroke rehabilitation teams. Semi-structured interviews were carried out and data were analysed using grounded theory methodology. Results The authors developed a theoretical model of how professionals engage with sexual concerns. Professionals’ own personal level of comfort with the topic of sexuality interacted with a series of barriers to limit opportunities for engagement. These barriers included factors relating to the context and workplace environment of stroke rehabilitation, professionals’ perceptions that they did not have adequate skills in this area and unhelpful attitudes towards stroke survivors and sexuality. Although the majority of participants rarely engaged with sexual issues, they adopted both direct and indirect strategies for engaging with their service users’ sexual concerns. Concerns were usually addressed through the provision of information and supportive conversations. Conclusions The findings suggest that sexuality is not a legitimised topic within stroke rehabilitation, and current work practises limit professionals’ abilities to address service-users’ concerns. Implications for developing effective training and staff support are discussed.

• Implications for rehabilitation

• Professionals working within stroke rehabilitation rarely directly bring up sexuality with patients, but an indirect method of approaching the topic is more common.

• Addressing sexual concerns often does not require expertise.

• Training should show professionals how to use transferable knowledge to address sexual issues and also enhance communication skills.

• Sexuality should be incorporated within local stroke policy and procedures, to support professionals in addressing the concerns of their patients and motivate them to act.

     

Reablement in a community setting

Abstract

Purpose: When older adults experience a decrease in functional independence including decreased ability to perform activities of daily living (ADL) tasks, rehabilitation services are required. The aim of this pilot study was to evaluate if a home-based reablement program influenced the ADL ability of older adults. Methods: Ninety-one older adults (80?±?9 years) were allocated to a 12-weeks home-based reablement program consisting of ADL task performance training by a home carer supervised by an occupational therapist. ADL ability was measured at baseline, at 12 weeks and at follow-up (range: 310–592?d) using the ADL-Interview (ADL-I). Results: Overall, ADL ability improved significantly over time (p?=?0.041). Post-hoc t-tests indicated that the improvements occurred between baseline and end of intervention (p?=?0.042) and were maintained at follow-up 10 months after intervention (p?=?0.674). There were no effects related to age (p?=?0.787) or to whether the older adult had received help previously (p?=?0.120). Conclusion: A 12-weeks home-based reablement program was found to improve ADL ability among older adults regardless of whether they previously received help. This implies that receiving home care services should not be considered a barrier to participation in a reablement program.

• Implications for Rehabilitation

• Older adults, motivated for obtaining independence within performance of ADL tasks, will potentially benefit from participation in the reablement program.

• Older adults, already receiving home care services, will also have the potential to benefit from participation in the reablement program.

     

2nd International Symposium on Gait and Balance in Multiple Sclerosis: interventions for gait and balance in MS

Abstract

Purpose: To provide a review of the 2nd International Symposium on Gait and Balance in Multiple Sclerosis (MS), emphasizing interventions in gait and balance for people with MS. Method: Review of current research on interventions used with people having MS and with people having other disorders that may provide novel insights into improving gait and balance and preventing falls in people with MS (pwMS). Results: Nine speakers provided evidence-based recommendations for interventions aimed at improving gait and balance dysfunction. Speaker recommendations covered the following areas: balance rehabilitation, self-management, medications, functional electrical stimulation, robotics, sensory augmentation, gait training with error feedback and fall prevention. Conclusions: The causes of gait and balance dysfunction in pwMS are multifactorial and therefore may benefit from a wide range of interventions. The symposium provides avenues for exchange of evidence and clinical experience that is critical in furthering physical rehabilitation including gait and balance dysfunction in MS.

• Implications for Rehabilitation

• Approaches to improve Gait and Balance dysfunction in Multiple Sclerosis.

• Balance exercises that include training of sensory strategies.

• Self-management and self-management support.

• Pharmacologic intervention, such as Dalfampradine.

• Functional electrical stimulation that may provide the extra stimulation to influence coordinated leg movements needed for walking.

     

Ultrasound in dysphagia rehabilitation: a novel approach following partial glossectomy

Purpose: While the presence of dysphagia following partial glossectomy has been widely reported, there is insufficient quality evidence to guide clinical decision making about the treatment of this disorder. This study investigated a novel dysphagia rehabilitation approach using ultrasound tongue imaging for patient training.

Method: Initially, a pilot study was conducted to investigate the feasibility of ultrasound visual feedback during swallow tasks. The protocol was then replicated using a single-case experimental designed study to investigate therapeutic effect. Swallow, speech, and oromotor functions were measured across multiple baselines using an A-B-A intervention study design.

Results: During intervention, both participants were able to interpret ultrasound tongue images during swallow tasks. Following intervention, positive therapeutic effect was achieved with reduced frequency of aspiration and self-initiated swallow strategies. Generalization of intervention was evidenced by reduced bolus transit duration on videofluoroscopy and improved functional oral intake scores. Speech and oromotor functions remained stable throughout the study demonstrating experimental control.

Conclusions: This study establishes that ultrasound visual feedback is feasible in dysphagia rehabilitation following partial glossectomy. In addition, the predicted therapeutic effect specifically to swallow but not speech or oromotor functions were demonstrated.

• Implications for Rehabilitation

• Partial glossectomy results in altered tongue shape, movement, and function which negatively impact on speech and swallowing

• There is limited research evidence to support previously used speech pathology interventions (in particular, tongue range of movement exercises) to rehabilitate dysphagia following tongue cancer surgery

• The tongue, and hence oral phase of swallowing, can be viewed by placing an ultrasound probe under the chin

• Ultrasound scanning of the tongue is not invasive, can be repeated without dosage side effect. It’s also comfortable for the patient and if a portable probe and monitor are used, can be performed within a variety of clinical settings for assessment or therapy

• This study shows specific therapeutic benefit following ultrasound visual feedback along with a motor learning approach to rehabilitate swallow function following partial glossectomy

• Visual and verbal feedback that focus specifically on the motor movements undergoing adaptation (e.g., tongue wave movement, tongue elevation, bolus clearance) following partial glossectomy are recommended

• Patients who are able to see the ultrasound monitor, hear the feedback given, are cognitively able to self-evaluate tongue movement, and remember intervention goals will most benefit from ultrasound tongue visual feedback in therapy

• Clinicians also benefit from visualizing the tongue with ultrasound during assessment and therapy as a direct view reduces the subjectivity of rating task performance

     

Real-time feedback of dynamic foot pressure index for gait training of toe-walking children with spastic diplegia

Purpose: The aim of this study was to determine whether and how real-time feedback of dynamic foot pressure index (DFPI) could be used to correct toe-walking gait in spastic diplegic children with dynamic equinus.

Methods: Thirteen spastic diplegic children with dynamic equinus were asked to wear a monitoring device to record their ambulation during daily gait, conventional training gait, and feedback training gait. Parameters based on their DFPI and stride duration were compared among the three test conditions.

Results: The results with feedback training were significantly better for all DFPI parameters in comparison to patients’ daily gait and showed significant improvements in DFPI for toe-walking gait and percentage of normal gait in comparison to conventional training methods. Moreover, stride duration under two training gaits was longer than patient’s daily gait, but there was no significant difference between the two training gaits.

Conclusions: Although the stride duration for the two training gaits was similar, gait training with real-time feedback of DFPI did produce noticeably superior results by increasing heel-loading impulse of toe-walking gait and percentage of normal gait in comparison to convention training methods. However, its effectiveness was still impacted by the motion limitations of diplegic children.

• Implications for Rehabilitation

• The DFPI-based gait training feedback system introduced in this study was shown to be more effective at toe-walking gait rehabilitation training over conventional training methods.

• The feedback system accomplished superior improvement in correcting toe-walking gait, but its effectiveness in an increasing heel-loading impulse in normal gait was still limited by the motion limitations of diplegic children.

• Stride duration of normal gait and toe-walking gait was similar under conventional and feedback gait training.

     

The progression of disability among older adults in Mexico

Purpose: This paper seeks to document the progression of disability in a developing country and to examine gender differences in this process.

Methods: The data come from the Mexican Health and Aging Study (MHAS), a nationally representative sample of older adults. An ordinal logistic regression (n?=?3283) is used to measure the progression of disability that considers: (1) no disability, (2) mobility problems, (3) mobility problems with IADLs limitations, (4) mobility problems with ADLs limitations, (5) combinations of the latter three and (6) death.

Results: Approximately 43% of the sample remained in the same level of disability after 2 years. The patterns of progression with two disabilities differ for men and women.

Conclusions: Our model reflects the importance of separating ADLs and IADLs in the study of disability progression in Mexico. Varying risk profiles and cultural differences might influence the divergent disability paths followed by each gender.

• Implications for Rehabilitation

• The disablement process involving transitions from mobility impairments to IADL and ADL limitations seen in developed countries differs for older adults in Mexico.

• Cultural differences may influence the progression from non-disabled to becoming disabled in different ways for females in developing countries like Mexico.

• One-fifth of individuals showed greater function and independence over time, suggesting that the disablement process is reversible. This finding highlights the need to focus on improving mobility, ADL, and IADL skills to facilitate successful aging.

• Although disability is often conceptualised as a combination of ADL and IADL limitations, gender differences seen in Mexico indicate the need to separate ADL and IADL when developing approaches to prevent or ameliorate disability.

     

Learning to use a rear-mounted power assist for manual wheelchairs

Abstract

Objectives: 1) To investigate how much training manual wheelchair users perceive is required to learn to use a rear-mounted power assist safely and confidently. 2) To evaluate how the power assist affected wheelchair users’ ability to negotiate a standardized obstacle course, wheelchair skills capacity and wheelchair mobility confidence.

Method: This study used a pre- versus post-test intervention design. Outcome measures included a standardized obstacle course, and modified versions of the Wheelchair Skills Test 4.2 (WST) and the Wheelchair Confidence Measure.

Results: The 11 participants felt safe and confident using the power assist within one to two training sessions. However, some potential safety concerns were noted. Participants performed two obstacle course tasks significantly more quickly with the power assist.

Conclusions: Participants felt safe using the device with limited training and the device facilitated some mobility task performance. Further research is needed to understand the outcomes of long-term, community use.

• Implications for Rehabilitation

• Most experienced wheelchair users wanted only one or two training sessions with a new rear mounted power assist device; however, some safety concerns were noted.

• The device did not appear to affect user’s confidence.

• The device enabled users to perform some mobility tasks more quickly and allowed some users to perform some mobility tasks they were unable to perform in their regular MWC.

     

Activities of daily living in people with lower limb amputation: outcomes of an intervention to reduce dependence in pre-prosthetic phase

Purpose: The main objective was to assess the change in the functional independence in basic activities of daily living (ADL) following a pre-prosthetic intervention in people with lower-limb amputation (LLA). Secondary objectives were to identify the factors contributing to the success of this intervention, and to analyze the effects on the presence of unmet needs for home adaptation.

Method: The ADL intervention was early and pre-prosthetic; it was focused on six self-care activities. Fifty-two adults with LLA, who required assistance in self-care, were included. Functional independence (Barthel) was assessed at baseline and after intervention (T2). Successful intervention was defined as independent performance of all self-care activities.

Results: There was a significant improvement in Barthel scores between baseline and T2 in toileting (p?p?p?p?p?=?0.025). The proportion of homes with an unmet need for adaptation decreased significantly in bathroom (p?=?0.008) and other internal areas (p?=?0.031). Intervention was successful for 61.5% of participants. In a multivariate model, age was significantly associated with successful intervention (OR 0.66, 95%CI 0.52–0.83).

Conclusions: A short and pre-prosthetic ADL intervention improves functional independence and reduces the need for home adaptation. ADL programs should be included in rehabilitation strategies.

• Implications for Rehabilitation

• Because basic activities of daily living (ADL) can be seriously compromised after a lower-limb amputation, it is important for this population to improve or maintain their level of independence.

• A short and pre-prosthetic ADL intervention is an effective method for an early recovery of functional independence in self-care activities and promotes home adaptation.

• Age is an important determinant of functional recovery, and most subjects can achieve independence in basic ADL regardless of the level of amputation.

• A pre-prosthetic ADL program should be included in rehabilitation strategies for adults with lower-limb amputation.