Face-to-face versus online training for the interpretation of findings in the fiberoptic endoscopic exam of the swallow procedure.

OBJECTIVE: The aim of this study was to evaluate the comparative effectiveness of an online, interdisciplinary, interactive course designed to increase the ability to accurately interpret the fiberoptic endoscopic exam of the swallow (FEES) procedure to traditional, face-to-face (F2F) lectures for both graduate medical education (GME) and graduate speech language pathology (GSLP) programs. DESIGN: This was a prospective, quantitative, nonrandomized study. Participants were medical residents in physical medicine and rehabilitation from two affiliated programs and graduate students in speech language pathology from two instructional cohorts at a single institution. Group 1, traditional group (n=51), participated in F2F lectures using an audience response system, whereas Group 2, online group (n=57), participated in an online, interactive course. The main outcome measure was pre- and post-course FEES knowledge test scores. RESULTS: For Group 1, the mean pre-course score was 26.94 (SD=3.24) and the post-course score was 34.96 (SD=2.51). Differences between pre- and post-course scores for Group 1 were significant (t=-16.38, P≤0.0001). For Group 2, the mean pre-course score was 27.05 (SD=2.74) and the post-course score was 34.05 (SD=2.84). Differences between pre- and post-course scores for Group 2 were significant (t=-13.5, P≤0.0001). The mean knowledge change score for Group 1 and Group 2 was 8.01 (SD=3.50) and 7.04 (SD=3.91), respectively (nonsignificant, t=1.372, P=0.173), suggesting groups made similar gains. CONCLUSION: Incorporating technology into GME and GSLP programs yielded comparable gains to traditional lectures. Findings support the use of online education as a viable alternative to the traditional F2F classroom format for the instruction of the cognitive component of the FEES procedure.

The effect of a single textured insole in gait rehabilitation of individuals with stroke.

Rehabilitation interventions designed to restore gait symmetry in individuals with stroke are not always effective. The goal was to evaluate the long-term effect of using a single textured insole in gait rehabilitation. Ten individuals with stroke who showed asymmetrical stance were randomly divided into two groups and participated in physical therapy. Individuals in the experimental group received a 6-week physical therapy while being provided with a textured insole in the shoe on the unaffected side. Individuals in the control group received a 6-week physical therapy only. Both groups underwent a battery of identical tests before the start of the rehabilitation intervention, following its completion, and 4 months after the end of therapy. After the intervention, weight bearing (WB) on the affected side and gait velocity increased in the experimental group (P<0.05) to a larger degree compared with the control group. Moreover, symmetry of gait was increased in the experimental group (P<0.05). Improvements in WB, gait velocity, and symmetry of gait were maintained in the experimental group after the end of 4-month retention period. The study outcome revealed that a 6-week intervention involving a single textured insole could result in a long-lasting improvement of gait velocity, symmetry of WB, and gait in individuals with stroke.

A textured insole improves gait symmetry in individuals with stroke.

PURPOSE: Gait asymmetry is a common consequence of stroke and improving gait symmetry is an important goal of rehabilitation. We investigated the effect of a single textured insole in improving gait symmetry in individuals with stroke. METHOD: Seventeen individuals with stroke who had asymmetrical gait were recruited and required to walk with a textured insole positioned in the shoe on the unaffected side or without the insole. Gait parameters were evaluated using the instrumented walkway. Gait velocity, cadence, and symmetry indices for the spatial and temporal parameters of gait and center of pressure displacements were obtained. RESULTS: When walking with a textured insole, symmetry indexes for stance, single support phases of gait, as well as center of pressure displacements improved significantly. While using a textured insole, the duration of the stance phase and a single support phase decreased on the unaffected side and increased on the affected side significantly. Gait velocity and cadence were not affected by the use of the insole. CONCLUSIONS: Individuals with stroke walking with a textured insole placed in the shoe on the unaffected side improved the symmetry of their gait. The outcome provides a foundation for future investigations of the efficacy of using a single textured insole in gait rehabilitation of individuals with unilateral impairment. Implications for Rehabilitation A single textured insole positioned in the shoe on the unaffected side improved gait symmetry in individuals with stroke. Gait velocity and cadence were not affected by the use of the insole.

Long-Term Follow-up to a Randomized Controlled Trial Comparing Peroneal Nerve Functional Electrical Stimulation to an Ankle Foot Orthosis for Patients With Chronic Stroke.

BACKGROUND: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle foot orthoses (AFO) for treatment of foot drop poststroke, but few long-term, randomized controlled comparisons exist. OBJECTIVE: Compare changes in gait quality and function between FES and AFOs in individuals with foot drop poststroke over a 12-month period. METHODS: Follow-up analysis of an unblinded randomized controlled trial (ClinicalTrials.gov #NCT01087957) conducted at 30 rehabilitation centers comparing FES to AFOs over 6 months. Subjects continued to wear their randomized device for another 6 months to final 12-month assessments. Subjects used study devices for all home and community ambulation. Multiply imputed intention-to-treat analyses were utilized; primary endpoints were tested for noninferiority and secondary endpoints for superiority. Primary endpoints: 10 Meter Walk Test (10MWT) and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test (6MWT), GaitRite Functional Ambulation Profile, and Modified Emory Functional Ambulation Profile (mEFAP). RESULTS: A total of 495 subjects were randomized, and 384 completed the 12-month follow-up. FES proved noninferior to AFOs for all primary endpoints. Both FES and AFO groups showed statistically and clinically significant improvement for 10MWT compared with initial measurement. No statistically significant between-group differences were found for primary or secondary endpoints. The FES group demonstrated statistically significant improvements for 6MWT and mEFAP Stair-time subscore. CONCLUSIONS: At 12 months, both FES and AFOs continue to demonstrate equivalent gains in gait speed. Results suggest that long-term FES use may lead to additional improvements in walking endurance and functional ambulation; further research is needed to confirm these findings.

The effects of two different ankle-foot orthoses on gait of patients with acute hemiparetic cerebrovascular accident.

Objective. To compare the effects of two types of ankle-foot orthoses on gait of patients with cerebrovascular accident (CVA) and to evaluate their preference in using each AFO type. Design. Thirty individuals with acute hemiparetic CVA were tested without an AFO, with an off-the-shelf carbon AFO (C-AFO), and with a custom plastic AFO (P-AFO) in random order at the time of initial orthotic fitting. Gait velocity, cadence, stride length, and step length were collected using an electronic walkway and the subjects were surveyed about their perceptions of each device. Results. Subjects walked significantly faster, with a higher cadence, longer stride, and step lengths, when using either the P-AFO or the C-AFO as compared to no AFO (P < 0.05). No significant difference was observed between gait parameters of the two AFOs. However, the subjects demonstrated a statistically significant preference of using P-AFO in relation to their balance, confidence, and sense of safety during ambulation (P < 0.05). Moreover, if they had a choice, 50.87 ± 14.7% of the participants preferred the P-AFO and 23.56 ± 9.70% preferred the C-AFO. Conclusions. AFO use significantly improved gait in patients with acute CVA. The majority of users preferred the P-AFO over the Cf-AFO especially when asked about balance and sense of safety.

The effects of peroneal nerve functional electrical stimulation versus ankle-foot orthosis in patients with chronic stroke: a randomized controlled trial.

BACKGROUND: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist. OBJECTIVE: To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke. METHODS: In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority. RESULTS: A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found. CONCLUSIONS: Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance.

Pregait balance rehabilitation in acute stroke patients.

Rehabilitation interventions designed to enhance balance control in individuals with acute stroke are quite limited. The goal was to develop and assess a technique of early pregait balance training involving the use of a combination of force platform visual feedback and the unweighting system in individuals with recent stroke. A total of 28 individuals with acute stroke were randomly divided into the experimental and control groups: individuals included in the experimental group received 1 week of treatment on the basis of retraining balance utilizing visual biofeedback (Balance Master) while provided with a body weight support harness system, whereas the individuals in the control group received conventional treatment. Both the groups undertook identical tests (Fugl-Meyer Balance test, Functional Independence Measure test for gait, and Fugl-Meyer lower extremity assessment) before the start of treatment and after its completion. Individuals in the experimental group showed larger gains as seen in the increased scores of the Fugl-Meyer Balance test and the Functional Independence Measure test for gait as compared with the control group. The outcome of the study provides a basis for future investigations of the applicability of the intervention in early balance rehabilitation of individuals with neurological disorders.

Compelled body weight shift approach in rehabilitation of individuals with chronic stroke.

PURPOSE: This study was designed to evaluate the effectiveness of the compelled body weight shift (CBWS) therapy approach in the rehabilitation of individuals with chronic stroke. CBWS involves a forced shift of body weight toward a person's affected side by means of a shoe insert that establishes a lift of the nonaffected lower extremity. METHOD: Eighteen individuals with chronic, unilateral stroke (mean age 57.7 ± 11.9 years, with a range of 35-75 years; mean time since stroke 6.7 ± 3.9 years, with a range of 1.1-14.1 years) who showed asymmetrical stance were randomly divided into 2 groups: the experimental group received 6 weeks of physical therapy combined with CBWS therapy, and the control group received only physical therapy. Both groups underwent a battery of identical tests (Fugl-Meyer Assessment, Berg Balance Scale, weight bearing, and gait velocity) before the start of the rehabilitation intervention, following its completion, and 3 months after the end of therapy. RESULTS: After the intervention, weight bearing on the affected side (measured with the Balance Master) increased in the experimental group to a larger degree compared to the control group (9.7% vs 6.4%). Similarly, gait velocity increased 10.5% in the experimental group compared to the control group. Improvements in weight bearing and gait velocity were maintained in the experimental group after the 3-month retention period. CONCLUSION: The study outcome revealed that a 6-week intervention involving CBWS therapy could result in a long-lasting improvement of the symmetry of weight bearing and velocity of gait in individuals with chronic stroke.

Auxiliary sensory cues improve automatic postural responses in individuals with diabetic neuropathy.

BACKGROUND: A loss of sensation in the lower limbs, observed in individuals with diabetes as well as elderly individuals, contributes to postural instability, altered gait patterns, increased risk of falling, and decreased quality of life. OBJECTIVE: To determine if somatosensory cues delivered to sensate areas of the lower limbs above the ankle joints enhance the control of posture in individuals with peripheral neuropathy. METHODS: Twelve subjects with sensory neuropathy due to diabetes participated in static and dynamic balance tests with and without auxiliary sensory cues provided to the lower limbs without stabilizing the ankle joints. During the tests the subjects were required to stand on a fixed or moving computer-controlled platform with their eyes open or closed. Equilibrium scores and response latency were obtained. RESULTS: For all tests, equilibrium scores were significantly larger in experiments with auxiliary sensory cues in comparison with conditions without cues (P < .05). Smaller latency scores were recorded in conditions with auxiliary sensory information. The results indicate that auxiliary sensory cues improved automatic postural responses. CONCLUSIONS: The observed enhancement of automatic postural responses has clinical implications that aid in the understanding of postural control in individuals with peripheral neuropathy. Future controlled trials could examine whether devices that provide auxiliary sensory cues can improve balance, mobility, and the performance of daily activities.

Perceived body position in standing individuals with recent stroke.

OBJECTIVES: The ability to maintain balance can be affected by misperception of the body position in space that is common in individuals with a stroke. The purpose of the study was to evaluate whether individuals with recent stroke could participate in assessment of their perceived body position in standing. METHODS: Eight individuals who sustained a stroke and who exhibited visiospatial problems and eight healthy control subjects participated in the study. They were positioned on a platform that was tilted in toes up/down or left/right directions and identified the position of their body when they felt that the body was vertical when the platform on which they were standing was returning back to a horizontal position after being tilted. RESULTS: Mean errors in perceived antero-posterior platform position were 1.75±0.25deg in patients and 0.66±0.28deg in control subjects (p<0.05). In the lateral plane mean errors in perceived platform position were 1.64±0.32deg in patients and 0.54±0.07deg in control subjects (p<0.05). Patients identified perceived body position approximately three times worse than control subjects in both anterior-posterior and lateral planes. CONCLUSIONS: This technique may be used for assessment of perceived body position in standing. SIGNIFICANCE: Objective measurement of perceived body position in standing could help to better understand the stroke-related disability.

Ankle-Foot Orthoses: Proprioceptive Inputs and Balance Implications.

Individuals with a loss of sensation in the lower limbs frequently experience postural instability, altered gait patterns, and an increased risk of falling culminating in a decreased quality of life. Previous studies have documented that using ankle-foot orthoses (AFOs) help such individuals to maintain their balance. This study was conducted to investigate whether somatosensory cues delivered to the intact tissues of the lower limbs above the ankle joints enhance the control of posture in individuals with peripheral neuropathy. The study involved 12 individuals with sensory neuropathy because of diabetes who participated in static and dynamic balance tests with and without specially designed AFOs that provided auxiliary sensory cues to the lower limbs without stabilizing the ankle joints. During the tests, the subjects were required to alternately stand on a fixed and moving platform with their eyes alternately open or closed. Equilibrium scores and response latencies were obtained. The results showed that equilibrium scores were significantly higher in experiments with the specially modified AFOs compared with conditions without AFOs. Smaller latency scores were recorded in conditions with AFOs as well. The outcome indicates that AFOs that substitute for the lack of proprioceptive feedback may improve automatic postural responses in individuals with diabetic peripheral neuropathy. It also highlights the need for further research focused on the design of assistive means that could improve the balance and the performance of activities of daily living in individuals with proprioceptive deficits.

Feasibility of instrumental swallowing assessments in patients with prolonged disordered consciousness while undergoing inpatient rehabilitation.

OBJECTIVE: To evaluate the feasibility, safety, and potential benefit of instrumental swallowing assessments for patients with prolonged disordered consciousness participating in rehabilitation. DESIGN: Case-control, retrospective. PARTICIPANTS: Thirty-five participants divided into 2 cohorts according to cognitive level at the time of baseline instrumental swallowing assessment. Group 1 (n = 17) participants were at Rancho Los Amigo (RLA) level II/III or RLA level III, while Group 2 (n = 18) participants were rated better than RLA level III. RESULTS: Aspiration and laryngeal penetration rates for both groups were similar (aspiration rate Group 1 = 41%, Group 2 = 39%; laryngeal penetration rate Group 1 = 59%, Group 2 = 61%). Overall, 76% (13/17) of Group 1 and 72% (13/18) of Group 2 were able to receive some type of oral feedings following baseline video fluoroscopic swallow study (VFSS) or endoscopic exam of the swallow (FEES). CONCLUSION: The majority of participants who underwent an instrumental swallowing examination while still functioning at RLA level II/III or RLA level III were able to return to some form of oral feedings immediately following their baseline examination. Swallowing as a treatment modality can be considered a part of the overall plan to facilitate neurobehavioral recovery for patients with prolonged disordered consciousness participating in rehabilitation.

Gait assessment during the initial fitting of an ankle foot orthosis in individuals with stroke.

PURPOSE: To evaluate if the measurement of gait parameters, examined during the fitting of an Ankle Foot Orthosis (AFO), has a beneficial effect on the gait pattern of individuals who were affected by a stroke. Also, this study seeks to provide evidence regarding the use of the portable GaitRite system in a clinical setting. METHOD: Before-after trial conducted at a stroke outpatient orthotic clinic of a freestanding rehabilitation hospital. Thirteen individuals with acute and 27 individuals with chronic stroke participated in the assessment of gait velocity, cadence, step length and stance phase. RESULTS: AFO use significantly improves gait velocity, cadence, step, and stride length in individuals with hemiparesis due to stroke. CONCLUSION: The results of the current study indicate that the assessment of temporo-spatial characteristics of gait can be incorporated into a clinical routine. This will be useful for patient education, justification of medical necessity of paying, monitoring progress, and in the decision-making process of weaning patients off orthoses.

Automatic postural responses in individuals with peripheral neuropathy and ankle-foot orthoses.

Eleven individuals with sensory neuropathy participated in static and dynamic balance tests with and without ankle-foot orthoses (AFOs). During the tests the subjects were required to stand on a fixed or moving computer-controlled platform with their eyes open or closed. Equilibrium scores, response latency, and strength scores were obtained. For all tests equilibrium scores were significantly larger in experiments with AFOs in comparison to conditions without AFOs (P<0.01). Decreased latency of responses with AFOs were recorded for medium and large magnitudes of movements of the platform in forward and backward directions. In addition, increased strength scores were observed when AFOs were used. The results indicate that AFOs could contribute significantly to postural control in individuals with peripheral neuropathy by providing auxiliary sensory cues to intact tissues of the lower extremities. These results have clinical implications that primarily aid in the understanding of how individuals with peripheral neuropathy benefit from the use of AFOs for postural stability.

Persons with disorders of consciousness: are oral feedings safe/effective?

PRIMARY OBJECTIVE: Evaluate the safety and efficacy of providing oral feedings to persons early in coma recovery following a severe brain injury. RESEARCH DESIGN: Descriptive, retrospective study. METHODS AND PROCEDURES: Medical chart reviews of all patients admitted to a rehabilitation hospital following severe brain injury. MAIN OUTCOMES AND RESULTS: Twenty-five patients met the inclusion criteria, 22 had a tracheostomy, and all were NPO. Subjects were divided into two cohorts. Group 1, n=10, mean age 43.5 years, received oral feedings early in coma recovery. Group 2, n=15, mean age 45.2 years, did not. Group 1, 30% returned to an oral diet of three meals daily at discharge from inpatient rehabilitation as compared to 40% in group 2 (chi2 = 0.260, p = 0.610). Average cost of care for group 1 = US$45 759 and group 2 = US$41 056 (p = 0.634). CONCLUSION: Safe therapeutic oral feedings, in accordance with findings from instrumental swallowing examinations, are possible for patients with disordered consciousness. The therapeutic oral feedings do not significantly increase the cost of care, but the effectiveness of oral feedings early in coma recovery requires further investigation.

Rehabilitation outcomes of 5 patients with severe West Nile virus infection: a case series.

OBJECTIVE: To report inpatient rehabilitation outcome in severe cases of West Nile virus (WNV) infection. DESIGN: Retrospective case series. SETTING: Freestanding rehabilitation hospital. PARTICIPANTS: Five consecutive patients admitted to an inpatient rehabilitation hospital with proven WNV infection. PATIENTS: had severe neurologic manifestations and functional deficits. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FIM instrument scores. RESULTS: On admission, overall FIM scores ranged from 31 to 68, with a mean of 44.40+/-15.85; overall FIM scores ranged from 52 to 90, with a mean of 76.00+/-15.03 at discharge. CONCLUSIONS: All patients demonstrated significant functional improvement ( P <.001). Length of stay ranged from 10 to 71 days, with a mean of 32 days. Lower functional outcome and higher cost of care were noted in patients and was attributable to severe muscle weakness and axonal neuropathy.

Task-specific modulation of anticipatory postural adjustments in individuals with hemiparesis.

OBJECTIVES: To study adaptation of anticipatory postural adjustments (APAs) in paretic and non-paretic muscles of individuals with hemiparesis to changes in the direction of the self-initiated perturbation and additional manual support. METHODS: Electrical activity of leg and trunk muscles on both sides of the body and ground reaction forces were recorded in 10 patients with hemiparesis and a group of matched control subjects. Subjects released a standard load, held in the hand of the extended relatively unimpaired arm. The load was released either in front of the body or to the side, with or without the impaired arm touching an external stable surface. RESULTS: APAs were reduced in individuals with hemiparesis, especially on the paretic side. In paretic muscles, the modulation of APAs with the direction of the perturbation was decreased or showed atypical patterns. Also the effects of touch were decreased in patients. Center of pressure displacements shortly after load release were similar in control subjects and patients. CONCLUSIONS: The results suggest that the ability of individuals with hemiparesis to prepare for a self-initiated predictable perturbation is reduced and that they may use alternative strategies of postural stabilization.

The Effect of Ankle-Foot Orthoses on Balance Impairment: Single-Case Study.

Instability and balance impairment is common in patients with diabetic sensory neuropathy placing them at a higher risk of falling when performing more challenging daily tasks. The report describes the results of a dynamic balance tests of a subject with neuropathy due to the long-standing diabetes. The Computerized Dynamic Posturography was performed with and without ankle-foot orthoses (AFOs). The apparatus provided six test conditions designed to systematically manipulate vestibular, somatosensory, or visual information. With no orthoses the patient had falls performing most of the tests. Bilateral orthoses improved his balance: a derived composite balance score increased four times. In view of these findings, AFOs, in addition to correcting the patient's foot placement during locomotion, could also be expected to improve the maintenance of balance during quiet stance or dynamic perturbation.