Therapeutic effects of extracorporeal shock wave therapy on patients with spastic cerebral palsy and Rett syndrome: clinical and ultrasonographic findings.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) is reportedly effective for improving spasticity and motor function in children with cerebral palsy (CP). Because late-stage Rett syndrome has a similar presentation, this study aimed to investigate the effects of ESWT on these two diseases. MATERIAL AND METHODS: Patients diagnosed with spastic CP and Rett syndrome received 1500 impulses of ESWT at 4 Hz and 0.1 mJ/mm2, on their spastic legsonce weekly for a total of 12 weeks. Outcomes were assessed before and 4 and 12 weeks after ESWT. Clinical assessments included the Modified Ashworth Scale (MAS), passive range of motion (PROM), and Gross Motor Function Measure 88 (GMFM-88). Ultrasonographic assessments included muscle thickness, acoustic radiation force impulse (ARFI), and strain elastography. RESULTS: Fifteen patients with CP and six with Rett syndrome were enrolled in this study. After ESWT, patients with CP showed significant clinical improvement in the MAS (P = 0.011), ankle PROM (P = 0.002), walking/running/jumping function (P = 0.003), and total function (P < 0.001) of the GMFM-88. The patients with Rett syndrome showed improved MAS scores (P = 0.061) and significantly improved total gross motor function (P = 0.030). Under ARFI, patients with CP demonstrated decreased shear wave speed in the gastrocnemius medial head (P = 0.038). Conversely, patients with Rett syndrome show increased shear-wave speeds after ESWT. CONCLUSION: Our study provides evidence that a weekly course of low-dose ESWT for 12 weeks is beneficial for children with both CP and Rett syndrome, with the clinical effects of reducing spasticity and improving the gross motor function of the lower limbs. The ARFI sonoelastography reveals improvement of muscle stiffness in patients with CP after ESWT, but deteriorated in patients with Rett syndrome. The diverse therapeutic response to ESWT may be caused by the MECP2 mutation in Rett syndrome, having a continuous impact and driving the pathophysiology differently as compared to CP, which is secondary to a static insult. Trial registration IRB 201700462A3. Registered 22March 2017, https://cghhrpms.cgmh.org.tw/HRPMS/Default.aspx .

Psychometric Comparisons of Three Depression Measures for Patients With Stroke.

IMPORTANCE: Psychometric examinations for patients with stroke remain insufficient. The Center for Epidemiologic Studies Depression Scale (CES-D), Beck Depression Inventory-II (BDI-II), and Geriatric Depression Scale (GDS) are promising outcome measures. OBJECTIVE: To examine and compare the reliability and validity of three depression measures in a sample of patients with stroke. DESIGN: Repeated-measures design. SETTING: A hospital in southern Taiwan. PARTICIPANTS: Fifty-nine outpatients, who completed three depression measures. OUTCOMES AND MEASURES: Cronbach's α and intraclass correlation coefficients (ICCs) were used to examine the internal consistency and test-retest reliability, respectively, of the three measures. An independent-samples t test was conducted to compare two groups of patients with different levels of disability to investigate discriminative validity. Pearson's rs were calculated among the three measures to examine concurrent validity. RESULTS: The three measures had good internal consistency (α = .85-.92) and sufficient test-retest reliability (ICC = .84-.91). The minimal detectable change (percentage of minimal detectable change) was 10.6 (63.3%), 13.5 (98.3%), and 5.8 (49.9%) for the CES-D, BDI-II, and GDS, respectively. There was a statistically significant difference between the two groups in CES-D score (p = .032) and no significant differences on the other two measures (p = .095-.187). The correlations among the three measures ranged from .79 to .89. CONCLUSION AND RELEVANCE: All three depression measures had sound internal consistency, test-retest reliability, and concurrent validity in patients with stroke. What This Article Adds: Of the three measures, the CES-D had better discriminative validity, and the GDS demonstrated greater reliability and smaller random measurement error in patients with stroke.

Practice effect and reliability of the motor-free visual perception test-4 over multiple assessments in patients with stroke.

PURPOSE: The Motor-Free Visual Perception Test-4 (MVPT-4) is a multidimensional measure of visual perception with five subscales (visual discrimination, figure-ground, visual memory, spatial relationships, and visual closure). The purpose of this study was to examine practice effect and test-retest reliability of the MVPT-4 over four serial assessments in patients with stroke. METHODS: We recruited outpatients with stroke with age above 20 years, able to follow instructions, and able to sign informed consent. We excluded patients who had visual neglect and visual deficits (e.g., diplopia, cataract, and glaucoma). Sixty patients completed the MVPT-4 four times, one week apart. Cumulative and plateau phases of the practice effect were evaluated across four assessments. Test-retest reliability was examined using the intraclass correlation coefficient (ICC). RESULTS: The MVPT-4 scale and five subscales showed cumulative phases. Only the spatial relationships subscale may have reached a plateau phase at the second assessment. The ICC values of the MVPT-4 scale and five subscales were 0.48-0.87. The minimum and maximum values of the 90% confidence interval (CI) of reliable change index modified for practice (RCIp) were: MVPT-4 scale [-5.0, 7.7]; visual discrimination [-1.7, 2.1]; figure-ground [-2.0, 2.6]; visual memory [-2.6, 3.2]; spatial relationships [-2.3, 3.0]; and visual closure [-2.5, 2.8]. CONCLUSIONS: The MVPT-4 scale and five subscales appeared increasing trends of practice effects and moderate to excellent test-retest reliability in patients with stroke. The minimum and maximum values of the 90% CI RCIp for the spatial relationships subscale which may have reached a plateau phase that can help clinicians and researchers to ascertain whether the real score change is occurred for an individual patient.Implications for rehabilitationThree multilevel regression models were conducted to evaluate the plateau phase of the practice effect over four assessments.The patterns of practice effects and evidences of test-retest reliability of the MVPT-4 scale and five subscales over four serial assessments can be used to follow the progress of patients with stroke.The minimum and maximum values of the 90% CI RCIp of the MVPT-4 can assist clinicians and researchers to explain score changes for an individual patient with stroke.

Validation of the Test of Visual Perceptual Skills-Third Edition in patients with stroke.

PURPOSE: The Test of Visual Perceptual Skills-Third Edition (TVPS-3) with seven subscales has been used to assess visual perception in patients with stroke. The purpose of this study was to investigate ecological validity, convergent validity, and discriminative validity of the TVPS-3 in patients with stroke. METHODS: One hundred patients were assessed with the TVPS-3, two measures of activities of daily living, and two cognitive measures. To examine ecological validity, we calculated correlations (Pearson's r) among the TVPS-3 and two measures of activities of daily living. To examine convergent validity, correlations (r) were estimated among the TVPS-3 and two cognitive measures. To examine discriminative validity, independent t-test was used to compare the two groups with different levels of disability and to detect whether there were statistically significant differences in the TVPS-3 between these groups. RESULTS: The correlations were 0.21-0.48 among the TVPS-3 and two measures of activities of daily living. The correlations were 0.29-0.68 among the TVPS-3 and two cognitive measures. Between the two groups, the t-test results showed statistically significant difference (p < 0.05) for the overall scale and the five subscales of the TVPS-3. CONCLUSIONS: The TVPS-3 has acceptable convergent validity, ecological validity, and discriminative validity and is useful to assess the visual perception in patients with stroke. Implications for rehabilitation The Test of Visual Perceptual Skills-Third Edition is a motor free visual perception test, which is an adequate tool for use in patients with stroke. The Test of Visual Perceptual Skills-Third Edition showed acceptable ecological validity, convergent validity, and discriminative validity in patients with stroke.

Cognitive effects of weight-shifting controlled exergames in patients with chronic stroke: a pilot randomized comparison trial.

BACKGROUND: The exergaming training involves motor as well as cognitive stimulation. Although exergame studies have been reported to have benefits in motor function, the effects of exergames on improving cognitive function remain inconclusive. Moreover, no study has been reported in stroke patients. AIM: The objective of this study was to compare the cognitive effects of 2 weight-shifting controlled exergaming systems and conventional weight- shifting training in patients with chronic stroke. DESIGN: This was a single-blind randomized controlled trial. SETTING: All participants were recruited from a rehabilitation department of a tertiary hospital. POPULATION: Patients (N.=37) with chronic hemiplegic stroke. METHODS: Patients were randomly allocated to one of the Wii Fit, Tetrax biofeedback, or conventional weight-shifting training groups. All interventions were administered 30 minutes per session, twice a week for 12 weeks. We used total score and the 9 domain scores of Cognitive Abilities Screening Instrument Chinese version (CASI C-2.0), and Berg Balance Scale (BBS) as the outcome measures. The outcome measures were assessed before and after training, and at 3 months follow-up. RESULTS: There were no significant differences among the 3 groups in the percentage of change in CASI total score and BBS, either post intervention or at the 3-month follow-up. At assessing the percentage of change in each domain of CASI, we found significant differences among the 3 groups in the abstraction/judgment domain after intervention (Wii Fit 16.25 [9.77, 37.50]% vs. Tetrax 0.00 [-10.00, 0.00]% vs. weight-shift 11.00 [0.00, 14.38]%, P=0.01], and at the 3-month follow-up (Wii Fit 20.00 [10.83, 31.25]% vs. Tetrax -10.00 [-11.11, 10.00]% vs. weight-shifting 0.00 [-2.27, 11.46]%, P=0.01). The differences came from the differences between Wii Fit and Tetrax mainly. There were significant differences among the 3 groups in language domain after intervention (Wii Fit 0.00 [0.00, 5.54]% vs. Tetrax 0.00 [-3.00, 0.00]% vs. weight-shift 0.00 [0.00, 0.00]%, P=0.045), but not at the 3-month follow-up (P=0.13). There was no correlation between the percentage of change in BBS and CASI total score postintervention ( r=-0.15 P=0.38). CONCLUSIONS: Wii Fit games training might be beneficial in some cognitive functions, such as abstraction/judgment, language in patients with chronic stroke. Wii Fit games, the commercial entertainment exergames, had superior effect in abstract/judgment and language domains as compared to the rehabilitation exergame (Tetrax balance system). Hence, Wii Fit games might be considered as a tool in post-stroke cognitive rehabilitation programs.

Test-Retest Reliability and Minimal Detectable Change of the Test of Visual Perceptual Skills-Third Edition in Patients With Stroke.

OBJECTIVES: To examine the test-retest reliability, calculate minimal detectable change (MDC), and report internal consistency of the Test of Visual Perceptual Skills-Third Edition (TVPS-3) in patients with stroke. DESIGN: Repeated-measures design (at an interval of 2wk). SETTING: Medical center. PARTICIPANTS: Patients (N=50) with chronic stroke who completed the TVPS-3. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: TVPS-3 that contains 7 subscales, namely, visual discrimination, visual memory, spatial relations, form constancy, sequential memory, visual figure-ground, and visual closure. RESULTS: The intraclass correlation coefficient value of the overall scale was .92 and those of the 7 subscales were .53 to .82. The MDC values of the overall scale and the subscales were 18.1 and 5.4 to 7.1, respectively. The MDC% value of the overall scale was 16.2% (<30%), showing acceptable random measurement error. However, the MDC% values of the subscales were 33.7% to 44.1% (>30%), indicating substantial random measurement errors. The Cronbach α of the 7 subscales were .71 to .89, indicating good internal consistency. CONCLUSIONS: Our results showed that the overall scale of the TVPS-3 had satisfactory test-retest reliability. However, the subscales demonstrated insufficient test-retest reliability. Therefore, the subscales should be used cautiously to explain the test results over repeated assessments in patients with stroke.

Feasibility of Using Tetrax Biofeedback Video Games for Balance Training in Patients With Chronic Hemiplegic Stroke.

BACKGROUND: Decreased weight bearing on the affected lower limb and poor weight shifting are common after a stroke occurs. The Tetrax biofeedback system is a center-of-pressure controlled video game system designed for patients with balance deficits. Although it is a commercial product, information about its clinical use for patients affected by stroke is limited. OBJECTIVE: To investigate the feasibility and potential efficacy of the Tetrax biofeedback system for balance training in patients with chronic stroke. DESIGN: Feasibility study. SETTING: Rehabilitation department of a medical center. PARTICIPANTS: Participants who had sustained a hemiplegic stroke at least 6 months prior to enrollment but were still able to stand independently for more than 5 minutes. METHODS: Participants were randomly assigned to an intervention group (IG) or control group (CG). All participants received conventional rehabilitation training. The IG also received 20 minutes of exposure to Tetrax biofeedback games controlled by change in center of pressure 3 times a week for 6 weeks. MAIN OUTCOME MEASUREMENTS: The primary outcome was feasibility, addressed by adherence, safety, and satisfaction. The secondary outcome was efficacy, which was evaluated by the subtests of physiological profile assessment, posturography, Timed Up and Go, and Forward Reach tests. We used percentage change (post-training score - pretraining score/pretraining score) to quantify the intervention effects. Mann-Whitney U tests were used to analyze differences in percentage of change between groups. RESULTS: A total of 14 participants were assigned to the IG, and 13 were assigned to the CG; 12 participants in the IG and 11 in the CG completed the study. In the IG group, those who completed the 6-week intervention attended 89.5% of planned sessions. No major adverse events or falls occurred within the intervention sessions. With use of 5-point Likert scales, participants rated their enjoyment of Tetrax games as 4.33 ± 0.78, their motivation as 4.17 ± 1.03, and perceived helpfulness as 4.25 ± 0.97. The IG demonstrated a significantly greater improvement in reaction time (P = .002), proprioception (P < .001), symmetric weight bearing (P = .027), Timed Up and Go (P < .001), and Forward Reach (P < .001) compared with the CG. CONCLUSIONS: Using Tetrax biofeedback video games for balance training is a feasible adjunctive program that may augment conventional therapy in persons affected by chronic hemiplegic stroke. LEVEL OF EVIDENCE: II.

Randomized comparison trial of balance training by using exergaming and conventional weight-shift therapy in patients with chronic stroke.

OBJECTIVE: To compare the effects of exergaming with conventional weight-shift training on balance function in patients with chronic stroke. DESIGN: Single-blind randomized controlled trial. SETTING: Medical center. PARTICIPANTS: Patients (N=30) with chronic stroke and balance deficits. INTERVENTIONS: Twelve weeks of Wii Fit training or conventional weight-shift training. MAIN OUTCOME MEASURES: Static balance was assessed using posturography. We recorded the stability index and percentage of weight bearing on the affected leg in 8 positions. We also used the timed Up and Go and forward reach tests for dynamic balance evaluation, Falls Efficacy Scale-International for fear of falling assessment, and Physical Activity Enjoyment Scale for estimating the enjoyment of training. RESULTS: The exergaming group showed more improvement in stability index than the control group in head straight with eyes open while standing on a foam surface, eyes closed while standing on a solid surface with head turned 30° to the left, and eyes closed while standing on a solid surface with head turned up positions (time-group interaction P=.02, .04, and .03, respectively); however, the effects were not maintained. At 3-month follow-up, the control group showed more improvement in weight-bearing symmetry in the head straight with eyes open while standing on a solid surface position than the exergaming group (time-group interaction P=.03). Both groups showed improvement in the timed Up and Go test, forward reach test, and fear of falling. The improvement in fear of falling was not maintained. The exergaming group enjoyed training more than the control group (P=.03). CONCLUSIONS: Exergaming is enjoyable and effective for patients with chronic stroke.

Long-term effect of an anterior ankle-foot orthosis on functional walking ability of chronic stroke patients.

OBJECTIVES: The objectives of this study are to investigate the long-term effect of anterior ankle-foot orthosis on the functional walking ability of chronic stroke patients and their subjective perception and to identify the type of chronic stroke patients who are better responders to the wearing of anterior ankle-foot orthosis. DESIGN: This is a cross-sectional cohort comparison study. Fifty-two stroke patients wearing an anterior ankle-foot orthosis for at least 5 mos were evaluated using the modified Emory Functional Ambulation Profile and the 6-min walking test with and without an anterior ankle-foot orthosis. Falls Efficacy Scale-International and a self-designed questionnaire were administered to assess subjective perceptions. RESULTS: All modified Emory Functional Ambulation Profile subscores significantly decreased with the anterior ankle-foot orthosis; the mean difference in favor of the anterior ankle-foot orthosis on the floor was -2.88 secs; the carpet, -5.44 secs; "up and go," -5.09 secs; obstacle, -8.42 secs; stairs, -6.45 secs; and in the 6-min walking test, 19.75 m (all P < 0.01). Patients who were of younger age or with low walking ability or both would have more benefits. The total scores of Falls Efficacy Scale-International were significantly lower with anterior ankle-foot orthosis as compared with that without anterior ankle-foot orthosis (31.57 ± 12.79 vs. 39.51 ± 12.65). Around 90% participants perceived that their walking performance improved with the anterior ankle-foot orthosis either indoors or outdoors, and they would recommend the anterior ankle-foot orthosis to other stroke patients. The greatest disadvantage of anterior ankle-foot orthosis is the difficulty in donning and doffing. CONCLUSIONS: The effects of the anterior ankle-foot orthosis on stroke patients' functional walking ability and fall efficacy were significant. Patients who were of younger age or with low walking ability or both were more suitable for using the anterior ankle-foot orthosis.