Six hours of task-oriented training optimizes walking competency post stroke: a randomized controlled trial in the public health-care system of South Africa.

OBJECTIVE: To evaluate a minimal dose intervention of six 1-hour sessions of task-oriented circuit gait training including a caregiver over a 12-week period to persons post stroke in the South African public health sector. DESIGN: Stratified, single blinded, randomized controlled trial with three intervention groups. PARTICIPANTS: Persons post stroke ( n = 144, mean age 50 years, 72 women), mean 9.5 weeks post stroke. INTERVENTIONS: Task group ( n = 51)-accompanied by a caregiver; task-oriented circuit gait training (to improve strength, balance, and task performance while standing and walking). Strength group ( n = 45); strength training of lower extremities while sitting and lying. Control group ( n = 48); one 90-minute educational session on stroke management. MEASURES: The six-minute walk test (6MinWT) was the primary outcome; the secondary outcomes included comfortable and fast gait speeds, Berg Balance Scale (BBS), and Timed Up and Go (TUG). Particpants evaluated at baseline, post intervention (12 weeks), and at follow-up 12 weeks later. Change scores were compared using generalized repeated measures analysis of variance (ANOVA). RESULTS: Task group change scores for all outcomes post intervention and at follow-up were improved compared to the other groups ( P-values between 0.000005 and 0.04). The change scores (mean, 1SD) between baseline and follow-up for the Task, Strength, and Control groups, respectively, were as follows: 6MinWT:119.52 m (81.92), 81.05 m (79.53), and 60.99 m (68.38); comfortable speed 0.35 m/s (0.23), 0.24 m/s (0.22), and 0.19 m/s (0.21); BBS: 9.94 (7.72), 6.93 (6.01), and 5.19 (4.80); and TUG: -14.24 seconds (16.86), -6.49 seconds (9.88), and -5.65 seconds (8.10). CONCLUSION: Results support the efficacy of a minimal dose task-oriented circuit training program with caregiver help to enhance locomotor recovery and walking competency in these persons with stroke.

Perspectives of health care professionals on the facilitators and barriers to the implementation of a stroke rehabilitation guidelines cluster randomized controlled trial.

BACKGROUND: The Stroke Canada Optimization of Rehabilitation by Evidence Implementation Trial (SCORE-IT) was a cluster randomized controlled trial that evaluated two knowledge translation (KT) interventions for the promotion of the uptake of best practice recommendations for interventions targeting upper and lower extremity function, postural control, and mobility. Twenty rehabilitation centers across Canada were randomly assigned to either the facilitated or passive KT intervention. The objective of the current study was to understand the factors influencing the implementation of the recommended treatments and KT interventions from the perspective of nurses, occupational therapists and physical therapists, and clinical managers following completion of the trial. METHODS: A qualitative descriptive approach involving focus groups was used. Thematic analysis was used to understand the factors influencing the implementation of the recommended treatments and KT interventions. The Clinical Practice Guidelines Framework for Improvement guided the analysis. RESULTS: Thirty-three participants were interviewed from 11 of the 20 study sites (6 sites from the facilitated KT arm and 5 sites from the passive KT arm). The following factors influencing the implementation of the recommended treatments and KT interventions emerged: facilitation, agreement with the intervention - practical, familiarity with the recommended treatments, and environmental factors, including time and resources. Each of these themes includes the sub-themes of facilitator and/or barrier. Improved team communication and interdisciplinary collaboration emerged as an unintended outcome of the trial across both arms in addition to a facilitator to the implementation of the treatment recommendations. Facilitation was identified as a facilitator to implementation of the KT interventions in the passive KT intervention arm despite the lack of formally instituted facilitators in this arm of the trial. CONCLUSIONS: This is one of the first studies to examine the factors influencing the implementation of stroke recommendations and associated KT interventions within the context of a trial. Findings highlight the important role of self-selected facilitators to implementation efforts. Future research should seek to better understand the specific characteristics of facilitators that are associated with successful implementation and clinical outcomes, especially within the context of stroke rehabilitation.

Getting on with the rest of your life following stroke: a randomized trial of a complex intervention aimed at enhancing life participation post stroke.

OBJECTIVE: To enhance participation post stroke through a structured, community-based program. DESIGN: A controlled trial with random allocation to immediate or four-month delayed entry. SETTING: Eleven community sites in seven Canadian cities. SUBJECTS: Community dwelling persons within five years of stroke onset, cognitively intact, able to toilet independently. INTERVENTIONS: Evidence-based program delivered in three 12-week sessions including exercise and project-based activities, done as individuals and in groups. MAIN MEASURES: Hours spent per week in meaningful activities outside of the home and Reintegration to Normal Living Index; Stroke-Specific Geriatric Depression Scale, Apathy Scale, gait speed, EuroQuol EQ-5D, and Preference-Based Stroke Index. All measures were transformed to a scale from 0 to 100. Assessments prior to randomization, after the first session at three months, six months, 12 months, and 15 months. RESULTS: A total of 186 persons were randomized. The between-group analysis showed no disadvantage to waiting and so groups were combined and a within-person analysis was carried out at three time points. There were statistically significant increases in all study outcomes on average over all persons. Over 45% of people met or exceeded the pre-specified target of a three hour per week increase in meaningful activity and this most often took a full year of intervention to achieve. Greatest gains were in satisfaction with community integration (mean 4.78; 95% CI: 2.01 to 7.55) and stroke-specific health-related quality of life (mean 4.14; 95% CI: 2.31 to 5.97). CONCLUSIONS: Community-based programs targeting participation are feasible and effective, but stroke survivors require time to achieve meaningful gains.

Modifications in ankle dorsiflexor activation by applying a torque perturbation during walking in persons post-stroke: a case series.

BACKGROUND: Results obtained in a previous study (Gait Posture 34:358-363, 2011) have shown that, in non-disabled participants, a specific increase in ankle dorsiflexor (Tibialis anterior [TA]) activation can be induced by walking with a torque perturbation that plantarflexes the ankle during the swing phase. After perturbation removal, the increased TA activation persisted temporarily and was associated with a more dorsiflexed ankle during swing. The objective of the present case-series study was to verify if these results can be reproduced in persons post-stroke. METHODS: Six participants who sustained a stroke walked on a treadmill before, during and after exposure to a torque perturbation applied at the ankle by a robotized ankle-foot orthosis. Spatiotemporal gait parameters, ankle and knee kinematics, and the electromyographic activity of TA and Soleus were recorded. Mean amplitude of the TA burst located around toe off and peak ankle dorsiflexion angle during swing were compared across the 3 walking periods for each participant. RESULTS: At the end of the walking period with the perturbation, TA mean amplitude was significantly increased in 4 of the 6 participants. Among these 4 participants, modifications in TA activation persisted after perturbation removal in 3 of them, and led to a statistically significant increase in peak dorsiflexion during swing. CLINICAL IMPLICATIONS: This approach may be helpful to evaluate the residual adaptive capacity in the ankle dorsiflexors after a stroke and guide decision-making for the selection of optimal rehabilitation interventions. Future work will investigate the clinical impact of a multiple-session gait training based on this approach in persons presenting a reduced ankle dorsiflexion during the swing phase of walking.

Maximal cardiorespiratory fitness testing in individuals with chronic stroke with cognitive impairment: practice test effects and test-retest reliability.

OBJECTIVES: To evaluate, for individuals with chronic stroke with cognitive impairment, (1) the effects of a practice test on peak cardiorespiratory fitness test results; (2) cardiorespiratory fitness test-retest reliability; and (3) the relationship between individual practice test effects and cognitive impairment. DESIGN: Cross-sectional. SETTING: Rehabilitation center. PARTICIPANTS: A convenience sample of 21 persons (men [n=12] and women [n=9]; age range, 48-81y; 44.9±36.2mo poststroke) with cognitive impairments who had sufficient lower limb function to perform the test. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Peak oxygen consumption (Vo(2)peak, ml·kg(-1)·min(-1)). RESULTS: Test-retest reliability of Vo(2)peak was excellent (intraclass correlation coefficient model 2,1 [ICC2,1]=.94; 95% confidence interval [CI], .86-.98). A paired t test showed that there was no significant difference for the group for Vo(2)peak obtained from 2 symptom-limited cardiorespiratory fitness tests performed 1 week apart on a semirecumbent cycle ergometer (test 2-test 1 difference, -.32ml·kg(-1)·min(-1); 95% CI, -.69 to 1.33ml·kg(-1)·min(-1); P=.512). Individual test-retest differences in Vo(2)peak were, however, positively related to general cognitive function as measured by the Mini-Mental State Examination (ρ=.485; P<.026). CONCLUSIONS: Vo(2)peak can be reliably measured in this group without a practice test. General cognitive function, however, may influence the effect of a practice test in that those with lower general cognitive function appear to respond differently to a practice test than those with higher cognitive function.

Normal aging and motor imagery vividness: implications for mental practice training in rehabilitation.

OBJECTIVE: To investigate the effects of normal aging on motor imagery vividness and working memory. DESIGN: Descriptive study with 3 groups. SETTING: Laboratory of a university-affiliated research rehabilitation center. PARTICIPANTS: A sample of healthy persons (N=80) divided into 3 age groups: young (26+/-5.0 y), intermediate (53.6+/-5.4 y), and elderly (67.6+/-4.6 y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The kinesthetic and visual imagery scores of the Kinesthetic and Visual Imagery Questionnaire and scores from 3 domains of working memory (visuospatial, kinesthetic, verbal). RESULTS: Results revealed that visual motor imagery scores were higher than kinesthetic scores (imagery effect: P=.001); however, there was also a significant imagery x group interaction (P=.017). Post hoc analyses showed that only the young and intermediate groups had higher visual than kinesthetic motor imagery scores (P=.005 and .001, respectively), indicating a loss of visual motor imagery dominance in the elderly group. There was no group effect (P=.963) signifying that the level of motor imagery vividness was comparable between age groups. Significant decreases (17.3% and 22.5%, respectively) in visuospatial working memory scores were found in the intermediate (P=.011) and elderly (P=.001) groups, whereas a significant reduction (P=.01) in kinesthetic working memory scores was observed only in the elderly group (26.7%). There was also an age-related significant decline of visuospatial (r= -.50) and kinesthetic (r=-.34) working memory. CONCLUSIONS: The level of motor imagery vividness does not diminish with age, but the quality changes. The dominance of visual motor imagery lessens with aging resulting in motor imagery modality-equivalence. These motor imagery alterations are associated with an age-related decline in visuospatial and kinesthetic working memory.

The influence of selected personal and environmental factors on leisure activities in adults with cerebral palsy.

PURPOSE: This study examined the influence of selected personal and environmental factors on leisure participation in adults with cerebral palsy (CP). METHODS: A group of 145 adults with CP (18-41 years old, 51% male) responded to questionnaires regarding 1) socio-demographic and health factors, 2) life habits (Life-H: short version 3.1) and 3) the environment (Measure of the Quality of the Environment: version 2.0). A chi2 statistic (p<0.05) estimated the association between 1) socio-demographic and health factors and the environment and 2) the level of leisure activity participation. RESULTS: Most participants (mean age=28 years) lived with their parents. Leisure activities were their principal occupation. Mobility and participation were positively associated. The environment (e.g. accompanying services, adapted transport, cultural services and computers) facilitated leisure for those with a high or moderate participation level. Individuals with low participation perceived the environment as having no influence. CONCLUSIONS: Adults with CP who are more mobile participate more in leisure activities. A positive perception of the environment (facilitating leisure participation) likely reflects the individual's ability to benefit from the environment, whereas a neutral view of the environment may reflect the fact that other factors, such as mobility limitations, are of greater relevance to leisure participation.

Benchmarking length of stay for inpatient stroke rehabilitation without adversely affecting functional outcomes.

OBJECTIVE: To evaluate the effects of introducing the practice of targeting a discharge date for patients admitted to an inpatient stroke rehabilitation unit on process and patient outcomes. DESIGN: Comparison of retrospective (control group n = 69) and prospective (experimental group n = 60) patients. METHODS: Rehabilitation professionals assessed both groups at admission and discharge using a standard-ized assessment toolkit. Benchmarks for length of rehabilitation stay (LoRS) were introduced based on median severity-specific LoRSs in the control group. The multidisciplinary team documented facilitators and obstacles affecting the prediction of patient benchmark attainment. Categorical variables were compared using a χ2 test with exact probabilities. Ordinal and continuous variables were analysed using rank-based non-parametric analysis of variance. Effect sizes were estimated using a relative treatment effect statistic. RESULTS: The mean combined length of stay in acute care and rehabilitation beds for the experimental group (82 days) was shorter (p = 0.0084) than that of the control group (103 days). This 21-day reduction in combined length of stay included a 10-day reduction in the mean time between stroke onset and admission to the stroke rehabilitation unit (p = 0.000014). Improvements in 6 func-tional and sensorimotor outcomes with rehabilitation were of similar magnitude in both groups, while Functional Independence Measure (FIMTM) efficiency improved (p = 0.022). The team was 87% successful in predicting which patients were discharged on the LoRS benchmark. CONCLUSION: Benchmarking the length of stay in rehabilitation resulted in reduced bed occupation and system costs without adversely affecting functional and sensorimotor patient outcomes.

Recovery of Sensorimotor Functional Outcomes at Discharge from In-Patient Rehabilitation in Three Stroke Units in the Province of Quebec.

Purpose: This study aimed to portray the characteristics, process variables, and sensorimotor outcomes of patients who had received their usual post-stroke in-patient rehabilitation in three stroke rehabilitation units in Quebec in 2013-2014. Method: We assessed patients (n = 264) at admission and discharge with a subset of a standardized assessment toolkit consisting of observational and performance-based assessment tools. Results: The patients, with a mean age of 60.3 (SD 15.4) years, were admitted 27.7 (SD 8.4) days post-stroke onset. They had a mean admission FIM score of 83.0 (SD 24.0), a mean length of stay of 48.4 (SD 31.1) days, a mean FIM discharge score of 104.0 (SD 17.0), and a mean FIM efficiency score of 0.44 (SD 0.29). All patient outcomes were significantly improved (p < 0.001) and clinically meaningful at discharge (moderate to large Glass's Δ effect sizes) with the improvements greater than or equal to the minimal detectable change at the 95% confidence level in 34%-75% of the patients. Improvements were larger on five of seven outcomes in a sub-group of patients with more severe stroke. Conclusions: The use of a combination of observational and performance assessment tools was essential to capture the full range of disabilities. We have documented significant and clinically meaningful improvements in functional independence, disability, and upper and lower extremity functions after usual post-stroke in-patient rehabilitation in the province of Quebec and provided baseline data for future studies.

Objectif : décrire les caractéristiques, le processus de réadaptation et les résultats sensorimoteurs de patients ayant reçu les services de réadaptation habituels après un accident vasculaire cérébral (AVC) dans trois unités de réadaptation du Québec en 2013 et 2014. Méthodologie : évaluation des patients (n = 264) à l'admission et au congé à l'aide du sous-ensemble d'une trousse d'évaluation standardisée composée d'outils d'évaluation fondés sur l'observation et la performance. Résultats : les patients, qui avaient un âge moyen de 60,3 ans (ÉT 15,4), ont été hospitalisés en réadaptation 27,7 jours (ÉT 8,4) après leur AVC. Leur mesure d'autonomie fonctionnelle (MAF) à l'admission était de 83,0 (ÉT 24,0), et leur séjour en réadaptation a duré 48,4 jours (ÉT 31,1); leur score de MAF au congé était de 104,0 (ÉT 17,0), pour un score d'efficacité de la MAF de 0,44 (ÉT 0,29). Tous les résultats cliniques des patients s'étaient considérablement améliorés (p < 0,001) et étaient cliniquement significatifs au congé (effet de taille delta de Glass de modéré à grand), et ces améliorations étaient supérieures ou égales au changement minimal décelable à un niveau de confiance de 95 % chez 34 % à 75 % des patients. Ces améliorations pour cinq des sept mesures étaient plus élevées dans le sous-groupe de patients ayant un AVC plus grave. Conclusion : une combinaison d'outils d'évaluation d'observation et de performance s'est avérée essentielle pour saisir tout l'éventail d'incapacités. Les auteures ont constaté des améliorations importantes et cliniquement significatives de l'autonomie fonctionnelle, de l'incapacité et de la fonction des membres supérieurs et inférieurs après l'hospitalisation en réadaptation habituelle des patients ayant un AVC dans la province de Québec et ont fourni des données de référence en vue de prochaines études.

Effects of practice, visual loss, limb amputation, and disuse on motor imagery vividness.

BACKGROUND: The ability to generate vivid images of movements is variable across individuals and likely influenced by sensorimotor inputs. OBJECTIVES: The authors examined (1) the vividness of motor imagery in dancers and in persons with late blindness, with amputation or an immobilization of one lower limb; (2) the effects of prosthesis use on motor imagery; and (3) the temporal characteristics of motor imagery. METHODS: Eleven dancers, 10 persons with late blindness, 14 with amputation, 6 with immobilization, and 2 groups of age-matched healthy individuals (27 in control group A; 35 in control group B) participated. The Kinesthetic and Visual Imagery Questionnaire served to assess motor imagery vividness. Temporal characteristics were assessed with mental chronometry. RESULTS: The late blindness group and dance group displayed higher imagery scores than respective control groups. In the amputation and immobilization groups, imagery scores were lower on the affected side than the intact side and specifically for imagined foot movements. Imagery scores of the affected limb positively correlated with the time since walking with prosthesis. Movement times during imagination and execution (amputation and immobilization) were longer on the affected side than the intact side, but the temporal congruence between real and imagined movement times was similar to that in the control group. CONCLUSIONS: The mental representation of actions is highly modulated by imagery practice and motor activities. The ability to generate vivid images of movements can be specifically weakened by limb loss or disuse, but lack of movement does not affect the temporal characteristics of motor imagery.

Added value of mental practice combined with a small amount of physical practice on the relearning of rising and sitting post-stroke: a pilot study.

BACKGROUND AND PURPOSE: : The additional effects of combining mental practice with a small amount of physical practice on the relearning of a motor task post-stroke are unknown. This study investigated the added value of mental practice on the relearning of rising up from a chair and sitting down when combined with a small amount of physical practice. METHODS: : Twelve individuals with chronic stroke were randomly assigned to one of three groups: a group that combined mental practice with physical practice (MP), a group that combined physical practice with cognitive training (Cog) and a group without training (NOT.). Training was provided three times per week for four weeks, and participants were assessed at baseline, after training, and three weeks later. The vertical forces were recorded under each foot, and the vertical impulse was calculated for five trials and converted in percent of body weight. RESULTS: : The MP and Cog groups received the same amount of physical training. Significant gains (P < 0.04) in limb loading found only in the MP group were retained. Larger (P < 0.03) change scores in limb loading for rising up from a chair and sitting down were found in the MP group (median = rising up: 18.4%; sitting down: 12.2%) compared with Cog group (median = rising up: -6.8%; sitting down: 5.4%) and a group without training (median = rising up: 6.2%; sitting down: 5.4%). CONCLUSION: : Combining series of mental repetitions ( approximately 1100 repetitions) with minimal physical repetitions ( approximately 120 repetitions) yielded significant gains and retention of those gains. These preliminary results provide some support to the added value of combining mental repetitions with a small number of physical repetitions to promote the relearning of motor strategies post-stroke and warrant further investigation in clinical trials.

Development, Implementation, and Clinician Adherence to a Standardized Assessment Toolkit for Sensorimotor Rehabilitation after Stroke.

Purpose: This study describes the development of a standardized assessment toolkit (SAT) and associated clinical database focusing on sensorimotor rehabilitation in three stroke rehabilitation units (SRUs). Implementation of the SAT was confirmed using objective measures of clinician adherence while exploring reasons for varied adherence. Method: Participants were patients post-stroke admitted for inpatient rehabilitation and clinicians from the three SRUs. A collaborative and iterative process was used to develop the SAT. Implementation was measured by clinician adherence, which was charted by means of assessment entries in patient records and transferred to the clinical database. Reasons for lower adherence were interpreted from therapist data logs at one SRU. Results: The SAT consisted of 25 assessment tools. Clinician adherence to a subset of the tools ranged from 33% to 99% at admission and from 28% to 94% at discharge. At one site, lower adherence among the tools was explained by patient-related factors (1%-36%) and protocol or logistical reasons (0%-7%) at admission; missing data ranged from 0% to 3%, except for the Montreal Cognitive Assessment (17%). Conclusions: In this pragmatic study, objective measures of clinician adherence demonstrated the feasibility of implementing an SAT in daily practice. Moreover, the reasons for lower adherence rates may be related to the patients, protocol, and logistics, all of which may vary with the assessment tool, rather than clinician compliance.

Objectif : décrire la création d'une trousse d'évaluation standardisée (TÉS) et d'une base de données cliniques connexe axée sur la réadaptation sensorimotrice dans trois unités de réadaptation fonctionnelle (URF). Les chercheurs ont confirmé la mise en application de la TÉS au moyen de mesures objectives de l'adhésion des cliniciens et ont exploré les raisons expliquant les variations à cette adhésion. Méthodologie : les participants étaient des patients victimes d'un accident vasculaire cérébral (AVC) admis en réadaptation et les cliniciens des trois URF. Les chercheurs ont utilisé un processus coopératif et itératif pour créer la TÉS. Ils en ont mesuré la mise en application par l'adhésion des cliniciens, recensée d'après les résultats d'évaluation dans les dossiers des patients, puis les ont transférées dans la base de données cliniques. Ils ont interprété les raisons d'une plus faible adhésion à partir des notes inscrites sur les feuilles de collecte de données des thérapeutes d'une des URF. Résultats : la TÉS se composait de 25 outils d'évaluation. L'adhésion des cliniciens à un sous-groupe d'outils se situait entre 33% et 99% à l'admission en réadaptation et entre 28% et 94% au congé. Dans un établissement, une plus faible adhésion aux outils s'expliquait par des facteurs liés aux patients (de 1% à 36%), au protocole ou à la logistique (0% à 7%) à l'admission, alors que les données manquantes variaient de 0% à 3%, sauf pour le « Montreal Cognitive Assessment ¼ (17%). Conclusions : dans cette étude pragmatique, les mesures objectives d'adhérence des cliniciens ont démontré la faisabilité de mettre en application une TÉS dans la pratique quotidienne. De plus, les raisons d'un taux d'adhérence plus faible peuvent être liées aux patients, au protocole ou à la logistique, facteurs qui peuvent varier en fonction de l'outil d'évaluation, plutôt qu'aux cliniciens.

Is Cerebral Palsy Changing in High Resource Settings? Data From the Quebec Cerebral Palsy Registry.

Advances in maternal and perinatal care in developed countries have led to improved health outcomes for children. These changes may have impacted the profile of children with a cerebral palsy (CP) and groups at risk for CP over time. Using data from the Canadian CP Registry, the objectives of this retrospective cohort study were to describe the profile of children with CP in Quebec born between 1999 and 2010 and identify possible temporal variation in CP risk factors and phenotypic profile. Our sample consisted of 662 children with CP in Quebec. No change in profile or associated risk factors was observed across the birth cohorts 1999 to 2010. Prematurity remains the largest risk factor for CP in Quebec, and children with CP have multiple comorbidities that contribute to overall CP burden. CP registries offer a unique platform to study spectrum disorders and their longitudinal changes over time.

Clinical assessment of motor imagery after stroke.

OBJECTIVE: The aim of this study was to investigate: (1) the effects of a stroke on motor imagery vividness as measured by the Kinesthetic and Visual Imagery Questionnaire (KVIQ-20); (2) the influence of the lesion side; and (3) the symmetry of motor imagery. METHODS: Thirty-two persons who had sustained a stroke, in the right (n = 19) or left (n = 13) cerebral hemisphere, and 32 age-matched healthy persons participated. The KVIQ-20 assesses on a 5-point ordinal scale the clarity of the image (visual scale) and the intensity of the sensations (kinesthetic scale) that the subjects are able to imagine from the first-person perspective. RESULTS: In both groups, the visual scores were higher (P = .0001) than the kinesthetic scores and there was no group difference. Likewise, visual scores remained higher than kinesthetic scores irrespective of the lesion side. The visual scores poststroke were higher (P = .001) when imagining upper limb movements on the unaffected side than those on the affected side. When focusing on the lower limb only, however, the kinesthetic scores were higher (P = .001) when imagining movements of the unaffected compared to those on the affected side. CONCLUSIONS: The vividness of motor imagery poststroke remains similar to that of age-matched healthy persons and is not affected by the side of the lesion. However, after stroke motor imagery is not symmetrical and motor imagery vividness is better when imagining movements on the unaffected than on the affected side, indicating an overestimation possibly related to a hemispheric imbalance or a recalibration of motor imagery perception.

Reliability of mental chronometry for assessing motor imagery ability after stroke.

OBJECTIVE: To examine the reproducibility of 2 chronometric tests: time-dependent motor imagery (TDMI) screening test and temporal congruence test. DESIGN: Test-retest 10 to 14 days apart. SETTING: Laboratory of a university-affiliated center for research in rehabilitation. PARTICIPANTS: Twenty persons post cerebrovascular accident (CVA) and 46 healthy persons (controls). INTERVENTION: The reproducibility of the TDMI screening test, wherein the number of stepping movements (performed in sitting) imagined over 15, 25, and 45 seconds is recorded, and of the temporal congruence test wherein the duration of physically executed (E) and imagined (I) stepping movements is recorded, was evaluated. MAIN OUTCOME MEASURES: The test-retest reliability of the number of imagined movements (TDMI screening test), movement duration and I/E time ratios (temporal congruence test), and intrasession reliability of the temporal congruence test were assessed by using intraclass correlation coefficients (ICCs). RESULTS: For the TDMI screening test, the ICCs ranged from .88 to .93 (CVA, n=20) and from .87 to .92 (controls, n=9). For the temporal congruence test, when the total duration of 2 series of 5 stepping movements was averaged, ICCs ranged from .76 to .97 (CVA, n=20) and from .77 to .93 (controls, n=46), whereas for 1 series the ICCs ranged from .71 to .95 and from .63 to .95 in the CVA and control groups, respectively. The ICCs for intrasession reliability for the CVA (n=20) and control (n=46) groups, respectively, ranged from .90 to .98 and .95 to .97. CONCLUSIONS: The present findings support the reproducibility of both tests in both groups. Mental chronometry can be used reliably for the screening of patients capable of motor imagery or for measuring temporal congruence between real and imagined movements poststroke.

Characteristics of personal space during obstacle circumvention in physical and virtual environments.

It is not known how the flexible protective zone maintained around oneself during locomotion (personal space or PS; see [Gérin-Lajoie M, Richards CL, McFadyen BJ. The negotiation of stationary and moving obstructions during walking: anticipatory locomotor adaptations and preservation of personal space. Motor Control 2005;9:242-69]) is modulated with walking speed, whether both sides of the PS are symmetrical, and whether the circumvention of physical and virtual obstructions elicit the same use of such PS. Personal space was measured in ten adults as they circumvented a cylindrical obstacle that was stationary within their path. Both left and right passes were performed at natural self-selected, slow and fast walking speeds. The same circumvention task was also performed at natural speeds in an immersive virtual environment (VE) replicating the same obstruction scenario. The shape and size of PS were maintained across walking speeds, and a smaller PS was generally observed on the dominant side. The general shape and lateral bias of the PS were preserved in the VE while its size was slightly increased. The systematic behavior across walking speeds and types of environment and the lateral bias suggest that PS is used to control navigation. This study deepens our understanding of normal adaptive walking behavior and has implications for the development of better tools for the assessment and retraining of locomotor capacity in different populations, from people with walking deficits to elite athletes. Since the PS behavior was shown to be robust in the VE used for this study, the virtual reality technology is proposed as a promising platform for the development of such assessment and retraining applications.

Converting Functional Autonomy Measurement System Scores of Patients Post-Stroke to FIM Scores.

Purpose: The Functional Independence Measure (FIM) is widely used to assess persons post-stroke. The Quebec government has selected the Functional Autonomy Measurement System (SMAF) for use in all care settings. In this article, we propose simple equations to convert SMAF scores to FIM scores for persons undergoing post-stroke rehabilitation. Method: Persons post-stroke (n=143) from three rehabilitation centres were assessed at admission and discharge using the FIM and SMAF. The sample was randomly split into derivation and validation data sets. Regression analysis was performed on the first data set to derive a conversion equation at each time point. The validity of the equations was measured using correlation coefficients, and differences between the observed and predicted FIM scores were computed from the second data set. Results: The relationship between the SMAF and FIM scores was linear at admission but quadratic at discharge. The proposed equations are, at admission, FIM=139-1.5×SMAF and, at discharge, FIM=118-0.018×SMAF2. The observed and predicted FIM scores were highly correlated in the validation data set (rs=0.92 and 0.93 at admission and discharge, respectively). Furthermore, the equations performed well in classifying stroke severity compared with a classification based on the observed FIM scores. Conclusions: SMAF scores can be reliably converted to FIM scores using the proposed equations, thus facilitating international trials in stroke rehabilitation.

Objectif : la mesure de l'indépendance fonctionnelle (MIF) est largement utilisée lors de l'évaluation après un accident vasculaire cérébral (AVC). Le gouvernement du Québec a retenu l'utilisation du système de mesure de l'autonomie fonctionnelle (SMAF) dans tous les établissements de soins. Le présent article présente des équations simples pour convertir les scores du SMAF en scores de MIF chez les personnes en réadaptation après un AVC. Méthodologie : les chercheurs ont évalué les personnes qui avaient subi un AVC (n=143) de trois centres de réadaptation à l'aide de la MIF et du SMAF à l'admission et au congé. Ils ont divisé l'échantillon aléatoirement en ensembles de données de dérivation et de validation. Ils ont procédé à une analyse de régression du premier ensemble de données pour dériver une équation de conversion à chaque point dans le temps. Ils ont mesuré la validité des équations au moyen de coefficients de corrélation et calculé les différences entre les scores de MIF observés et prédits à partir du deuxième ensemble de données. Résultats : la relation entre les scores du SMAF et de MIF était linéaire à l'admission, mais quadratique au congé. À l'admission, l'équation proposée est MIF=139−1,5×SMAF et, au congé, MIF=118−0,018×SMAF2. Les scores de MIF observés et prédits étaient hautement corrélés dans l'ensemble de données de validation (r = 0,92 et 0,93 à l'admission et au congé, respectivement). De plus, les équations donnaient de bons résultats dans le classement de la gravité des AVC par rapport au classement reposant sur les scores de MIF observés. Conclusions : on peut convertir les scores de SMAF en toute fiabilité à l'aide des équations proposées, facilitant ainsi les essais internationaux sur la réadaptation après un AVC.

Amount and Content of Sensorimotor Therapy Delivered in Three Stroke Rehabilitation Units in Quebec, Canada.

Purpose: This study creates a baseline clinical portrait of sensorimotor rehabilitation in three stroke rehabilitation units (SRUs) as a first step in implementing a multi-centre clinical research platform. Method: Participants in this cross-sectional, descriptive study were the patients and rehabilitation teams in these SRUs. Prospective (recording of therapy time and content and a Web-based questionnaire) and retrospective (chart audit) methods were combined to characterize the practice of the rehabilitation professionals. Results: The 24- to 39-bed SRUs admitted 100-240 inpatients in the year audited. The mean combined duration of individual occupational and physical therapy was 6.3-7.5 hours/week/patient. When evening hours and the contributions of other professionals as well as group therapy and self-practice were included, the total amount of therapy was 13.0 (SD 3) hours/patient/week. Chart audit and questionnaire data revealed the Berg Balance Scale was the most often used outcome measure (98%-100%), and other outcome measure use varied. Clinicians favoured task-oriented therapy (35%-100%), and constraint-induced movement therapy (0%-15%), electrical stimulation of the tibialis anterior (0%-15%), and body weight-supported treadmill training (0%-1%) were less often used. Conclusions: This study is the first to provide objective data on therapy time and content of stroke rehabilitation in Quebec SRUs.

Objectif : créer un portrait clinique de base de la réadaptation sensorimotrice offerte après un accident vasculaire cérébral dans trois unités de réadaptation fonctionnelle intensive (URFI) comme première étape en vue de la mise en œuvre d'une plateforme de recherche clinique multicentrique. Méthodologie : les participants à cette étude descriptive transversale étaient des patients et des équipes de réadaptation de ces URFI. Les chercheurs ont combiné la méthode prospective (consignation de la durée et du contenu du traitement et questionnaire en ligne) et la méthode rétrospective (audit de dossiers) pour caractériser la pratique des professionnels en réadaptation. Résultats : les URFI de 24 à 39 lits ont admis de 100 à 240 patients hospitalisés pendant l'année de l'audit. Les interventions en ergothérapie et physiothérapie étaient d'une durée moyenne combinée de 6,3 à 7,5 heures par semaine par patient. Lorsqu'on incluait les soirées, l'apport d'autres professionnels, la thérapie de groupe et la pratique autonome, le total s'élevait à 13,0 heures (ÉT 3,0) par semaine par patient. Les données tirées de l'audit des dossiers et des questionnaires ont révélé que l'échelle d'évaluation de l'équilibre de Berg était la plus utilisée (98 % à 100 %), alors que l'utilisation des autres mesures était variable. Les cliniciens favorisaient les traitements orientés vers les tâches (35 % à 100 %), et utilisaient moins la thérapie par contrainte induite (0 % à 15 %), la stimulation électrique du jambier antérieur (0 % à 15 %) et l'entraînement sur tapis roulant avec support de poids (0 % à 1 %). Conclusions : la présente étude est la première à fournir des données objectives sur la durée et le contenu de la réadaptation après un accident vasculaire cérébral dans les URFI du Québec.

Gait Training after Stroke on a Self-Paced Treadmill with and without Virtual Environment Scenarios: A Proof-of-Principle Study.

Purpose: The purpose of this proof-of-principle study was to show that virtual reality (VR) technology could be coupled with a self-paced treadmill to further improve walking competency in individuals with chronic stroke. Method: A 62-year-old man with a chronic right hemispheric stroke participated in a treadmill walking programme involving first a control (CTL) protocol, then VR training. In CTL training, he walked without time constraints while viewing still pictures and reacting to treadmill movements similar to those that he would have experienced later in VR training. In VR training, he experienced treadmill movements programmed to simulate changes encountered in five virtual environments rear-projected onto a large screen. Training difficulty in nine sessions over 3 weeks was increased by varying the time constraints, terrain surface changes, and obstacles to avoid. Effects on walking competency were assessed using clinical measures (5 m walk test, 6 min walk test, Berg Balance Scale, Activities-specific Balance Confidence scale) and questionnaires (Assessment of Life Habits Scale and personal appraisal). Results: CTL and VR training resulted in a similar progression through the training sessions of total time walked on the treadmill. The VR training led to an additional increase in speed as measured by walking 5 metres as fast as possible and distance walked in 6 minutes, as well as improved balance self-efficacy and anticipatory locomotor adjustments. As reported by the participant, these improved outcomes transferred to real-life situations. Conclusions: Despite the limited potential for functional recovery from chronic stroke, an individual can achieve improvements in mobility and self-efficacy after participating in VR-coupled treadmill training, compared with treadmill training with the same intensity and surface perturbations but without VR immersion. A larger scale, randomized controlled trial is warranted to determine the efficacy of VR-coupled treadmill training for mobility intervention post-stroke.

Objectif : la présente étude de validation visait à démontrer que la réalité virtuelle (RV) peut être jumelée à un tapis roulant autocontrôlé pour améliorer l'aptitude à marcher des personnes ayant un accident vasculaire cérébral (AVC) chronique. Méthodologie : un homme de 62 ans ayant un AVC chronique de l'hémisphère droit a participé à un programme de marche sur tapis roulant, d'abord au moyen d'un protocole de contrôle (CTL), puis d'un entraînement en RV. Pendant l'entraînement CTL, l'homme a marché sans contrainte de temps tout en regardant des images fixes et en réagissant aux mouvements du tapis roulant semblables à ceux repris par la suite en RV. Pendant l'entraînement en RV, il a ressenti les mouvements du tapis roulant programmés pour simuler les changements observés dans cinq environnements virtuels rétroprojetés sur grand écran. La difficulté de l'entraînement au cours de neuf séances réparties sur trois semaines a augmenté en variant les contraintes de temps, les changements de surface du terrain et les obstacles à éviter. Les chercheurs ont évalué les effets sur l'aptitude à marcher à l'aide de mesures cliniques (tests de marche de cinq mètres et de six minutes, échelle d'évaluation de l'équilibre de Berg, échelle de confiance en l'équilibre pendant des activités) et de questionnaires (échelle d'évaluation des habitudes de vie et évaluation personnelle). Résultats : l'entraînement CTL et celui en RV ont suscité une progression similaire de la durée totale de marche sur le tapis roulant pendant les séances d'entraînement. L'entraînement en RV a favorisé une amélioration supplémentaire de la marche rapide sur cinq mètres et de la distance parcourue en six minutes, de même qu'une meilleure auto-efficacité de l'équilibre et de meilleurs ajustements locomoteurs anticipés. Comme l'a indiqué le participant, cette amélioration des résultats se transposait dans la vie quotidienne. Conclusions : malgré le potentiel limité de récupération fonctionnelle en cas d'AVC chronique, une personne peut améliorer sa mobilité et son auto-efficacité après avoir participé à un entraînement sur tapis roulant jumelé à la RV, par rapport à un entraînement sur tapis roulant de la même intensité et selon les mêmes perturbations de la surface du sol, mais sans l'immersion de la RV. Un essai aléatoire et contrôlé à plus vaste échelle s'impose pour déterminer l'efficacité de l'entraînement sur tapis roulant jumelé à la RV dans le cadre d'une intervention de mobilité après un AVC.

Navigational strategies during fast walking: a comparison between trained athletes and non-athletes.

Many common activities such as walking in a shopping mall, moving in a busy subway station, or even avoiding opponents during sports, all require different levels of navigational skills. Obstacle circumvention is beginning to be understood across age groups, but studying trained athletes with greater levels of motor ability will further our understanding of skillful adaptive locomotor behavior. The objective of this work was to compare navigational skills during fast walking between elite athletes (e.g. soccer, field hockey, basketball) and aged-matched non-athletes under different levels of environmental complexity in relation to obstacle configuration and visibility. The movements of eight women athletes and eight women non-athletes were measured as they walked as fast as possible through different obstacle courses in both normal and low lighting conditions. Results showed that athletes, despite similar unobstructed maximal speeds to non-athletes, had faster walking times during the navigation of all obstructed environments. It appears that athletes can process visuo-spatial information faster since both groups can make appropriate navigational decisions, but athletes can navigate through complex, novel, environments at greater speeds. Athletes' walking times were also more affected by the low lighting conditions suggesting that they normally scan the obstructed course farther ahead. This study also uses new objective measures to assess functional locomotor capacity in order to discriminate individuals according to their level of navigational ability. The evaluation paradigm and outcome measures developed may be applicable to the evaluation of skill level in athletic training and selection, as well as in gait rehabilitation following impairment.