COVID-19 Pandemic and Beyond: Considerations and Costs of Telehealth Exercise Programs for Older Adults With Functional Impairments Living at Home-Lessons Learned From a Pilot Case Study.

OBJECTIVE: The purpose of this study was to describe the process and cost of delivering a physical therapist-guided synchronous telehealth exercise program appropriate for older adults with functional limitations. Such programs may help alleviate some of the detrimental impacts of social distancing and quarantine on older adults at-risk of decline. METHODS: Data were derived from the feasibility arm of a parent study, which piloted the telehealth program for 36 sessions with 1 participant. The steps involved in each phase (ie, development, delivery) were documented, along with participant and program provider considerations for each step. Time-driven activity-based costing was used to track all costs over the course of the study. Costs were categorized as program development or delivery and estimated per session and per participant. RESULTS: A list of the steps and the participant and provider considerations involved in developing and delivering a synchronous telehealth exercise program for older adults with functional impairments was developed. Resources used, fixed and variable costs, per-session cost estimates, and total cost per person were reported. Two potential measures of the "value proposition" of this type of intervention were also reported. Per-session cost of $158 appeared to be a feasible business case, especially if the physical therapist to trained assistant personnel mix could be improved. CONCLUSIONS: The findings provide insight into the process and costs of developing and delivering telehealth exercise programs for older adults with functional impairments. The information presented may provide a "blue print" for developing and implementing new telehealth programs or for transitioning in-person services to telehealth delivery during periods of social distancing and quarantine. IMPACT: As movement experts, physical therapists are uniquely positioned to play an important role in the current COVID-19 pandemic and to help individuals who are at risk of functional decline during periods of social distancing and quarantine. Lessons learned from this study's experience can provide guidance on the process and cost of developing and delivering a telehealth exercise program for older adults with functional impairments. The findings also can inform new telehealth programs, as well as assist in transitioning in-person care to a telehealth format in response to the COVID-19 pandemic.

Bilateral Assessment of the Corticospinal Pathways of the Ankle Muscles Using Navigated Transcranial Magnetic Stimulation.

Distal leg muscles receive neural input from motor cortical areas via the corticospinal tract, which is one of the main motor descending pathway in humans and can be assessed using transcranial magnetic stimulation (TMS). Given the role of distal leg muscles in upright postural and dynamic tasks, such as walking, a growing research interest in the assessment and modulation of the corticospinal tracts relative to the function of these muscles has emerged in the last decade. However, methodological parameters used in previous work have varied across studies making the interpretation of results from cross-sectional and longitudinal studies less robust. Therefore, use of a standardized TMS protocol specific to the assessment of leg muscles' corticomotor response (CMR) will allow for direct comparison of results across studies and cohorts. The objective of this paper is to present a protocol that provides the flexibility to simultaneously assess the bilateral CMR of two main ankle antagonistic muscles, the tibialis anterior and soleus, using single pulse TMS with a neuronavigation system. The present protocol is applicable while the examined muscle is either fully relaxed or isometrically contracted at a defined percentage of maximum isometric voluntary contraction. Using each subject's structural MRI with the neuronavigation system ensures accurate and precise positioning of the coil over the leg cortical representations during assessment. Given the inconsistency in CMR derived measures, this protocol also describes a standardized calculation of these measures using automated algorithms. Though this protocol is not conducted during upright postural or dynamic tasks, it can be used to assess bilaterally any pair of leg muscles, either antagonistic or synergistic, in both neurologically intact and impaired subjects.

Dimensionality and Item-Difficulty Hierarchy of the Lower Extremity Fugl-Meyer Assessment in Individuals With Subacute and Chronic Stroke.

OBJECTIVE: To investigate the dimensionality and item-difficulty hierarchy of the Fugl-Meyer Assessment of the lower extremity (FMA-LE). DESIGN: Secondary analyses of data pooled from 4 existing datasets: a phase III randomized controlled trial investigating the effectiveness of body weight support and a treadmill for rehabilitation of walking poststroke, and 3 cross-sectional studies investigating the link between impaired motor performance poststroke and walking. SETTING: University research centers and rehabilitation centers. PARTICIPANTS: A pooled sample of individuals with a stroke (N=535, men=313; mean age ± SD, 61.91±12.42y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Confirmatory factor analyses (CFA) and Rasch residual principal component analysis (PCA) investigated the dimensionality of the FMA-LE. The Rasch analysis rating scale model investigated item-difficulty hierarchy of the FMA-LE. RESULTS: The CFA showed adequate fit of a 3-factor model, with 2 out of 3 indices (CFA=.95; Tucker-Lewis Index=.94; root mean square error of approximation=.124) showing good model fit. Rasch PCA showed that removal of the reflex and coordination items explained 90.8% of variance in the data, suggesting that the abnormal synergy items contributed to the measurement of a unidimensional construct. However, rating scale model results revealed deviations in the item-difficulty hierarchy of the unidimensional abnormal synergy items from the originally proposed stepwise sequence of motor recovery. CONCLUSIONS: Our findings suggest that the FMA-LE might represent a multidimensional construct, challenging the use of a total score of the FMA-LE to predict lower extremity motor recovery. Removal of the misfit items resulted in creation of a unidimensional scale composed of the abnormal synergy items. However, this unidimensional scale deviates from the originally proposed hierarchical ordering.

Evaluation of abnormal synergy patterns poststroke: relationship of the Fugl-Meyer Assessment to hemiparetic locomotion.

BACKGROUND: Assessment of poststroke motor impairment has historically focused on the ability to move within and outside of abnormal synergistic motor patterns and is typically quantified by the Fugl-Meyer Assessment (FMA). However, it is unclear if the voluntary, isolated movement tasks of the FMA are appropriate for evaluating walking task-specific motor control requirements because walking is cyclical and involves considerable sensorimotor integration. OBJECTIVE: The purpose of this study is to test whether the motor impairment measured by the FMA is indicative of motor dysfunction during walking in poststroke adults. METHODS: Thirty-four individuals with chronic poststroke hemiparesis and 17 healthy controls walked for 60 seconds on an instrumented treadmill while recording electromyographic activity (EMG) from 8 lower extremity muscles. EMG recordings were also obtained during the FMA for those with hemiparesis to examine muscle activation patterns. Each participant was examined with a battery of walking-specific clinical and biomechanical assessment tools and stratified based on the FMA synergy (FMS) score. To further quantify muscle activation patterns during walking, a nonnegative matrix factorization (NNMF) determined the number of independent modules required to describe 90% of the total variance in the EMG patterns. RESULTS: Stratification poorly differentiated motor activation across FMA tasks as well as EMG patterns during walking. While FMS correlated with 2 of 6 walking assessments, the number of EMG modules significantly correlated with all 6 walking performance measures. CONCLUSIONS: Voluntary, discrete activities as performed in the FMA may be inadequate to capture the complex motor behavior in walking. Conversely, walking-specific evaluations such as NNMF appear more appropriate.