Sample Entropy Improves Assessment of Postural Control in Early-Stage Multiple Sclerosis.

Postural impairment in people with multiple sclerosis (pwMS) is an early indicator of disease progression. Common measures of disease assessment are not sensitive to early-stage MS. Sample entropy (SE) may better identify early impairments. We compared the sensitivity and specificity of SE with linear measurements, differentiating pwMS (EDSS 0-4) from healthy controls (HC). 58 pwMS (EDSS ≤ 4) and 23 HC performed quiet standing tasks, combining a hard or foam surface with eyes open or eyes closed as a condition. Sway was recorded at the sternum and lumbar spine. Linear measures, mediolateral acceleration range with eyes open, mediolateral jerk with eyes closed, and SE in the anteroposterior and mediolateral directions were calculated. A multivariate ANOVA and AUC-ROC were used to determine between-groups differences and discriminative ability, respectively. Mild MS (EDSS ≤ 2.0) discriminability was secondarily assessed. Significantly lower SE was observed under most conditions in pwMS compared to HC, except for lumbar and sternum SE when on a hard surface with eyes closed and in the anteroposterior direction, which also offered the strongest discriminability (AUC = 0.747), even for mild MS. Overall, between-groups differences were task-dependent, and SE (anteroposterior, hard surface, eyes closed) was the best pwMS classifier. SE may prove a useful tool to detect subtle MS progression and intervention effectiveness.

A Practical Post-Stroke Elbow Spasticity Assessment Using an Upper Limb Rehabilitation Robot: A Validation Study.

Spasticity is a motor disorder characterised by a velocity-dependent increase in muscle tone, which is critical in neurorehabilitation given its high prevalence and potential negative influence among the post-stroke population. Accurate measurement of spasticity is important as it guides the strategy of spasticity treatment and evaluates the effectiveness of spasticity management. However, spasticity is commonly measured using clinical scales which may lack objectivity and reliability. Although many technology-assisted measures have been developed, showing their potential as accurate and reliable alternatives to standard clinical scales, they have not been widely adopted in clinical practice due to their low usability and feasibility. This paper thus introduces an easy-to-use robotic based measure of elbow spasticity and its evaluation protocol. Preliminary results collected with one post-stroke patient and one healthy control subject are presented and demonstrate the feasibility of the approach.

High-Level Mobility Assessment Tool Normative Values for Children.

BACKGROUND: Physical therapists need to be able to evaluate high-level gross motor skills of children to determine their capacity to engage in activities such as running, jumping, hopping, and stair climbing. The High-Level Mobility Assessment Tool (HiMAT) has excellent interrater and retest reliability and is less susceptible to a ceiling effect than existing mobility scales in children who are 6 to 17 years old and have traumatic brain injury. OBJECTIVE: The purposes of this study were to develop normative HiMAT score ranges for Australian children and to investigate the relationship between children's HiMAT scores and their age, height, weight, and body mass index (BMI). DESIGN: This study used a cross-sectional design. METHODS: Children included in this study were 5 to 12 years old, had no condition affecting their mobility, could follow 2-stage instructions, and had written informed consent from their parent or guardian. A total 1091 children were assessed at their local school, where their height, weight, and HiMAT score were recorded. The relationships between children's age, height, weight, and BMI were summarized using Spearman rank correlations. Truncated regression models were used to determine the most appropriate predictor variable for developing sex-specific normative ranges. RESULTS: There was a positive correlation between children's HiMAT scores and their age, height, weight, and BMI. Age explained the most variability in HiMAT scores for both boys and girls. LIMITATIONS: The reliability, validity, and responsiveness of the HiMAT have not been tested across a broad range of children with mobility limitations. Normative data reported in this study are for Australian children only. CONCLUSIONS: HiMAT scores for children in this study increased with age, height, weight, and BMI. Age was the most appropriate variable for developing a normative dataset of HiMAT scores for children of primary school age.

Comparison of estimated energy requirements using predictive equations with total energy expenditure measured by the doubly labelled water method in acute spinal cord injury.

STUDY DESIGN: Prospective, observational OBJECTIVES: To evaluate agreement between a reference method (doubly labelled water, DLW) of total energy expenditure (TEE) and published equations for estimating energy requirements in acute spinal cord injury (SCI). SETTING: Victoria, Australia METHODS: Twenty participants (18 male) within 8 weeks of traumatic SCI completed DLW, anthropometric and dietary intake assessments. Energy requirements were predicted using Harris-Benedict, Schofield, Henry, Nelson, Buchholz and Chun equations, multiplied by a combined activity and stress factor of 1.3, and the ratio method (kJ/kg body weight). Fat-free mass (FFM) and fat mass (FM) were calculated from TBW-derived DLW and from bioelectrical impedance spectroscopy (BIS). RESULTS: Median time since injury was 41 days. Median TEE was 9.1 MJ. Fair agreement was found between TEE and predicted energy requirements for the Chun (rc = 0.39), the Harris-Benedict equation (rc = 0.30), the ratio method (rc = 0.23) and the Buchholz (rc = 0.31) and Nelson equations (rc = 0.35), which incorporate measures of FFM and/or FM. Other equations showed weak concordance with DLW. When two hypermetabolic patients were removed, agreement between TEE and predicted energy requirements using the Buchholz equation increased to substantial (rc = 0.72) and using the Nelson (rc = 0.53) and Chun equations (rc = 0.53) increased to moderate. The Buchholz equation had the smallest limits of agreement (-2.4-2.3 MJ/d). CONCLUSION: The population-specific Buchholz equation that incorporates FFM, predicted from either BIS or DLW, demonstrated the best agreement in patients with acute SCI. SPONSORSHIP: The study was funded by grants from the Institute for Safety, Compensation and Recovery Research (ISCRR Project # NGE-E-13-078) and Austin Medical Research Foundation. M Panisset was supported by an Australian Postgraduate Award.

Intensive exercise program after spinal cord injury ("Full-On"): study protocol for a randomized controlled trial.

BACKGROUND: Rehabilitation after spinal cord injury (SCI) has traditionally involved teaching compensatory strategies for identified impairments and deficits in order to improve functional independence. There is some evidence that regular and intensive activity-based therapies, directed at activation of the paralyzed extremities, promotes neurological improvement. The aim of this study is to compare the effects of a 12-week intensive activity-based therapy program for the whole body with a program of upper body exercise. METHODS/DESIGN: A multicenter, parallel group, assessor-blinded randomized controlled trial will be conducted. One hundred eighty-eight participants with spinal cord injury, who have completed their primary rehabilitation at least 6 months prior, will be recruited from five SCI units in Australia and New Zealand. Participants will be randomized to an experimental or control group. Experimental participants will receive a 12-week program of intensive exercise for the whole body, including locomotor training, trunk exercises and functional electrical stimulation-assisted cycling. Control participants will receive a 12-week intensive upper body exercise program. The primary outcome is the American Spinal Injuries Association (ASIA) Motor Score. Secondary outcomes include measurements of sensation, function, pain, psychological measures, quality of life and cost effectiveness. All outcomes will be measured at baseline, 12 weeks, 6 months and 12 months by blinded assessors. Recruitment commenced in January 2011. DISCUSSION: The results of this trial will determine the effectiveness of a 12-week program of intensive exercise for the whole body in improving neurological recovery after spinal cord injury. TRIAL REGISTRATION: NCT01236976 (10 November 2010), ACTRN12610000498099 (17 June 2010).

Early intensive hand rehabilitation after spinal cord injury ("Hands On"): a protocol for a randomised controlled trial.

BACKGROUND: Loss of hand function is one of the most devastating consequences of spinal cord injury. Intensive hand training provided on an instrumented exercise workstation in conjunction with functional electrical stimulation may enhance neural recovery and hand function. The aim of this trial is to compare usual care with an 8-week program of intensive hand training and functional electrical stimulation. METHODS/DESIGN: A multicentre randomised controlled trial will be undertaken. Seventy-eight participants with recent tetraplegia (C2 to T1 motor complete or incomplete) undergoing inpatient rehabilitation will be recruited from seven spinal cord injury units in Australia and New Zealand and will be randomised to a control or experimental group. Control participants will receive usual care. Experimental participants will receive usual care and an 8-week program of intensive unilateral hand training using an instrumented exercise workstation and functional electrical stimulation. Participants will drive the functional electrical stimulation of their target hands via a behind-the-ear bluetooth device, which is sensitive to tooth clicks. The bluetooth device will enable the use of various manipulanda to practice functional activities embedded within computer-based games and activities. Training will be provided for one hour, 5 days per week, during the 8-week intervention period. The primary outcome is the Action Research Arm Test. Secondary outcomes include measurements of strength, sensation, function, quality of life and cost effectiveness. All outcomes will be taken at baseline, 8 weeks, 6 months and 12 months by assessors blinded to group allocation. Recruitment commenced in December 2009. DISCUSSION: The results of this trial will determine the effectiveness of an 8-week program of intensive hand training with functional electrical stimulation. TRIAL REGISTRATION: NCT01086930 (12th March 2010)ACTRN12609000695202 (12th August 2009).

Evaluation of the psychometric properties of the upper limb subscales of the Motor Assessment Scale using a Rasch analysis model.

OBJECTIVES: To apply Rasch analysis to evaluate the psychometric properties of the composite score of the 3 upper limb subscales of the Motor Assessment Scale (UL-MAS) when administered in the acute/subacute phase post-stroke. DESIGN: Prospective data collection of UL-MAS scores. PARTICIPANTS: Eighty Eighty individuals a mean of 64.8 days (standard deviation 53.3; range 4-193 days) following the onset of unilateral stroke. METHODS: All UL-MAS test items were administered in 30 participants assessed longitudinally over 3 occasions, and in 50 participants assessed on a single occasion. These 140 observations were pooled to be evaluated using Rasch analysis. RESULTS: With the elimination of the wrist radial deviation test item, the UL-MAS demonstrated uni-dimensionality with no significant test item response bias. The test item difficulty hierarchy was validated in the Upper Arm and Hand Movements subscales, but not in the Advanced Hand Activities subscale. The acceptable floor (14%) and ceiling (9%) effects and the high Person Separation Reliability Index (0.96) indicated that the scale was appropriately targeted to discriminate statistically between groups of acute/subacute stroke participants with differing upper limb motor recovery. CONCLUSION: The findings support the psychometric properties of the composite UL-MAS score in this clinical population.

Effect of test position on pelvic floor muscle assessment.

The aims of this study were to analyse the effect of different body positions on pelvic floor muscle (PFM) assessment using digital muscle testing, manometry and transabdominal ultrasound. In addition, subject acceptance of each testing position was recorded. Subjects were 20 women's health physiotherapists. The testing protocol included the best of three maximum voluntary contractions tested in each of four positions (crook lying, supine, sitting and standing). Significant differences in muscle strength and subject acceptance between positions were found with each tool, most often between lying and upright positions. Digital muscle testing and vaginal squeeze-pressure scores were highest in the lying position, and vaginal resting pressure and transabdominal ultrasound scores were highest in the standing position. Subjects preferred the lying positions for internal examinations. The clinical significance of these differences and the reasons for these variations require further investigation.

Reliability of pelvic floor muscle strength assessment using different test positions and tools.

AIMS: The aims of this study were to determine the intra-therapist reliability for digital muscle testing and vaginal manometry on maximum voluntary contraction strength and endurance. In addition, we assessed how reliability varied with different tools and different testing positions. METHODS: Subjects included 20 female physiotherapists. The modified Oxford scale was used for the digital muscle testing, and the Peritron perineometer was used for the vaginal resting pressure and vaginal squeeze pressure assessments. Strength and endurance testing were performed. The highest of the maximum voluntary contraction scores was used in strength analysis, and a fatigue index value was calculated from the endurance repetitions. Bent-knee lying, supine, sitting, and standing positions were used. The time interval for between-session reliability was 2-6 weeks. RESULTS: Kappa values for the between-session reliability of digital muscle testing were 0.69, 0.69, 0.86, and 0.79 for the four test positions, respectively. Intra-class correlation coefficient (ICC) values for squeeze pressure readings for the four positions were 0.95, 0.91, 0.96, and 0.92 for maximum voluntary contraction, and 0.05, 0.42, 0.13, and 0.35 for endurance testing. ICC values for resting pressure were 0.74, 0.77, 0.47, and 0.29. CONCLUSIONS: Reliability of digital muscle testing was very good in sitting and good in the other three positions. vaginal resting pressure demonstrated very good reliability in all four positions for maximum voluntary contraction, but was unreliable for endurance testing. Vaginal resting pressure was not reliable in upright positions. Both measurement tools are reliable in certain positions, with manometry demonstrating higher reliability coefficients.

Survey of clinical practice: pre- and postoperative physiotherapy for pelvic surgery.

BACKGROUND: The objective of this survey was to obtain information about current physiotherapy practice for patients undergoing pelvic surgery. The aims were to evaluate whether differences exist in service provision between women's health physiotherapists (WHPTs) and hospital physiotherapists (HPTs) and in the guidelines used by physiotherapists to direct their service delivery. METHODS. A questionnaire was posted to the members of the Victorian Continence and Women's Health Physiotherapy Group (n = 130) and physiotherapists working in metropolitan and rural hospitals (n = 90). The questionnaire comprised questions relating to the aspects of treatment, including how referrals are made, funding, interventions provided and how they are delivered, and use of outcome measures. Data were summarized using descriptive statistics and Chi-square analysis of differences between WHPTs and HPTs. RESULTS: The response rate was 75.9%. In 67% of cases, service delivery was initiated by surgeon request, and most commonly for gynecologic patients (85%). Individual consultations were used on 96% of occasions and 8% were group sessions. Content of physiotherapy treatment for in-patients varied, with WHPTs significantly more likely to prescribe pelvic floor muscle exercises (P = 0.003), bowel advice (P = 0.001), avoidance of risk activities (P = 0.002), and awareness of postoperative symptoms (P = 0.001). Conversely, HPTs were significantly more likely to perform respiratory checks (P = 0.002) and mobilization (P = 0.001). Eighty-seven percent of respondents regarded their service as suboptimal, citing the need for evidence to support the content and best timing of intervention. CONCLUSION: Differences exist in physiotherapy treatment for pelvic surgery patients. Further research is required to establish whether, and which, elements of physiotherapy intervention are effective.