Impact of a new post-operative care model in a rural hospital after total hip replacement and total knee replacement.

PROBLEM: The predicted global trend of increasing total hip replacement and total knee replacement numbers leads to a direct and growing impact on health care services. Models of care including 'fast-track' mobilisation after total hip replacement and total knee replacement have been reported to reduce length of stay. This has not been verified in rural settings. SETTING: Armidale Rural Referral Hospital. KEY MEASURES FOR IMPROVEMENT: The new post-operative care included early discharge planning with or without Day 0 mobilisation with aims to decrease hospital length of stay without affecting complication rates, compared to the conventional model of care. STRATEGIES FOR CHANGE: Consistent communication and planning for early discharge occurred before and throughout admission and Day 0 mobilisation. EFFECTS OF CHANGE: There was a statistically significantly less median length of stay following implementation of the new post-operative care model (3.24 vs 2.29 days [P < .01]). There was no statistically significant difference in complications or readmissions following the change. Those who were allocated to mobilise on Day 0 had a lesser median length of stay than those who did not (2.40 vs 2.27 days, P = .03). LESSONS LEARNT: Our results indicate that the new post-operative care model is safe and feasible for total knee replacement or total hip replacement patients in a rural setting and might reduce length of stay without compromising clinical outcomes.

Physiotherapy using a free-standing robotic exoskeleton for patients with spinal cord injury: a feasibility study.

BACKGROUND: Evidence is emerging for the use of overground lower limb robotic exoskeletons in the rehabilitation of people with spinal cord injury (SCI), with suggested benefits for gait speed, bladder and bowel function, pain management and spasticity. To date, research has focused on devices that require the user to support themselves with a walking aid. This often precludes use by those with severe trunk, postural or upper limb deficits and places the user in a suboptimal, flexed standing position. Free-standing exoskeletons enable people with higher level injuries to exercise in an upright position. This study aimed to evaluate the feasibility of therapy with a free-standing exoskeleton for those with SCI, and to determine the potential health-related benefits of this intervention. METHODS: This 12-week intervention study with 12-week waitlist control and 12-week follow up, provided people with SCI scoring < 5 on the mobility section of the spinal cord independence measure (SCIM-III) twice weekly therapy in the REX (Rex Bionics, Auckland, NZ), a free-standing lower limb robotic exoskeleton. The primary outcome measure of interest was function, as measured on the SCIM-III. A battery of secondary outcomes was included. Participants also completed a survey on their perceptions of this treatment modality, to determine acceptability. RESULTS: Forty-one potential participants were screened for eligibility. Two females (one ASIA A, one ASIA C) and one male (ASIA B) completed all 24 intervention sessions, and the follow up assessment. One participant showed positive trends in function, fatigue, quality of life and mood during the intervention phase. Grip and quadriceps strength, and lower limb motor function improved in another. Two improved their percentage of lean body mass during the intervention phase. Remaining results were varied across patients, time points and outcomes. The intervention was highly acceptable to all participants. CONCLUSION: With three of 41 potential participants being eligible and completing this study, our results show that there are potential benefits of exercise in a free-standing exoskeleton for people with severe mobility impairment due to SCI, for a small subset of patients. Further research is warranted to determine those most likely to benefit, and the type of benefit depending on the patient characteristics. Trial registration The trial was registered prospectively on 20 April 2018 at www.anzctr.org.au/ (ACTRN12618000626268).

Gait and Balance Measures Can Identify Change From a Cerebrospinal Fluid Tap Test in Idiopathic Normal Pressure Hydrocephalus.

OBJECTIVES: To identify in patients with idiopathic normal pressure hydrocephalus (iNPH) undergoing a cerebrospinal fluid (CSF) tap test (TT) for consideration of a ventricular peritoneal (VP) shunt: (1) gait and balance measures, which identify symptom change; (2) differences present between pre- and post-CSF TT scores between patients classified as responders and nonresponder; (3) ability of patients with iNPH to accurately quantify change in their gait and balance symptoms from a CSF TT. DESIGN: Prospective observational study. Post-CSF TT assessment was completed 2-4 hours post. SETTING: Tertiary referral neurological and neurosurgical hospital. PARTICIPANTS: Patients (N=74) with iNPH receiving a 30 mL CSF TT for consideration of a VP shunt. INTERVENTIONS: Patients underwent a battery of gait and balance measures pre- and post-CSF TT and indicated their perceived change on a global rating of change (GRC). Patients deemed to improve and offered VP shunt insertion by a neurologist or neurosurgeon were labeled responders. MAIN OUTCOME MEASURES: Performance oriented mobility assessment (Tinetti), Berg Balance Scale (BBS), timed Up and Go (TUG), 10-meter walk test (10MWT), GRC. RESULTS: Forty patients were classified responders, 34 nonresponders. Significant differences were identified for responders: Tinetti (3.88 points), TUG (3.98 seconds), 10MWT (0.08 m/sec), and BBS (5.29 points). Significant differences were found for nonresponders for the Tinetti (0.91 points) and BBS (2.06 points). Change scores for responders and nonresponders were significantly different for all tests between responders and nonresponders. GRC scores for gait (+2 for responders, 0 for nonresponders) and balance (+2.5 for responders, 0 for nonresponders) were both significantly different. CONCLUSIONS: The Tinetti, BBS, and TUG can identify change in patients undergoing a CSF TT for iNPH. Patients appear to be able to accurately identify if change has occurred.

Clinical Benefits of Joint Mobilization on Ankle Sprains: A Systematic Review and Meta-Analysis.

OBJECTIVE: To assess the clinical benefits of joint mobilization for ankle sprains. DATA SOURCES: MEDLINE, MEDLINE In-Process, Embase, AMED, PsycINFO, CINAHL, Cochrane Library, PEDro, Scopus, SPORTDiscus, and Dissertations and Theses were searched from inception to June 2017. STUDY SELECTION: Studies investigating humans with grade I or II lateral or medial sprains of the ankle in any pathologic state from acute to chronic, who had been treated with joint mobilization were considered for inclusion. Any conservative intervention was considered as a comparator. Commonly reported clinical outcomes were considered such as ankle range of movement, pain, and function. After screening of 1530 abstracts, 56 studies were selected for full-text screening, and 23 were eligible for inclusion. Eleven studies on chronic sprains reported sufficient data for meta-analysis. DATA EXTRACTION: Data were extracted using the participants, interventions, comparison, outcomes, and study design approach. Clinically relevant outcomes (dorsiflexion range, proprioception, balance, function, pain threshold, pain intensity) were assessed at immediate, short-term, and long-term follow-up points. DATA SYNTHESIS: Methodological quality was assessed independently by 2 reviewers, and most studies were found to be of moderate quality, with no studies rated as poor. Meta-analysis revealed significant immediate benefits of joint mobilization compared with comparators on improving posteromedial dynamic balance (P=.0004), but not for improving dorsiflexion range (P=.16), static balance (P=.96), or pain intensity (P=.45). Joint mobilization was beneficial in the short-term for improving weight-bearing dorsiflexion range (P=.003) compared with a control. CONCLUSIONS: Joint mobilization appears to be beneficial for improving dynamic balance immediately after application, and dorsiflexion range in the short-term. Long-term benefits have not been adequately investigated.

Garment Therapy does not Improve Function in Children with Cerebral Palsy: A Systematic Review.

AIMS: To conduct a systematic review asking, does garment therapy improve motor function in children with cerebral palsy? METHODS: A systematic review with meta-analysis was conducted to review the literature. Inclusion criteria involved the wearing of therapy suits/garments in children with cerebral palsy. The primary outcome of interest was movement related function and secondary outcomes included impairment, participation, parental satisfaction and adverse outcomes of garment wear. RESULTS: 14 studies with 234 participants were included, of which 5 studies were included for meta-analysis. Garment therapy showed a nonsignificant effect on post-intervention function as measured by the Gross Motor Function Measure when compared to controls (MD = -1.9; 95% CI = -6.84, 3.05). Nonsignificant improvements in function were seen long-term (MD = -3.13; 95% CI = -7.57, 1.31). Garment therapy showed a significant improvement in proximal kinematics (MD = -5.02; 95% CI = -7.28, -2.76), however significant improvements were not demonstrated in distal kinematics (MD = -0.79; 95% CI = -3.08, 1.49). CONCLUSIONS: This review suggests garment therapy does not improve function in children with cerebral palsy. While garment therapy was shown to improve proximal stability, this benefit must be considered functionally and consider difficulties associated with garment use.

Transcranial Direct-Current Stimulation on Motor Function in Pediatric Cerebral Palsy: A Systematic Review.

PURPOSE: To determine effects of transcranial direct-current stimulation (tDCS) on motor function for children with cerebral palsy. METHODS: Six electronic databases were searched using terms related to tDCS, combined with functional deficits/associated clinical measures. Results were filtered, including randomized controlled trials in English and children with cerebral palsy. Data were extracted using standardized procedures, and the PEDro scale was used to assess quality and meta-analyses conducted. RESULTS: From 135 articles, 9 studies with moderate quality met inclusion criteria. Six were included in 7 separate meta-analyses supporting a benefit of tDCS for static balance, only at follow-up. Benefits of tDCS on dynamic balance, step length, and mobility were not established. CONCLUSIONS: The findings from meta-analyses suggest that tDCS may provide improvements in static balance at follow-up in children with cerebral palsy and positive effects on gait velocity; however, there was heterogeneity. Further research is needed before this therapy can be endorsed.

Surviving, not thriving: a qualitative analysis of parents' perceptions of physical activity participation for rurally residing children with a disability.

INTRODUCTION: Preliminary research suggests that rurally residing children with a disability seldom participate in the recommended 60 minutes of moderate-to-vigorous physical activity per day and face multiple barriers to participation. The purpose of this study was to explore parents' perceptions of physical activity participation of rurally residing children with a disability, including barriers and any factors that may facilitate their participation. METHODS: Participants were parents or carers of a school-aged child with a disability residing in a rural or remote area of the state of New South Wales, Australia. Data were collected using semi-structured focus group interviews, which were audio-recorded and transcribed. Qualitative data were analysed inductively using qualitative content analysis. RESULTS: Focus group interviews were conducted with 10 parents. Thematic analysis yielded the overarching description of the study, surviving, not thriving, which described the participants' limited success in augmenting the health of their child with a disability, despite their desire to do so. Within this description, three main themes emerged. (1) A parent's predicament described the parents' struggle to support their child's participation in physical activity, despite understanding its numerous benefits. (2) Barriers to participation described the various barriers to physical activity participation that were perceived to be hampering their child's potential to thrive. Some of these barriers were related to the child's disability, while others were specific to the rural context. (3) Facilitators to participation described the factors that served to motivate and enable children with a disability to participate in physical activity. CONCLUSIONS: This investigation of parents' perceptions suggests that the physical activity participation of rurally residing children with a disability is currently insufficient to adequately support the health of this population. It appears service providers need to address the factors that impede participation, including issues surrounding access, ability and isolation, but should also support the parents' behaviours, community opportunities and the child's own drive to participate. Existing support structures aimed at promoting physical activity should be enhanced and more inclusive, and accessible strategies should be developed.

The influence of tai chi and yoga on balance and falls in a residential care setting: A randomised controlled trial.

Abstract Falls amongst older people is a global public health concern. Whilst falling is not a typical feature of ageing, older people are more likely to fall. Fall injuries amongst older people are a leading cause of death and disability. Many older people do not do regular exercise so that they lose muscle tone, strength, and flexibility which affect balance and predispose them to falls. The management of falls in residential care settings is a major concern with strategies for prevention and monitoring a focus in this setting. Yoga and tai chi have shown potential to improve balance and prevent falls in older adults. They also have potential to improve pain and quality of life. The aim of this study was to determine the feasibility of conducting a three-arm randomised controlled trial (RCT) with frail older people in a residential care setting to test the hypothesis that a 14-week modified tai chi or yoga programme is more effective than usual care activity in improving balance function, quality of life, pain experience and in reducing number of falls. There were no statistically significant differences between the three groups in the occurrence of falls. Yoga demonstrated a slight decrease in fall incidence; quality of life improved for the tai chi group. Only the yoga group experienced a reduction in average pain scores though not statistically significant. The findings of the study suggest it is possible to safely implement modified yoga and tai chi in a residential care setting and evaluate this using RCT design. They show positive changes to balance, pain and quality of life and a high level of interest through attendance amongst the older participants. The results support offering tai chi and yoga to older people who are frail and dependent with physical and cognitive limitations.

Physical Exercise for Healthy Older Adults and Those with Frailty: What Exercise Is Best and Is There a Difference? A Systematic Review and Meta-Analyses.

Methods: All English studies published after 1989 with a controlled design, investigating PE in adults 65 years and over were considered if the study design compared PE to a nonexercise control group. Health-related outcomes included physical, cognitive, and psychological function. Studies that investigated cardiorespiratory disease and used designs like systematic review were excluded. Results and Discussion. Altogether, 57 studies were included of which 38 had data that were useable for meta-analysis. In the healthy aged, a significant benefit of multicomponent exercises (p=0.006, SMD = 1.40, CI = 0.41, 2.40) and tai chi (p=0.01, MD = 0.51, CI = 0.12, 0.91) on physical function was revealed, while strength exercise benefitted cognitive function (p=0.04, SMD = 0.86, CI = 0.03, 1.68). In frail older adults, there was a significant benefit of multicomponent exercises on physical function (p < 0.0001, SMD = -10.85, CI = 5.66, 16.04) and mental health (p=0.0002, SMD = -0.39, CI=-0.18, 0.59). Strength exercise had a significant benefit on activity of daily living (ADL) (p < 0.0003, SMD = 15.78, CI = 7.28, 24.28). Conclusion: The substantial disparity of research in the field of exercise in older adults renders synthesis of the evidence problematic. However, it appears that multicomponent exercise is the most suitable approach for both healthy and frail older adults although the benefit may be reflected in different health outcomes.

An observational study of the impact of professional walking aid prescription on gait parameters for individuals with suspected balance impairments.

Background: The primary management strategy for gait impairment is the adoption of a walking aid. However, there are no established criteria upon which to base a decision regarding the need for a walking aid. It appears clinicians prescribe aids based on preference, clinical experience and intuition rather than standardised objective rationale. This may contribute to the inconsistent gait response to walking aids reported in the published literature. Understanding gait changes resulting from gait aid usage may have significant impact on clinical practice by improving confidence of prescribing clinicians and compliance of walking aid usage by patients, maximising the benefits of use, and reducing any risks associated with non-use or inappropriate use, of the walking aid. Research question: Do professionally prescribed walking aids improve gait parameters? Methods: This is a secondary data analysis of a cross-sectional study where participants, identified by healthcare staff requiring a mobility assessment due to potential balance impairment of any cause, walked a 20-m straight walking course under three different walking conditions (no aid, walking stick and 4-wheeled walker). Fifty-eight participants were recruited. Commonly reported spatial and temporal gait parameters were assessed using a validated gait analysis device. Changes in gait parameters across the three conditions were compared, noting the individual's professionally prescribed aid and interpreting changes in parameters towards outcomes of the 'no aid required group'. Results and significance: Gait cycle, cadence, stance, swing and stride length during unaided walking were significantly changed when a walking stick was prescribed (p < 0.05). Stance, swing, double support, stride length, speed, max toe clearance and minimum toe clearance were significantly changed when a 4-wheel walker was prescribed (p < 0.05). Professional walking aid prescription improves some gait parameters. A greater number and magnitude of gait parameter improvements were seen in people requiring a 4-wheel walker than people requiring a walking stick.

Predicting post-surgical outcomes in idiopathic normal pressure hydrocephalus using clinically important changes from the cerebrospinal fluid tap test.

OBJECTIVE: Patients diagnosed with idiopathic Normal Pressure Hydrocephalus (iNPH) typically experience symptom improvements after undergoing a cerebrospinal fluid-tap test (CSF-TT), These improvements are recognized as indicative of potential improvements following surgical intervention. As gait disturbance is the most common iNPH symptom, gait improvements are of predominant interest. The purpose of this study was to examine if clinically important changes in gait and balance from CSF-TT predict meaningful changes following surgery. METHOD: The study involved analysis of data collected in a prospective observational study for 34 iNPH patients who underwent a CSF-TT and subsequent surgery. Linear regression, logistic regression and classification trees were used for predictive modelling comparing changes from CSF-TT with post-surgical changes in Tinetti, Timed Up and Go (TUG) and Berg Balance Scale (BBS) outcomes. RESULTS: Predictive models for minimal clinically important differences (MCIDs) from CSF-TT to surgery were significant for Tinetti (odds ratio = 1.42, p = 0.02) and BBS (odds ratio = 1.57, p < 0.01). Four items on Tinetti and two items on BBS were identified with a predictive accuracy of 79% and 76% respectively. BBS has the highest sensitivity (85%) and negative predictive value (77%). TUG had a 100% specificity and 100% positive predictive value. The predictive model using MCIDs for TUG was not significant (odds ratio = 1.13, p = 0.06). CONCLUSION: Clinically important changes from CSF-TT are useful in predicting post-surgical outcomes in iNPH patients. Tinetti and BBS, both have predictive value using MCID scores as cut off values, of which BBS is a stronger outcome measure for prediction.

"Are we there yet?" expectations and experiences with lower limb robotic exoskeletons: a qualitative evaluation of the therapist perspective.

PURPOSE: Lower limb robotic exoskeletons can assist movement, however, clinical uptake in neurorehabilitation is limited. The views and experiences of clinicians are pivotal to the successful clinical implementation of emerging technologies. This study investigates therapist perspectives of the clinical use and future role of this technology in neurorehabilitation. METHODS: Australian and New Zealand-based therapists with lower limb exoskeleton experience were recruited to complete an online survey and semi-structured interview. Survey data were transposed into tables and interviews transcribed verbatim. Qualitative data collection and analysis were guided by qualitative content analysis and interview data were thematically analysed. RESULTS: Five participants revealed that the use of exoskeletons to deliver therapy involves the interplay of human elements - experiences and perspectives of use, and mechanical elements - the device itself. Two overarching themes emerged: the "journey", with subthemes of clinical reasoning and user experience; and the "vehicle" with design features and cost as subthemes, to explore the question "Are we there yet?" CONCLUSION: Therapists expressed positive and negative perspectives from their experiences with exoskeletons, giving suggestions for design features, marketing input, and cost to enhance future use. Therapists are optimistic that this journey will see lower limb exoskeletons integral to rehabilitation service delivery.

Further innovation of design features, marketing, and cost are needed to enhance ongoing development and integration.Routine clinical implementation of lower limb exoskeletons is unlikely at this time in Australia and New Zealand.Therapists do expect lower limb exoskeletons to have an ongoing role in future rehabilitation.

Balance outcomes from two small rural hospitals.

OBJECTIVES: To describe predicted and measured balance changes in patients receiving physiotherapy in two rural hospitals, and to explore the relationship among balance at discharge, carer availability and patients' discharge destination. DESIGN: Prospective measurement study. SETTING: Two rural Australian hospitals. PARTICIPANTS: Eighty-nine inpatients with a median age of 84. MAIN OUTCOME MEASURES: Berg Balance Scale (BBS) on admission and the treating physiotherapist's estimate at admission of individual patient's discharge BBS. Follow-up measures included discharge BBS, carer availability after discharge and patient discharge destination. RESULTS: Although change in measured balance of study participants had wide variability, balance measured by the BBS displayed a statistically and clinically significant improvement. A strong relationship was found between balance scores and discharge destination. However, no relationship was found between carer availability and discharge destination. Physiotherapists' estimates of discharge BBS displayed an average error of 7/56. CONCLUSIONS: The strong relationship between measured balance and discharge destination in these elderly study participants suggests that maximising their balance might minimise admissions to nursing home. The high variability of measured balance change suggests outcomes are difficult to predict. The study results suggest that premature assessment of patient's suitability for nursing home placement should be avoided. The accuracy of physiotherapist's estimates of discharge BBS suggests that greater weight might be placed on their input to facilitate the discharge planning process.

Ten-Second Tandem Stance Test: A Potential Tool to Assist Walking Aid Prescription and Falls Risk in Balance Impaired Individuals.

Objective: To assess the utility of a 10-second tandem stance test in predicting gait impairment and the need for a mobility aid. Design: Cross-sectional study. Setting: Public hospital ambulatory and hospitalized care. Participants: Participants were drawn from referrals to the physiotherapy service and patients identified by health care staff as needing mobility assessment. Eighty-seven people were referred to the study. Sixty-one individuals (N=61) consented to participate; mean age was 76±9.8 years and 61% were female. All participants were community dwelling. Intervention: The 10-second tandem stance test and gait parameters were measured while walking with no walking aid, a walking stick, and a 4-wheeled walker were assessed. Main Outcome Measures: Associations between the 10-second tandem stance test performance with prescribed walking aids (primary outcome variable), gait parameters (gait cycle time, cadence, stance phase, swing phase, double support, stride length, speed, peak angle velocity, maximal heel clearance), falls history, falls risk (Falls Risk for Older People in the Community [FROP-Com]), and walking aid use. Results: Inability to maintain tandem stance for 10 seconds significantly increased the odds of requiring a prescribed walking aid (odds ratio [OR], 5.19; P=.01). Tandem stance test time was positively correlated with stride length, gait speed, peak angle velocity, and maximal heel clearance during the gait cycle. Correlation between tandem stance time and number of falls was weak but significant (ρ=-0.31, P=.01), and FROP-Com score for falls risk was negative and moderate for nonpreferred foot behind (ρ=-0.58, P<.01). The 10-second tandem stance with nonpreferred foot behind was associated with falling in previous 12 months (P=.04). Walking aid use history in subgroups with the individuals who cannot maintain the tandem stance with nonpreferred foot behind for 10 seconds was associated with falling in previous 12 months (OR, 55.00; 95% CI, 2.44-1238.46; P=.01). Conclusions: The 10-second tandem stance test was associated with professionally prescribed walking aids, gait parameters with prescribed walking aids, falls, and walking aid use history, indicating the test may be useful to guide the prescription of walking aids.

Effects of therapy with a free-standing robotic exoskeleton on motor function and other health indicators in people with severe mobility impairment due to chronic stroke: A quasi-controlled study.

INTRODUCTION: Robotic exoskeletons facilitate therapy in upright postures. This study aimed to evaluate potential health-related effects of this therapy for people with severe mobility impairment due to chronic stroke. METHODS: This quasi-controlled trial with 12 weeks of twice weekly therapy in a free-standing exoskeleton, and 12 weeks follow up, included people dependent for mobility, with stroke at least 3 months prior. The primary outcome was lower limb motor function. A battery of secondary outcomes was evaluated. RESULTS: Nine participants were enrolled. There was no change in motor function. There was a significant between phase difference in level of independence with activities of daily living (median post-intervention change = 5, IQR = 0, 10, p = 0.01), and grip strength (affected limb) (median post-intervention change = 1, IQR = 0, 2, p = 0.03). A significant difference was found for quadriceps strength (affected limb) (median change in wait phase = 4, IQR = 2, 7.5, p = 0.01). Participants consistently reported positive perceptions of the therapy. CONCLUSIONS: Therapy with a free-standing exoskeleton is acceptable to participants and can facilitate improvements in level of independence and grip strength. Restrictions regarding eligibility to use the device, may reduce the clinical application of this therapy for people with stroke.

Hippotherapy in adults with acquired brain injury: A systematic review.

BACKGROUND: Hippotherapy is used to supplement conventional therapy in neurological conditions with evidence supporting its use in pediatric patients. However, evaluation of its merit in adults with acquired brain injury (ABI) is lacking. The aim of this study was to determine if hippotherapy can improve motor function in adults with ABI. Methods: A systematic review of all available controlled studies investigating the use of hippotherapy, in adults with ABI, was conducted. The primary outcome of interest was movement related function and secondary outcomes included impairment, quality of life, and adverse events. Results: Nine studies with 256 participants were included, of which six studies with 204 participants were included for meta-analysis. When the data were pooled, hippotherapy did not produce statistically significant improvements in balance (SMD = 0.24, 95% CI -0.05, 0.54, p = 0.1) or gait parameters (SMD = -0.04, 95% CI -0.79, 0.72 p = 0.92) when compared to control and measured immediately after the intervention. Long-term effects remain unknown due to lack of follow-up evaluation. Conclusions: This review suggests that hippotherapy is safe and well tolerated by adults with ABI. Short-term functional benefits were not associated with the use of hippotherapy. Further high-quality research is required before hippotherapy can be endorsed as a modality in adult neurological rehabilitation.

The Metabolic Cost of Exercising With a Robotic Exoskeleton: A Comparison of Healthy and Neurologically Impaired People.

While neuro-recovery is maximized through active engagement, it has been suggested that the use of robotic exoskeletons in neuro-rehabilitation provides passive therapy. Using oxygen consumption (VO2) as an indicator of energy expenditure, we investigated the metabolic requirements of completing exercises in a free-standing robotic exoskeleton, with 20 healthy and 12 neurologically impaired participants (six with stroke, and six with multiple sclerosis (MS)). Neurological participants were evaluated pre- and post- 12 weeks of twice weekly robotic therapy. Healthy participants were evaluated in, and out of, the exoskeleton. Both groups increased their VO2 level from baseline during exoskeleton-assisted exercise (Healthy: mean change in VO2 = 2.10 ± 1.61 ml/kg/min, p =< 0.001; Neurological: 1.38 ± 1.22, p = 0.002), with a lower predicted mean in the neurological sample (-1.08, 95%CI -2.02, -0.14, p = 0.02). Healthy participants exercised harder out of the exoskeleton than in it (difference in VO2 = 3.50, 95%CI 2.62, 4.38, p =< 0.001). There was no difference in neurological participants' predicted mean VO2 pre- and post- 12 weeks of robotic therapy 0.45, 95%CI -0.20, 1.11, p = 0.15), although subgroup analysis revealed a greater change after 12 weeks of robotic therapy in those with stroke (MS: -0.06, 95%CI -0.78, 0.66, p = 0.85; stroke: 1.00, 95%CI 0.3, 1.69, p = 0.01; difference = 1.06, p = 0.04). Exercise in a free-standing robotic exoskeleton is not passive in healthy or neurologically impaired people, and those with stroke may derive more benefit than those with MS.

Clinimetric Properties and Minimal Clinically Important Differences for a Battery of Gait, Balance, and Cognitive Examinations for the Tap Test in Idiopathic Normal Pressure Hydrocephalus.

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is treated by insertion of a ventricular peritoneal (VP) shunt. To help identify who would benefit from a VP shunt, patients undergo a tap test (TT). Several measures can identify change from a TT, but the magnitude of change and the combination of measures that indicate the improvement from a TT is unclear. OBJECTIVE: To develop minimal clinically important differences (MCIDs) for a battery of gait, balance, and cognitive measures in relation to improvement from the TT, and to identify which combination of measures best identifies when improvement has occurred. METHODS: Observational study of iNPH patients undergoing a TT for consideration of a VP shunt. Patients completed the: The Timed Up and Go (TUG), Timed Up and Go cognition (TUG-C), Performance Oriented Mobility Assessment (Tinetti), and Berg Balance Scale (BBS) pre- and post-TT. A Global Rating of Change scale assessed patients' perceived improvements in gait and balance post-TT. RESULTS: MCIDs for the TT were (calculated as percentage changes): TUG: 13%, TUG-C: 11% Tinetti: 36%, and BBS: 20%. A combination of the TUG-C and Tinetti resulted in sensitivity of 90.28% to identify improvement, while the Tinetti and BBS resulted in specificity of 98.58% to exclude improvement from a TT. CONCLUSION: These MCIDs provide the first evidence to quantify the significance of post-TT symptom changes and provides objective data to guide recommendations for clinical management. Utilizing a combination of measures, and these MCIDs as cut off values, results in high sensitivity and specificity for identifying improvement from a TT.

Do powered over-ground lower limb robotic exoskeletons affect outcomes in the rehabilitation of people with acquired brain injury?

Purpose: To assess the effects of lower limb robotic exoskeletons on outcomes in the rehabilitation of people with acquired brain injury.Materials and methods: A systematic review of seven electronic databases was conducted. The primary outcome of interest was neuromuscular function. Secondary outcomes included quality of life, mood, acceptability and safety. Studies were assessed for methodological quality and recommendations were made using the GRADE system.Results: Of 2469 identified studies, 13 (n = 322) were included in the review. Five contained data suitable for meta-analysis. When the data were pooled, there were no differences between exoskeleton and control for 6-Minute Walk Test, Timed Up and Go or 10-Meter Walk Test. Berg Balance Scale outcomes were significantly better in controls (MD = 2.74, CI = 1.12-4.36, p = 0.0009). There were no severe adverse events but drop-outs were 11.5% (n = 37). No studies reported the effect of robotic therapy on quality of life or mood. Methodological quality was on average fair (15.6/27 on Downs and Black Scale).Conclusions: Only small numbers of people with acquired brain injury had data suitable for analysis. The available data suggests no more benefit for gait or balance with robotic therapy than conventional therapy. However, some important outcomes have not been studied and further well-conducted research is needed to determine whether such devices offer benefit over conventional therapy, in particular subgroups of those with acquired brain injury.Implications for RehabilitationThere is adequate evidence to recommend that powered over-ground lower limb robotic exoskeletons should not be used clinically in those with ABI, and that use should be restricted to research.Further research (controlled trials) with dependent ambulators is recommended.Research of other outcomes such as acceptability, spasticity, sitting posture, cardiorespiratory and psychological function, should be considered.

Cognitive and upper limb symptom changes from a tap test in Idiopathic Normal Pressure Hydrocephalus.

OBJECTIVES: To determine which cognitive and upper limb assessments can identify change in patients undergoing a Cerebrospinal fluid (CSF) tap test (TT) diagnosed with idiopathic Normal Pressure Hydrocephalus (iNPH). PATIENTS AND METHODS: Prospective observational study of 74 iNPH patients undergoing a CSF TT for consideration of a ventricular peritoneal shunt. Patients who were offered surgical intervention were classified as responders. Patients were assessed with a battery of cognitive and upper limb assessments prior to and following a CSF TT. The Timed up and go cognition (TUG-C), Montreal Cognitive assessment (MoCA) and 9-hole peg test were utilised. RESULTS: 40 patients were classified responders. Significant differences were identified for responders for the MoCA (0.62 points) and TUG-C (-6.02 s). Only the executive function and orientation sub scores of the MoCA showed significant changes for responders. The 9 hole peg test mean change of 4.33 s for responders was not significant. Non-responder change scores for the MoCA (0.22 points), TUG-C (0.3 s) and 9 hole peg test (2.58 s) were not significant. CONCLUSION: The TUG-C has the potential to identify change in patients resulting from a CSF TT. While statistically significant change was found for the MoCA, a mean change of less than 1 point on this scale is unlikely to be clinically relevant. Similarly, the 9 hole peg test cannot be endorsed as an assessment tool for identifying changed performance in iNPH.