Occupational Therapy to Improve Activities of Daily Living of People With Parkinson's Disease.

Evidence Connection articles are offered by the American Occupational Therapy Association's Evidence-Based Practice Program to inform and assist occupational therapy practitioners in methods that translate findings from the literature into usable knowledge for daily practice. These articles can guide professional reasoning and help practitioners operationalize findings from systematic reviews into practical strategies that can improve patient outcomes and support evidence-based practice. This Evidence Connection article is based on findings from a systematic review of interventions within the scope of occupational therapy practice to improve performance with activities of daily living (ADLs) for adults with Parkinson's disease (Doucet et al., 2021). In this article, we present a case study of an older adult with Parkinson's disease. We discuss suggested evaluation tools and intervention strategies that might be used as part of occupational therapy to address limitations and meet his desired needs for improved participation in ADLs. A client-centered, evidence-based plan was constructed for this case.

Occupational Performance and Hand Function in People With Parkinson's Disease After Participation in Lee Silverman Voice Treatment (LSVT) BIG®.

IMPORTANCE: People with Parkinson's disease (PD) experience motor and functional impairment that can negatively affect daily living and participation. OBJECTIVE: To examine the occupational performance and hand function outcomes of people with PD who participated in a Lee Silverman Voice Treatment (LSVT) BIG® program. DESIGN: Retrospective record review. SETTING: Outcomes were extracted from patient charts at a hospital outpatient clinic. PARTICIPANTS: Sixty-six clinic outpatients with PD who completed the LSVT BIG program. INTERVENTION: An occupational therapist and a physical therapist who were certified in LSVT BIG administration delivered the 16-session LSVT BIG program. Outcomes and Measures: The Canadian Occupational Performance Measure (COPM), grip strength, and Minnesota Manual Dexterity Test (MMDT) were administered before and after participation in LSVT BIG training. RESULTS: For participant-identified COPM goals, pre-post changes were significant, ranging from 3 to 6 points for performance and satisfaction (p < .001). Grip strength in both hands showed significant gains; median scores for the right hand increased from 55.0 lb (interquartile range [IQR] 41.0, 70.0) to 64.0 lb (IQR 46.0, 80.0; p < .001) and for the left hand from 52.0 lb (IQR 39.0, 64.0) to 63.0 lb (IQR 44.5, 79.5; p < .001). MMDT median scores for right to left also significantly improved, from 124.0 s (IQR 113.0, 181.0) to 119.5 s (IQR 105.5, 163.5; p = .014). CONCLUSIONS AND RELEVANCE: Participation in the LSVT BIG program can improve perceived occupational performance and satisfaction and produce gains in hand strength and dexterity for people with PD. What This Article Adds: This study is the first retrospective review of data on occupational performance and hand function outcomes after participation in the LSVT BIG program. The findings of beneficial outcomes support the use of LSVT BIG in occupational therapy services to increase functional abilities among people with PD.

Interventions Within the Scope of Occupational Therapy to Improve Activities of Daily Living, Rest, and Sleep in People With Parkinson's Disease: A Systematic Review.

IMPORTANCE: People with Parkinson's disease (PD) commonly experience difficulty in performing activities of daily living (ADLs), which affects their perceived quality of life. OBJECTIVE: To examine the evidence for the effectiveness of interventions within the scope of occupational therapy to improve performance and participation in ADLs, rest, and sleep in adults with PD. DATA SOURCES: Databases searched were MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane Collection. Included articles were published between January 2011 and December 2018. Study Selection and Data Collection: Articles describing Level 1b, 2b, and 3b studies that examined outcomes related to ADLs, rest, and sleep in people with PD were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. FINDINGS: Forty-five articles (10 Level 1b, 27 Level 2b, and 8 Level 3b) met the inclusion criteria. CONCLUSIONS AND RELEVANCE: Strong strength of evidence was found to support inpatient multidisciplinary intensive rehabilitation treatment (MIRT) to improve ADLs, and moderate strength of evidence that MIRT improves sleep performance. Low strength of evidence was present for outpatient occupational therapy to improve ADL and sleep outcomes. Low strength of evidence was found for resistance exercise programs to improve ADLs, but moderate strength of evidence indicates that multimodal exercise programs and targeted exercise programs can improve ADLs. Low to moderate strength of evidence suggested that alternative therapies and cognitive-behavioral therapy have a positive impact on ADLs and sleep. These results can be used to inform evidence-based occupational therapy practice. What This Article Adds: This article provides information for practitioners on the effectiveness of interventions within the scope of occupational therapy practice to improve ADLs and sleep.

Low-frequency electrical stimulation with variable intensity preserves torque.

The neuromuscular electrical stimulation (NMES) parameters that optimally modulate torque output during prolonged stimulation protocols are not well-established. The purpose of this study was to compare torque output between low-frequency and high-frequency NMES protocols while increasing stimulation intensity. Eleven healthy young individuals received a repetitive, intermittent low-frequency (20 Hz) and high-frequency (60 Hz) NMES over the quadriceps muscles. Stimulation intensity was increased throughout the protocol to achieve a submaximal target torque output. Mean torque, peak torque and torque-time integral (TTI) were measured. The 20 Hz protocol produced a higher mean torque (P = 0.001) and TTI (P = 0.008) compared to the 60 Hz protocol. The stimulation intensity required to achieve target torque during NMES was not different between frequencies (P > 0.0001). When the goal is to optimize torque output during prolonged submaximal NMES, such as during functional electrical stimulation, low-frequency stimulation may be preferred.

High-Frequency Neuromuscular Electrical Stimulation Increases Anabolic Signaling.

PURPOSE: Neuromuscular electrical stimulation (NMES) is commonly used in rehabilitation settings to increase muscle mass and strength. However, the effects of NMES on muscle growth are not clear and no human studies have compared anabolic signaling between low-frequency (LF) and high-frequency (HF) NMES. The purpose of this study was to determine the skeletal muscle anabolic signaling response to an acute bout of LF- and HF-NMES. METHODS: Eleven young healthy volunteers (6 men, 5 women) received an acute bout of LF-NMES (20 Hz) and HF-NMES (60 Hz). Muscle biopsies were obtained from the vastus lateralis muscle before the first NMES treatment and 30 min after each NMES treatment. Phosphorylation of the following key anabolic signaling proteins was measured by Western blot, and proteins are expressed as a ratio of phosphorylated to total: mammalian target of rapamycin, p70-S6 kinase 1, and eukaryotic initiation factor 4E binding protein 1. RESULTS: Compared with pre-NMES, phosphorylation of mammalian target of rapamycin was upregulated 40.2% for LF-NMES (P = 0.018) and 68.4% for HF-NMES (P < 0.0001), and HF-NMES was 29.3% greater than LF-NMES (P = 0.026). Phosphorylation of p70-S6 kinase 1 after HF-NMES was 96.6% higher than pre-NMES (P = 0.001) and was not different between pre-NMES and LF-NMES (although it was 50.4% higher after LF-NMES) or LF- and HF-NMES (P > 0.05). There were no differences between treatment conditions for eukaryotic initiation factor 4E binding protein 1 phosphorylation (P > 0.05). CONCLUSIONS: An acute bout of LF- and HF-NMES upregulated anabolic signaling with HF-NMES producing a greater anabolic response compared with LF-NMES, suggesting that HF stimulation may provide a stronger stimulus for processes that initiate muscle hypertrophy. In addition, the stimulation frequency parameter should be considered by clinicians in the design of optimal NMES treatment protocols.

Pilot Study Combining Electrical Stimulation and a Dynamic Hand Orthosis for Functional Recovery in Chronic Stroke.

OBJECTIVE: We investigated the effect of a combined neuromuscular electrical stimulation (ES) and dynamic hand orthosis (DHO) regimen with a group of people with chronic stroke to improve performance on specific daily tasks. METHOD: Four people with chronic stroke participated in an ES-DHO regimen using the affected upper extremity 5×/wk for 6 wk. Outcome measures included grip strength, range of motion (ROM), and analysis of muscle activation-deactivation during release of grasp through electromyography. Ability to perform specific daily living tasks was assessed using the Assessment of Motor and Process Skills (AMPS). RESULTS: Results suggested that improvements in strength, ROM, and grasp deactivation are possible with the combined ES-DHO regimen. All participants' AMPS motor scores improved. CONCLUSIONS: An ES-DHO regimen may improve motor skills needed for functional task performance in people with chronic stroke. Results should be interpreted cautiously because of the pilot nature of the study and the small sample size.

Neuromuscular Electrical Stimulation and Anabolic Signaling in Patients with Stroke.

INTRODUCTION: Stroke results in limited ability to produce voluntary muscle contraction and movement on one side of the body, leading to further muscle wasting and weakness. Neuromuscular electrical stimulation is often used to facilitate involuntary muscle contraction; however, the effect of neuromuscular electrical stimulation on muscle growth and strengthening processes in hemiparetic muscle is not clear. This study examined the skeletal muscle anabolic response of an acute bout of neuromuscular electrical stimulation in individuals with chronic stroke and healthy older adults. METHODS: Eleven individuals (59.8 ± 2.7 years old) were divided into a chronic stroke group (n = 5) and a healthy older adult control group (n = 6). Muscle biopsies were obtained before and after stimulation from the vastus lateralis of the hemiparetic leg for the stroke group and the right leg for the control group. The neuromuscular electrical stimulation protocol consisted of a 60-minute, intermittent stimulation train at 60 Hz. Phosphorylation of mammalian target of rapamycin and ribosomal protein S6 kinase beta-1 were analyzed by Western blot. FINDINGS: An acute bout of neuromuscular electrical stimulation increased phosphorylation of mammalian target of rapamycin (stroke: 56.0%; control: 51.4%; P = .002) and ribosomal protein S6 kinase beta-1 (stroke: 131.2%; control: 156.3%; P = .002) from resting levels to post-neuromuscular electrical stimulation treatment, respectively. Phosphorylated protein content was similar between stroke and control groups at both time points. CONCLUSION: Findings suggest that paretic muscles of patients with chronic stroke may maintain ability to stimulate protein synthesis machinery in response to neuromuscular electrical stimulation.

Force Irregularity Following Maximal Effort: The After-Peak Reduction.

Irregularities in force output are present throughout human movement and can impair task performance. We investigated the presence of a large force discontinuity (after-peak reduction, APR) that appeared immediately following peak in maximal effort ramp contractions performed with the thumb adductor and ankle dorsiflexor muscles in 25 young adult participants (76% males, 24% females; M age 24.4 years, SD = 7.1). The after-peak reduction displayed similar parameters in both muscle groups with comparable drops in force during the after-peak reduction minima (thumb adductor: 27.5 ± 7.5% maximal voluntary contraction; ankle dorsiflexor: 25.8 ± 6.2% maximal voluntary contraction). A trend for the presence of fewer after-peak reductions with successive ramp trials was observed, suggesting a learning effect. Further investigation should explore underlying neural mechanisms contributing to the after-peak reduction.

Moving toward 2017: progress in rehabilitation intervention effectiveness research.

Halfway into the 10-yr American Occupational Therapy Association Centennial Vision initiative, occupational therapy has made notable progress in establishing itself as a science-driven profession. Through the diligent work of many talented occupational therapy scholars, 42 research studies exploring interventions used in rehabilitation research were published in the past 5 years. A variety of both novel and established intervention strategies were investigated using diverse research designs and measurement tools. A predominant number of studies were conducted with the poststroke population. Moving forward to 2017 and building on our success, we can recognize our full potential by fostering knowledge translation, expanding participant numbers, exploring less-studied populations, increasing the volume of systematic reviews published, and reporting occupation-centered outcomes, the unique and defining component of our profession.

Sildenafil increases muscle protein synthesis and reduces muscle fatigue.

Reductions in skeletal muscle function occur during the course of healthy aging as well as with bed rest or diverse diseases such as cancer, muscular dystrophy, and heart failure. However, there are no accepted pharmacologic therapies to improve impaired skeletal muscle function. Nitric oxide may influence skeletal muscle function through effects on excitation-contraction coupling, myofibrillar function, perfusion, and metabolism. Here we show that augmentation of nitric oxide-cyclic guanosine monophosphate signaling by short-term daily administration of the phosphodiesterase 5 inhibitor sildenafil increases protein synthesis, alters protein expression and nitrosylation, and reduces fatigue in human skeletal muscle. These findings suggest that phosphodiesterase 5 inhibitors represent viable pharmacologic interventions to improve muscle function.

Five years later: achieving professional effectiveness to move neurorehabilitation forward.

The AOTA Centennial Vision outlined in 2007 challenged the occupational therapy profession to become a "powerful, widely recognized, science-driven, and evidence-based" profession that could adapt to changing societal and cultural needs and flourish well into the future. That challenge can be met by simply being effective at what we do; this will increase our value and validate our worth. Neurorehabilitation in occupational therapy can also thrive if we verify that the interventions we use and the strategies we implement are grounded in evidence. Professional effectiveness will emerge by (1) increasing the dissemination of research that supports the methods we use and informs others of the successful patient outcomes we achieve and (2) expanding development and validation of instruments that quantitatively and qualitatively measure functional outcomes. Occupational therapists can individually develop professional effectiveness by fostering greater academic-clinical alliances, objectifying evaluation and intervention methods, and preparing future practitioners appropriately for evidence-driven practice.

High-versus low-frequency stimulation effects on fine motor control in chronic hemiplegia: a pilot study.

BACKGROUND: The optimal parameters of neuromuscular electrical stimulation (NMES) for recovery of hand function after stroke are not known. This clinical pilot study examined whether higher or lower frequencies are more effective for improving fine motor control of the hand in a chronic poststroke population. METHODS: A 1-month, 4 times per week, in-home regimen of either a high-frequency (40 Hz) or low-frequency (20 Hz) NMES program was applied to the hemiplegic thenar muscles of 16 persons with chronic stroke. Participants were identified a priori as having a low level of function (LF) or a high level of function (HF). Outcome measures of strength, dexterity, and endurance were measured before and after participation in the regimen. RESULTS: LF subjects showed no significant changes with either the high- or the low-frequency NMES regimen. HF subjects showed significant changes in strength, dexterity, and endurance. Within this group, higher frequencies of stimulation yielded strength gains and increased motor activation; lower frequencies affected dexterity and endurance. CONCLUSIONS: The results suggest that higher frequencies of stimulation could be more effective in improving strength and motor activation properties and that lower frequencies may affect coordination and endurance changes. Results also indicate that persons with a higher functional level of recovery may respond more favorably to NMES regimens, but further study with larger patient groups is warranted.

Effects of a dynamic progressive orthotic intervention for chronic hemiplegia: a case series.

STUDY DESIGN: Case series design on a single subgroup of participants. INTRODUCTION: Management of hypertonicity and resistance to passive movement (RTPM) in the upper extremity is an intractable problem for persons with stroke and the therapists who provide their care. Therapists have limited options for assessment and treatment of this condition which can profoundly limit functional performance and quality of life. PURPOSE OF THE STUDY: To evaluate the effect of a 12-week dynamic progressive orthotic intervention in persons with chronic stroke exhibiting wrist flexion contracture who are residents of a long-term skilled nursing facility. METHODS: A custom-fitted dynamic progressive wrist extension orthotic was applied to 6 residents with chronic stroke. The orthotic was worn for 4 h daily, 4×/week for 12 weeks. Wrist passive range of motion (PROM) and RTPM were measured weekly and after discontinuation of the orthotics using the Modified Ashworth Scale and the Tardieu Scale of Spasticity. Signal analysis of electromyographical (EMG) flexor response to extensor stretching was also measured before and after orthotic intervention using maximal root mean square (RMS) values and EMG burst onset time. RESULTS: A moderate effect was found for changes in PROM with the orthotic intervention. Progress made diminished following discontinuation. Moderate effects were also seen in EMG measures which indicated increases in amount of resistive-free movement following intervention. CONCLUSION: A dynamic progressive orthotic intervention can be an effective option for increasing wrist PROM and reducing RTPM in persons with chronic stroke. LEVEL OF EVIDENCE: 4.

The free post-stroke clinic: a successful teaching and learning model.

Healthcare students are often challenged in understanding the complexities associated with the diagnosis of cerebrovascular accident (CVA, stroke). Due to the diversity of clinical presentations following stroke and the intractable nature of some stroke sequelae, learning to effectively manage persons with stroke cannot always be translated solely through didactic methods. This paper describes a free post-stroke clinic, organized as part of the occupational therapy (OT) and physical therapy (PT) curricula, that offered hands-on learning with actual patients with stroke, provided a needed service to the community, and established a pathway for university stroke research. Quantitative and qualitative data were collected from students, faculty supervisors, and patients. Seventy-eight persons with stroke, of diverse ages, ethnicities, and socioeconomic backgrounds, participated in our clinic over the course of a year. In post-clinic questionnaires, all students (n = 119, 100%) reported that the clinic enhanced learning of stroke diagnosis; 98% of PT students (n = 67) and 94% of OT students (n = 52) indicated that the clinic prepared them for future clinical rotations. An average of 93% of patients who participated reported that they made functional progress during the clinic, and 96% indicated they would recommend the clinic to others. Faculty supervisors reported the clinic was ideal for assessing professional and clinical behavior of students. The free post-stroke clinic can serve as an effective learning and teaching model for other educational programs by offering significant benefit to individuals, universities, and communities while simultaneously providing a mechanism for reliable assessment of student readiness for clinical practice.

Neurorehabilitation: are we doing all that we can?

Occupational therapists have many intervention tools available for working with clients having a neurological injury; however, some of the most innovative and effective methods have not gained acceptance by many clinicians. Emerging research and new technologies provide occupational therapists with a multitude of treatment strategies and novel devices, but incorporation of those tools into clinical practice appears to be limited by the time necessary to learn about the intervention, educational requirements associated with implementation, or lack of awareness regarding the evidence supporting the use of such tools. Strategies to combat this trend include educating clinicians on evidence-based methods for neurological rehabilitation, aligning academics with practitioners to translate evidence into practical treatment strategies, and accepting that occupational therapy can use these innovations as a means toward state-of-the art, occupation-based practice.

Neuromuscular electrical stimulation for skeletal muscle function.

Lack of neural innervation due to neurological damage renders muscle unable to produce force. Use of electrical stimulation is a medium in which investigators have tried to find a way to restore movement and the ability to perform activities of daily living. Different methods of applying electrical current to modify neuromuscular activity are electrical stimulation (ES), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and functional electrical stimulation (FES). This review covers the aspects of electrical stimulation used for rehabilitation and functional purposes. Discussed are the various parameters of electrical stimulation, including frequency, pulse width/duration, duty cycle, intensity/amplitude, ramp time, pulse pattern, program duration, program frequency, and muscle group activated, and how they affect fatigue in the stimulated muscle.

Variable stimulation patterns in younger and older thenar muscle.

Neuromuscular electrical stimulation (NMES) is typically used with older adults receiving rehabilitation therapies, but little is known about the stimulation patterns that maximize force output and minimize fatigue in this population. The purpose of this study was to apply variable patterns of stimulation to the thenar muscles of the hand in younger and older adults to determine if force production and neuromuscular fatigue effects were similar. Three submaximal stimulation patterns were administered: A 20Hz constant frequency pattern, a pattern that increased from 20 to 40Hz, and a pattern that incorporated two closely spaced (5ms) doublet pulses. The doublet stimulation produced significantly higher average forces and force-time integrals (FTIs) than the constant frequency and increasing frequency patterns in both age groups. Additionally, older adults showed less fatigue than the younger group during isometric contractions performed after the fatiguing stimulation patterns. These results suggest that variable pulse NMES patterns enhance force production in the hand in both younger and older individuals better than constant frequency patterns, which are typically used in clinical applications. Also, greater fatigue resistance to electrical stimulation protocols may exist in the older population; this is critical information for the design and application of NMES rehabilitation regimens used with older adults.

Variable stimulation patterns for poststroke hemiplegia.

Neuromuscular electrical stimulation can improve motor function in those affected by paralysis, but its use is limited by a high rate of muscular fatigue. Variable stimulation patterns have been examined in young adults with and without spinal cord injury, but much less investigation has been devoted to studying the effects of variable stimulation patterns administered to older adults or those paralyzed by stroke. Significant changes occur in the neuromuscular system with age that may affect the response to variable stimulation patterns. We administered three, 3-min intermittent stimulation patterns to the median nerves of 10 individuals with hemiplegia from stroke and 10 age-matched able-bodied adults: (1) constant 20 HZ, (2) a pattern that began at 20 HZ and progressively increased to 40 HZ in the latter half of the task, and (3) a 20-HZ pattern that switched to a 20-HZ doublet pattern after 90 s. In the able-bodied group the doublet pattern produced significantly higher force time integrals (FTI) (1409.72 +/- 3.15 N s) than the 20-40-HZ pattern (1067.46 +/- 1.15 N s) or the 20-HZ pattern (831 +/- 1.87 N s). In the poststroke individuals the doublet pattern also produced the highest FTI (724.04 +/- 2.02 N s), and there was no significant difference between the 20-40-HZ (636.42 +/- 1.65 N s) and 20-HZ (583.64 +/- 3.02 N s) patterns. These results indicate that protocols that incorporate doublets in the later stages of fatigue are effective in older adults and in older adults with paralysis from stroke.