Cross-cultural adaptation and test-retest reliability of the Italian version of the Pediatric Balance Scale in children with typical and atypical development.

BACKGROUND: Balance disorders in children are complex and disabling. The pediatric balance scale assesses functional balance in the contest of everyday tasks. It is recommended for balance assessment in children. The cross-cultural validation of an assessment instrument allows to assess individuals in the appropriate cultural context. We designed our study with the aim of translating and cross-cultural adapting the Pediatric Balance Scale into Italian, and investigating the reliability of the translated version. METHODS: Two forward translation of the Pediatric Balance Scale were conducted. Two blind backward translations were subsequently performed. A multidisciplinary group compared the content of the translations with those of the original Pediatric Balance Scale. Ambiguities and discrepancies were amended. To assess conceptual equivalence of the translation, we conducted cognitive debriefing involving physiotherapists, parents, and children. Suggestions for rewording were sought and considered for eventual modification. The Italian Pediatric Balance Scale was administered to 18 children with typical development (age 4.7-7.9 years, female 61.1%, scores 51-56), and to 18 children with atypical development (age 4.9-15.0 years, female 44.4%, scores 38-56). Test-retest reliability (i.e., intrarater and interrater reliability, and agreement between raters) of the scale was assessed by mean of single-rating, absolute-agreement, two-way mixed effects model intra-class correlation coefficients (ICC3,1) and the Bland-Altman method. The standard error of measurement and the minimal detectable change were subsequently computed. RESULTS: The forward and backward translations showed no substantial differences in content; wording discrepancies were resolved by consensus. The multidisciplinary group proposed some minor changes. Twenty-three physiotherapists, 36 parents, and 36 children participated in cognitive interviewing and further changes were made. Perfect agreement was observed in test-retest reliability assessment of the Italian pediatric balance scale in children with typical development. High reliability (intrarater: ICC3,1 0.998, 95% CI 0.994 to 0.999; interrater: ICC3,1 0.994, 95% CI 0.984 to 0.998) and agreement among raters (Bland-Altman plots: 89%, 95% CI 67% to 97%, of the data within the 95% CI limits of the bias estimate) were found assessing children with atypical development. Very small standard error of measurement and the minimal detectable change values were observed (intrarater: 0.212 and 0.588; interrater: 0.368 and 1.019). CONCLUSIONS: The present study provides a translated and cross-culturally adapted Italian version of the Pediatric Balance Scale. The full cross-cultural validity of the tool requires further steps to complete the psychometric testing.

Physical functioning and health-related quality of life after COVID-19: a long-term perspective case series.

The purpose of our study was to monitor the long-term changes in physical functioning and health-related quality of life in individuals who received outpatient rehabilitation after COVID-19. Individuals referred to outpatient rehabilitation for post-COVID-19 physical therapy were assessed before the treatment, at the end of the treatment, and 2 and 6 months after the end of the treatment. The physical functioning was assessed by Barthel Index, Timed Up and Go test, Short Physical Performance Battery test (SPPB), Patient-Specific Functioning Scale (PSFS), and EuroQOL 5D-3L. Friedman's test was utilized to assess changes in the assessments. The proportions of individuals showing variation in performance equal to or greater than the absolute minimal detectable change (MDC) value of the SPPB and PSFS were calculated. Forty-four cases were monitored for 7.3-15.6 months. At baseline, they showed substantial independence in activities of daily living, moderate mobility limitations, and below-average health-related quality of life. Their status significantly improved over time (Friedman's test P = 0.002 to <0.001); post hoc analysis confirmed the improvement of mobility and health-related quality of life at 6-month follow-up relative to the baseline. After accounting for MDC values, 55% meaningfully improved on SPPB and 45% on PSFS, although some worsened (11 and 5%, respectively) and the remaining showed no meaningful change. Despite good independence in activities of daily living and perceived health, individuals surviving the COVID-19 may not have fully recovered their premorbid functioning status seven to 15 months after the infection.

The muscle shortening maneuver in individuals with stroke: a consideration-of-concept randomized pilot trial.

BACKGROUND AND PURPOSE: The Muscle Shortening Maneuver (MSM) is derived from Feldman's λ model of motor control, and seems to induce a more balanced agonist- antagonist-muscular action. The hypothesized mechanism of action is a modulation of the Tonic Stretch Reflex Threshold (TSRT). We designed a pilot, randomized trial aimed to explore the mechanisms of action of the technique. An ancillary objective was to research the implementation of the MSM as a stroke rehabilitation intervention. METHODS: A sample of 10 participants with chronic stroke was enrolled and randomly assigned to MSM (n, 5) or conventional physical therapy (CPT) (n, 5) treatments. The TSRTs were assessed by the Montreal Spasticity Measure device. A selection of clinical and instrumental outcome measures was taken to investigate function and activity levels. Data were collected at baseline, end-of-treatment, and one month after the end-of-treatment. RESULTS: No adverse events were observed. In both between- and within-group post-treatment assessments, in the affected ankle the MSM group showed decreased TSRTs of the plantar flexor, increased strength of the dorsiflexor and active range of motion; also, the time needed to perform the Timed Up and Go test decreased. No changes were evident across assessments in the CPT group. DISCUSSION AND CONCLUSIONS: The MSM seems able to modulate the TSRTs in individuals with stroke. Although with the limitations due to the pilot design, the variation in participants' responses appear to be promising. Many methodological issues have to be clarified and specified conceiving the progression toward a confirmatory trial.

Treatment approaches for pusher behaviour: a scoping review.

BACKGROUND: Some individuals with hemiplegia show a postural disorder called pusher behavior. Various underlying theoretical mechanisms have been proposed, thus leading to various treatment approaches. OBJECTIVES: The aim of this scoping review is to identify and analyze the available evidence on the treatment approaches for pusher behavior. METHODS: Two independent reviewers conducted a literature search for original studies reporting on treatments for pusher behavior. Studies were searched in PubMed, Scopus, Web of Science, CINAHL and PEDro from their inception to December 2020. Treatment approaches were grouped in homogeneous areas based on the supposed underlying mechanism. To assess the reporting of the interventions, the Template for Intervention Description and Replication (TIDieR) was used. RESULTS: Thirty-one papers describing 45 interventions were included in the review. Most of the studies were case reports (i.e. including 1 person) (n = 16), followed by randomized controlled trials (n = 5), single subject design trials (n = 5), non-randomized controlled trials (n = 3), and case series (i.e. including more than 1 person) (n = 2). Treatment approaches were grouped into five categories: visual feedback, somatosensory cues, visual-somatosensory integration, brain stimulation, and other nonspecific treatments. The median number of TIDIeR items reported was 7 (range 4 to 10). CONCLUSION: Pusher behavior is still little-known. Five main categories of treatment approaches based on the alleged etiological underlying mechanisms have been identified. Most of studies are case reports; controlled trials should be further conducted. Intervention reporting should be improved to allow treatment replication in larger trials.

The Muscle Shortening Maneuver: a noninvasive approach to the treatment of peroneal nerve injury. A case report.

BACKGROUND: The treatment of peripheral nerve injuries is a debated topic. The Muscle Shortening Maneuver (MSM), a physiotherapy approach, is noninvasive and free of side effects; it consists of a muscle shortening and a solicitation in traction applied simultaneously. OBJECTIVE: The focus of this report is to describe the effects of the MSM combined with walking retraining in a patient with incomplete injury of the peroneal nerve. DESCRIPTION: The patient was a 17-year-old man, who underwent osteotomy surgery of the proximal two-thirds of the fibula, due to an Ewing sarcoma that caused a partial injury of the left peroneal nerve. Our assessment plan of the left ankle movement ability comprised range of movement, muscle strength, and surface electromyography (EMG); and a gait analysis was conducted by using an iPhone application. MSM and walking retraining were administered twice and once a week, respectively, for 4 weeks. OUTCOMES: The active range of movement substantially improved in dorsiflexion (≥15°), whereas slightly decreased in plantar flexion (-5°). Aside from the tibialis anterior, an increase in muscle strength was detected. Surface EMG showed an increased activation, particularly in the peroneus longus. A decrease in gait speed and step length was recorded from the gait analysis, with a better bilateral symmetry. CONCLUSIONS: Positive outcomes were reported without evidence of risk or adverse events for the participant.

THE MUSCLE SHORTENING MANOEUVRE: APPLICABILITY AND PRELIMINARY EVALUATION IN CHILDREN WITH HEMIPLEGIC CEREBRAL PALSY: A RETROSPECTIVE ANALYSIS.

INTRODUCTION: Physiotherapy plays a key role in cerebral palsy rehabilitation, through addressing body function/structure deficits, minimizing activity limitations, and encouraging participation. The muscle shortening manoeuvre is an innovative therapeutic technique, characterized by the ability to induce changes in muscle strength in a short time. OBJECTIVE: To describe the applicability and estimate the effect of the muscle shortening manoeuvre applied to improve motor weakness and joint excursion of the ankle in children with hemiplegic cerebral palsy. METHODS: Nine children with hemiplegic cerebral palsy received 3 intervention sessions in one week. Muscle strength, passive and active range of motion were assessed before, during and after the training, and at 1-week follow-up. RESULTS: The children experienced an immediate increase in muscle strength and joint excursion of the ankle; the improvements were still present at follow-up after 7 days. CONCLUSION: The muscle shortening manoeuvre may be an effective intervention to induce an immediate increase in muscle strength and range of motion of the ankle in children affected by hemiplegia due to cerebral palsy, thus promoting better physical functioning.

Measurement properties of the Gross Motor Function Classification System, Gross Motor Function Classification System-Expanded & Revised, Manual Ability Classification System, and Communication Function Classification System in cerebral palsy: a systematic review with meta-analysis.

AIM: To systematically review and meta-analyse the measurement properties of the Gross Motor Function Classification System (GMFCS), Gross Motor Function Classification System-Expanded & Revised (GMFCS-E&R), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS) in children with cerebral palsy (CP). METHOD: Six databases were searched. Articles on the measurement properties of the GMFCS, GMFCS-E&R, MACS, and CFCS administered to children with CP were included. Quality was assessed by means of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. The level and grading of evidence were defined for each measurement property. RESULTS: Forty-four articles were included in the systematic review and 37 articles were included in the meta-analysis. The level (grading) of evidence was strong (positive) for reliability and construct validity. Content validity displayed an unknown level of evidence for the GMFCS, limited evidence (positive) for the MACS, and moderate evidence (positive) for the CFCS. There was moderate (positive) evidence for measurement error in the GMFCS and MACS. The level of evidence for responsiveness was unknown. No studies investigated cross-cultural validity. INTERPRETATION: These instruments can be used by health care professionals and caregivers to quantify the constructs needed to measure ability in children with CP. Current high-quality evidence supports the use of these tools to classify ability in children with CP. Adopting the COSMIN guidelines, content, and cross-cultural validity should be investigated further. What this paper adds Strong evidence supports the reliability and construct validity of the GMFCS, GMFCS-E&R, MACS, and CFCS as functional classification systems in children with cerebral palsy. The GMFCS, GMFCS-E&R, MACS, and CFCS can be used by both health care professionals and caregivers. The GMFCS, GMFCS-E&R, MACS, and CFCS should not be used to detect change.

Reliability of the six-minute walk test in individuals with stroke: systematic review and meta-analysis.

PURPOSE: The six-minute walking test (6MWT) is a simple and widely used measure of functional capacity. The aim of this systematic review is to summarize findings on reliability of 6MWT in subjects who have had a stroke. METHODS: Two independent investigators conducted an extensive search in multidisciplinary electronic databases from inception to August 2019, and selected complete original studies on the reliability of the 6MWT used to assess individuals with stroke. Two reviewers independently extracted data and evaluated methodological quality. Outcome for meta-analysis was reliability, measured by intraclass correlation coefficient (ICC). In addition, standard error of measurement (SEM) and minimal detectable change (MDC) were recorded. RESULTS: Of the 241 potentially relevant articles screened, 6 met inclusion criteria and 5 of them were included in meta-analysis. Combined correlation coefficient of .98 (confidence interval .98-.99) was found for test-retest reliability. Only one study investigated inter-rater and intra-rater reliability. SEM and MDC values were rarely reported. CONCLUSIONS: The 6MWT has high test-retest reliability, when used to assess individuals with stroke. Other types of reliability and SEM and MDC need further investigations in populations with a stroke.

Generalizability of Results from Randomized Controlled Trials in Post-Stroke Physiotherapy.

Purpose: The randomized controlled trial (RCT) is considered a reliable experimental design, able to detect the effect of an intervention. However, a criticism frequently levelled at RCTs by clinicians is their lack of generalizability. This study aimed to evaluate the generalizability of findings from RCTs of physiotherapy interventions for individuals with stroke. Method: A sample of RCTs of physiotherapy interventions after stroke indexed in the PEDro database was selected, and the reported inclusion and exclusion criteria were analyzed. Results: We reviewed 100 articles, which included 7,366 participants (41.6% women, with a mean weighted age of 65.5 years). The most frequent criteria for exclusion were comorbidity (83%), cognitive impairments (69%), communication skills (55%), recurrent stroke (53%), low functional level (47%) and being elderly (25%). Conclusions: A variety of cohorts of individuals who have had a stroke are excluded from RCTs published in the field of physiotherapy. Because they represent a substantial proportion of the real-world population with stroke, and consequently treated in clinical practice, more vulnerable cohorts of participants should be included in RCTs.

Objectif : l'essai aléatoire et contrôlé (EAC) est considéré comme une méthodologie expérimentale fiable, en mesure de déterminer l'effet d'une intervention. Cependant, les cliniciens en critiquent souvent l'absence de généralisabilité. La présente étude visait à évaluer la généralisabilité des résultats des EAC sur des interventions de recherche en physiothérapie auprès de personnes ayant subi un accident vasculaire cérébral (AVC). Méthodologie : les auteurs ont sélectionné un échantillon d'EAC sur des interventions de physiothérapie après un AVC indexées dans la base de données PEDro. Ils ont analysé les critères d'inclusion et d'exclusion déclarés. Résultats : les auteurs ont examiné 100 articles, qui incluaient 7 366 participants (41,6 % de femmes, d'un âge moyen pondéré de 65,5 ans). Les critères d'exclusion les plus fréquents étaient la comorbidité (83 %), les déficiences cognitives (69 %), les aptitudes à la communication (55 %), les AVC récurrents (53 %), un faible niveau fonctionnel (47 %) et le fait d'être âgé (25 %). Conclusion : diverses cohortes de personnes qui ont subi un AVC sont exclues des EAC publiés en physiothérapie. Puisqu'elles représentent une forte proportion de la population de personnes qui subissent un AVC en situation réelle et qui sont ensuite traitées en pratique clinique, il faudrait inclure plus de cohortes de participants vulnérables dans les EAC.

Ethics reporting practices in randomized controlled trials of physical therapy interventions after stroke.

BACKGROUND: Adequate reporting of ethics-related research methods promotes convergence on best ethics practices. In physical therapy, studies on ethics reporting are limited to few aspects, and none focuses on stroke research. Our objectives were to investigate the reporting of multiple ethics-related features and its variation over time, and the characteristics of the studies associated with ethics reporting in Randomized Controlled Trials (RCTs) of physical therapy interventions after stroke. METHODS: A random sample of RCTs published in the years 2004, 2009 and 2014, was extracted from the PubMed database, regardless of the publishing journal. For each trial we investigated year of publication, trial registration, sample size, stroke subtype, phase of the disease, setting, interventions and dosing, outcome measures, outcome of the study, PEDro score and 5-year impact factor of the publishing journal. Reporting of ethics-related issues was analyzed. Differences between groups were examined. Multiple regression was used to evaluate the relationship between ethics-related issues reporting and some studies' characteristics. RESULTS: Eighty studies were reviewed. Groups differed in the proportion of registered trials (p = .009), 5-year impact factor (p = .011), assessment of cognitive capacity (p = .049), declaration about conflict of interest (p < .001), and number of ethics-related issues reported (p = .009). The proportion of issues reported ranged from 92.5% (consent obtaining) to 0% (eventual follow up care). Post-hoc comparisons showed significantly greater reporting of ethics issues in trials published in the year 2014 compared to 2004 (p = .014, 95%CI = 0.40/4.26). Year of publication and PEDro score were significant predictors of adequate reporting. CONCLUSIONS: Authors, editors, and reviewers should be more rigorous and demanding about the reporting of ethic-related methods in randomized controlled trials of physical therapy interventions after stroke.

The Salford Gait Tool: Does the clinical experience of the raters influence the inter-rater reliability?

PURPOSE: The purpose of this study was to verify if the amount of experience or the specific professional field of the raters may influence inter-rater reliability of the Salford Gait Tool (SF-GT). METHODS: Standardized videos of gait of seven children with cerebral palsy were recorded and assessed by three physiotherapists with experience in pediatrics (PPTs), three physiotherapists with experience with adult individuals (n-PPTs), and three students of physiotherapy. RESULTS: The inter-rater reliability both for joints and gait events was acceptable (ICC ≥ .70) for PPTs and n-PPTs, but not for students. CONCLUSIONS: The inter-rater reliability of the SF-GT can be influenced by the experience of the raters and the amount of clinical experience seems to be more relevant than the specific professional field. Further research should be conducted with larger samples.

First-Person Perspective Action Observation Training in Individuals With Parkinson's Disease: A Consideration-of-Concept Controlled Pilot Trial.

BACKGROUND AND PURPOSE: Action observation training (AOT) consists of the observing of actions performed by others, followed by imitation. Physical therapy techniques based on action observation may influence motor performance in individuals with idiopathic Parkinson's disease (IPD). OBJECTIVES: The aim of this pilot study was to provide a preliminary approach to assess AOT in anatomical first-person perspective (FPP) as a rehabilitation technique to improve body function and activity in individuals with disability due to IPD. METHODS: Videos showing in FPP movements of the upper and lower limbs were produced. A research protocol was designed and tested for feasibility. After baseline assessment, 16 participants with mild to moderate disability due to IPD, all receiving conventional physical therapy group treatment, were nonrandomly assigned to either 1 extra hour of individualized FPP AOT per session or comparison group. Upper and lower limb functioning, independence in activity of daily living, and mobility were assessed before and after training. Data were analyzed by descriptive statistics; statistical comparisons were conducted as part of the feasibility assessment of the data management plan by means of nonparametric tests. RESULTS: A set of 22 videos was created and administered. Groups were comparable at baseline assessment. All participants completed the study and had complete data. Compared with baseline, both groups improved significantly. The experimental group had a better response based on change scores, and the differences were large for 3 of the outcome measures. No significant between-group differences were observed. DISCUSSION: The equipment needed for the production of the videos was easily available. The study protocol was successfully implemented. Adherence rates to study procedures were excellent, and no adverse events occurred. Differences in methods and participant populations prevented comparison in our experimental approach. The number and content of videos, and the length of the sessions proposed, was close to that of other studies providing an FPP AOT program in individuals with cerebral palsy and stroke. Both groups improved and the effect was greater for the experimental one. However, no significant difference between the groups was observed. CONCLUSIONS: This pilot study suggests that FPP AOT is a feasible intervention and the research protocol designed would be suitable, with minor modifications, for the conduction of a subsequent stage 2 trial designed to verify the hypothesis that the adjunct of FPP AOT might improve motor performance in individuals with IPD.

Passive standing as an adjunct rehabilitation intervention after stroke: a randomized controlled trial.

BACKGROUND: Early physical rehabilitation enhances functional recovery in stroke survivors. Supported standing is a common adjunctive therapeutic practice in subjects with several central nervous diseases who are unable to stand actively. Data on the effect of supported positioning on standing frames in individuals with recent stroke are scarce and contradictory. OBJECTIVES: To verify if the addition of supported standing practice (SSP), delivered by means of a standing frame in two durations, to conventional physical therapy (CPT), may improve motor function, autonomy, and mobility in individuals with disability due to recent stroke. METHODS: After baseline assessment, 75 participants with severe disability due to stroke, all receiving CPT, were randomly assigned to adjunctive 20 or 40 min of SSP, or CPT only (control). Motor function, autonomy, and mobility were assessed before and after training, and three months later. RESULTS: All participants assessed received the planned dose of intervention. No adverse events of SSP were detected. Most outcome measures improved from baseline through the end of treatment and in the follow-up in all groups; the extent of change was comparable across the three randomization groups. CONCLUSIONS: In this randomized trial, SSP was unable to provide any sizeable adjunctive benefit, above and beyond CPT, in subjects with recent stroke.

Tools for observational gait analysis in patients with stroke: a systematic review.

BACKGROUND: Stroke severely affects walking ability, and assessment of gait kinematics is important in defining diagnosis, planning treatment, and evaluating interventions in stroke rehabilitation. Although observational gait analysis is the most common approach to evaluate gait kinematics, tools useful for this purpose have received little attention in the scientific literature and have not been thoroughly reviewed. OBJECTIVES: The aims of this systematic review were to identify tools proposed to conduct observational gait analysis in adults with a stroke, to summarize evidence concerning their quality, and to assess their implementation in rehabilitation research and clinical practice. METHODS: An extensive search was performed of original articles reporting on visual/observational tools developed to investigate gait kinematics in adults with a stroke. Two reviewers independently selected studies, extracted data, assessed quality of the included studies, and scored the metric properties and clinical utility of each tool. Rigor in reporting metric properties and dissemination of the tools also was evaluated. RESULTS: Five tools were identified, not all of which had been tested adequately for their metric properties. Evaluation of content validity was partially satisfactory. Reliability was poorly investigated in all but one tool. Concurrent validity and sensitivity to change were shown for 3 and 2 tools, respectively. Overall, adequate levels of quality were rarely reached. The dissemination of the tools was poor. CONCLUSIONS: Based on critical appraisal, the Gait Assessment and Intervention Tool shows a good level of quality, and its use in stroke rehabilitation is recommended. Rigorous studies are needed for the other tools in order to establish their usefulness.

Efficacy of physiotherapy interventions late after stroke: a meta-analysis.

OBJECTIVE: Physiotherapy is usually provided only in the first few months after stroke, while its effectiveness and appropriateness in the chronic phase are uncertain. The authors conducted a systematic review and meta-analysis of randomised clinical trials (RCT) to evaluate the efficacy of physiotherapy interventions on motor and functional outcomes late after stroke. METHODS: The authors searched published studies where participants were randomised to an active physiotherapy intervention, compared with placebo or no intervention, at least 6 months after stroke. The outcome was a change in mobility and activities of daily living (ADL) independence. The quality of the trials was evaluated using the PEDro scale. Findings were summarised across studies as effect size (ES) or, whenever possible, weighted mean difference (WMD) with 95% CI in random effects models. RESULTS: Fifteen RCT were included, enrolling 700 participants with follow-up data. The meta-analysis of primary outcomes from the original studies showed a significant effect of the intervention (ES 0.29, 95% CI 0.14 to 0.45). The efficacy of the intervention was particularly evident when short- and long-distance walking were considered as separate outcomes, with WMD of 0.05 m/s (95% CI 0.008 to 0.088) and 20 m (95% CI 3.6 to 36.0), respectively. Also, ADL improvement was greater, though non-significantly, in the intervention group. No significant heterogeneity was found. INTERPRETATION: A variety of physiotherapy interventions improve functional outcomes, even when applied late after stroke. These findings challenge the concept of a plateau in functional recovery of patients who had experienced stroke and should be valued in planning community rehabilitation services.