Virtual reality in stroke rehabilitation: still more virtual than real.

PURPOSE: To assess the utility of virtual reality (VR) in stroke rehabilitation. METHOD: The Medline, Proquest, AMED, CINAHL, EMBASE and PsychInfo databases were electronically searched from inception/1980 to February 2005, using the keywords: Virtual reality, rehabilitation, stroke, physiotherapy/physical therapy and hemiplegia. Articles that met the study's inclusion criteria were required to: (i) be published in an English language peer reviewed journal, (ii) involve the use of VR in a stroke rehabilitation setting; and (iii) report impairment and/or activity oriented outcome measures. Two assessors independently assessed each study's quality using the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) grading system. RESULTS: Eleven papers met the inclusion criteria: Five addressed upper limb rehabilitation, three gait and balance, two cognitive interventions, and one both upper and lower limb rehabilitation. Three were judged to be AACPDM Level I/Weak, two Level III/Weak, three Level IV/Weak and three Level V quality of evidence. All articles involved before and after interventions; three randomized controlled trials obtained statistical significance, the remaining eight studies found VR-based therapy to be beneficial. None of the studies reported any significant adverse effects. CONCLUSION: VR is a potentially exciting and safe tool for stroke rehabilitation but its evidence base is too limited by design and power issues to permit a definitive assessment of its value. Thus, while the findings of this review are generally positive, the level of evidence is still weak to moderate, in terms of research quality. Further study in the form of rigorous controlled studies is warranted.

Evaluation of consultation-based rehabilitation for hospitalized cancer patients with functional impairment.

OBJECTIVE: To evaluate prospectively the effect of consultation-based interdisciplinary rehabilitation in hospitalized cancer patients. PATIENTS AND METHODS: Three hundred forty-one hospitalized patients with cancer were referred to the Cancer Adaptation Team (interdisciplinary rehabilitation services) over an 8-month period. Functional status at enrollment and dismissal was evaluated with a Barthel Mobility Index and Karnofsky Performance Status scale. Quality-of-life parameters were evaluated with specifically designed questionnaires. RESULTS: Two hundred ninety patients met the inclusion criteria. One hundred eighty-nine survived and completed the study. Significant functional improvement was observed between enrollment and dismissal on both functional indexes (P< or =.001). Quality-of-life questionnaires, while limited by low completion rate, showed significant improvement on multiple parameters. CONCLUSION: Significant functional gains were observed in hospitalized cancer patients who received interdisciplinary rehabilitation services on a consultation basis.

Neural adaptations to fatigue: implications for muscle strength and training.

PURPOSE: This paper investigates the neural mechanisms responsible for the increase in strength that occurs during serial isometric contractions. METHODS: A three-session design was used. Thirteen subjects (N = 13) were asked to perform five maximal isometric elbow extension strength trials to serve as baseline. After a 5-min rest, the subjects were administered a 30-trial fatigue protocol. This process was repeated two more times at 2-wk intervals. Elbow extension torque and surface electromyography (EMG) of the triceps and biceps brachii were monitored concurrently. The criterion measures were elbow extension torque, root-mean-square EMG amplitude, and mean power frequency (MPF). RESULTS: Intraclass reliability ranged from good to excellent. Within each experimental session, the fatigue protocol resulted in a decrease in maximal isometric elbow extension torque as well as biceps and triceps EMG amplitude and MPF (P < 0.05). However, the mean of the 30 trials and the magnitude of the linear decrease in elbow extension torque increased across the three sessions (P < 0.05). Biceps and triceps EMG amplitude increased and MPF decreased as the number of sessions increased (P < 0.05). CONCLUSIONS: These findings suggest that the fatigue protocol served as a training stimulus to down regulate motor-unit firing frequency.

Training-related changes in the maximal rate of torque development and EMG activity.

This study monitored the effects of a short-term elbow flexor training program on surface electromyographic (SEMG) spike activity. The experimental paradigm consisted of three test sessions separated by 2-week intervals. At the beginning of each session, participants (N=13) performed five maximal effort isometric contractions of the elbow flexors to serve as baseline. After 5 min of rest, the participants then engaged in a 30-trial isometric fatigue protocol during which maximal elbow flexion torque was measured with a load-cell, and the maximal rate of change in the torque (dtau/dt(max)) was obtained from the differentiated torque-time curve. Bipolar electrodes were used to monitor the SEMG spike activity of the biceps brachii. Mean spike amplitude (MSA) and mean spike frequency (MSF) were calculated for the torque development and constant-torque phases of the isometric contraction, termed Segment 1 and Segment 2, respectively. Mean power frequency (MPF) was also calculated for Segment 2. The five baseline contractions of the second and third sessions were compared with those of the first session and analyzed for training-related changes. Training increased dtau/dt(max) but failed to change maximal elbow flexion torque or MSA. However, there was an increase in the MSF during the torque development phase of the contraction (Segment 1). Both MSA and MSF were greatest during the constant-torque phase of the isometric contraction (Segment 2). There was a strong linear correlation (r=0.90, P<0.05) between MSF and MPF during (Segment 2). We hypothesize that the increase in dtau/dt(max) is due to enhanced motor-unit rate-coding. The demonstrated correlation between MSF and MPF measures will allow investigators to use spike analysis to examine the frequency content of the SEMG signal under non-stationary conditions.

Influences of cane length on the stability of stroke patients.

The purpose of this study was to investigate the influence of cane length on the standing and walking stability of stroke patients. Ten stroke patients were used as subjects and evaluated by using two different cane lengths based on the measurements of the distance from distal wrist crease to the ground (WC cane), and the distance from greater trochanter to ground (GT cane). Force plates were used to determine the center of pressure (COP). The maximum sways, the total travel distances, and the mean travel speeds of the COP were analyzed for each patient standing and walking with and without canes. It was found that the total travel distance and the mean travel speed of the COP in the medial-lateral (M-L) direction were significantly lower when standing with a cane than when standing without one. It was also found that the values of these parameters and the maximum sways of the COP in both anterior-posterior (A-P) and M-L directions were significantly lower when standing with the WC cane than when standing with the GT cane. No significant difference was found in the maximum M-L sway, the total travel distance, and the mean travel speed of the COP in walking. These results suggest that the standing stability of stroke patients is improved by using canes, especially by using a WC cane, although no significant influence of using canes on the walking stability was detected. Based on the results of this study, the vertical distance from the wrist crease to ground is recommended as the appropriate cane length for stroke patients.

Comparative study of isokinetic eccentric and concentric quadriceps training.

Address reprint requests to Dr. J. R. Basford, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. The purpose of this study was to compare the effects of eccentric and concentric isokinetic training exercises on eccentric and concentric quadriceps performance in 63 healthy subjects during a six-week training period. The subjects were randomly divided into three groups: eccentric training, concentric training, and no training. Members of the training groups exercised their right quadriceps only. Orientation, training, and testing were performed on a computer-assisted isokinetic dynamometer (KIN-COM) at 100 degrees /sec. All subjects were tested concentrically and eccentrically on both quadriceps; and peak torque, total work, and position angle at peak torque were measured. Analysis of variance and post hoc analyses were performed on the mean changes (pretest and posttest differences) for all groups. The concentric training group demonstrated the most significant increases in concentric torque and work; the eccentric training group demonstrated the most significant increases in eccentric torque and work. No significant changes were seen in the untrained left limbs of any group. These results support the concept of mode specificity in isokinetic exercise training. J Orthop Sports Phys Ther 1991;14(1):31-36.

The clinical status of low energy laser therapy in 1989.

Low energy laser therapy has gained varying acceptance as a treatment for a broad range of soft tissue, musculoskeletal and neurological conditions. A controversial, but surprisingly large body of research with cell cultures suggests that laser irradiation can nondestructively alter cellular processes. Unfortunately, animal and human studies are often contradictory and difficult to evaluate due to differing study designs. As a result, the clinical effectiveness of low energy laser therapy remains debatable. Nevertheless, the findings are intriguing and deserve further investigation.

Weightlifting, weight training and injuries.

Although millions of men and women in the United States are regularly involved in some form of weightlifting, the average physician knows, and frequently cares, little about the sports involved. As a result, his or her knowledge of the medical and physiological issues involved is limited This article attempts to address this lack by beginning with a brief introductory section outlining some of the similarities differences between the major weight lifting approaches (power lifting, olympic lifting, weight training and body building). Next it reviews major issues and controversies such as age restrictions for lifters, physiological effects, drug use, potential strength gains and hypertrophy. Finally, it discusses some of the more frequent and unique injuries that can occur in lifters.

Laser therapy: scientific basis and clinical role.

The ability of laser irradiation to destroy tissue is well known. Less well known is the fact that the same radiation, at much lower intensities, can non-destructively alter cellular function. This latter phenomenon, which occurs in the absence of significant heating, is now a basis for the conservative treatment of a variety of musculoskeletal, neurological, and soft tissue conditions in many parts of the world. This review first examines the 25-year history and scientific basis of "laser therapy." Clinical applications are discussed and the reasons for its relative lack of acceptance in the US are examined. The article concludes with an overview of current research and the impact it will have on laser therapy's role in US clinical practice.

Shoe insoles in the workplace.

Ninety-six women participated in a crossover study to evaluate the effectiveness of viscoelastic polyurethane insoles in reducing back, leg, and foot pain among adults who spend the majority of each work day standing. Twenty-five of the subjects reported that the insoles made their shoes too tight to be comfortable. The remainder, however, found the insoles very comfortable (P less than .002, Wilcoxon, signed-rank test) and reported significant reductions in back pain (P less than .02), foot pain (P less than .03), and leg pain (P less than .007). When these subjects were asked whether they would prefer to wear their shoes alone or with insoles, the preference for insoles was overwhelming (P less than .007, back; P less than .03, leg; and P less than .009, foot pain). It is concluded that viscoelastic insoles can effectively improve comfort and reduce back, leg, and foot pain in individuals who must stand throughout the day.

Clinical evaluation of the rocker bottom crutch.

One hundred fifty hospitalized patients referred to a physical therapy department for crutch walking instruction were evaluated in a randomized, controlled crossover study with "rocker bottom" and conventional axillary crutches. A large training effect was observed with each crutch, but no significant differences (all P greater than .05) of gait speed, stride length, heart rate, stability, or feeling of security were noted between the groups. Thus, rocker bottom crutches, despite potential stability and energy conservation benefits, were found to be no more effective than conventional axillary crutches in this hospital setting.

Tender point count and total myalgic score in fibromyalgia: changes over a 28-day period.

Tender point count (TPC) is central to fibromyalgia syndrome (FMS), and with total myalgic score (TMS) is often used to monitor the patient's condition. This study aimed to determine the stability of TPC and TMS over time, and to examine how well these measures reflected patients' perceptions of their condition. Twenty-four patients with FMS completed the Fibromyalgia Impact Questionnaire (FIQ) and a visual analogue scale (VAS) measuring well-being, at entrance into the study, and 7 and 28 days later. There was no significant change in TPC (P = 0.074), FIQ score (P = 0.291) or VAS (P = 0.079) of well-being with time. However, mean TMS score did change over time (P = 0.021). There was no correlation between total FIQ score and the other measures (all P-values > 0.05). The significant change in TMS over time may reflect the natural fluctuation in the clinical presentation of FMS.

A historical perspective of the popular use of electric and magnetic therapy.

OBJECTIVES: To review the history of the therapeutic use of static electric and magnetic fields and to understand its implications for current popular and medical acceptance of these and other alternative and complementary therapies. DATA SOURCES: Comprehensive MEDLINE (1960-2000) and CINAHL (1982-2000) computer literature searches by using key words such as electricity, magnetism, electromagnetic, therapy, medicine, EMF, history of medicine, and fields. Additional references were obtained from the bibliographies of the selected articles. In addition, discussions were held with curators of medical history museums and supplemental searches were made of Internet sources through various search engines. STUDY SELECTION: Primary references were used whenever possible. In a few instances, secondary references, particularly those requiring translations of early texts, were used. DATA SYNTHESIS: The use of electric and magnetic forces to treat disease has intrigued the general public and the scientific community since at least the time of the ancient Greeks. The popularity of these therapies has waxed and waned over the millennia, but at all times the popular imagination, often spurred by dynamic and colorful practitioners of pseudoscience, has been more excited than the medical or political establishment. In fact, a pattern seems to reappear. In each era, unsophisticated public acceptance is met first with medical disdain, then with investigation, and, finally, with a failure to find objective evidence of efficacy. This pattern continues today with the public acceptance of magnetic therapy (and alternative and complementary medicine in general) far outstripping acceptance by the medical community. CONCLUSION: The therapeutic implications of applying electrical and magnetic fields to heal disease have continually captured the popular imagination. Approaches thousands of years apart can be remarkably similar, but, in each era, proof has been lacking and the prevailing medical establishment has remained unconvinced. Interest persists today. Although these agents may have a future role in the healing of human disease, their history and a minimal scientific rationale makes it unlikely that the dichotomy between the hopes of the public and the medical skepticism will disappear.

Low intensity laser therapy: still not an established clinical tool.

The surgical, ophthalmological, and dermatological applications of high power lasers are well known and easily understood. What is neither as well known nor as easily understood is that lasers at powers that are orders of magnitude smaller have also been used in the laboratory and clinic for nearly 30 years to modulate cell function, lessen pain, and accelerate healing of soft tissue injuries. This article analyzes the rationale of this approach, examines the utility of laser therapy in its most common clinical applications, reviews and synthesizes the findings, and concludes that although laboratory findings seem authentic, clinical utility remains unestablished.

Autonomic dysreflexia due to medication: misadventure in the use of an isometheptene combination to treat migraine.

Autonomic dysreflexia, a syndrome sometimes occurring in spinal cord injured (SCI) individuals, may be life-threatening. It involves, in varying degrees, hypertension, diaphoresis, headache, bradycardia, anxiety, and flushing and is believed due to unrestricted sympathetic activity below the level of the lesion in individuals with injuries above T4-6. The most frequent causes of the syndrome are urinary infections, rectal impaction, bladder distention, and decubitus ulcers. To our knowledge, medication has seldom been described as causal agent. We report here on an autonomic dysreflexic syndrome following use of an isometheptene combination (Midrin), to treat migraine. The individual involved is a C4-quadriplegic man with a long history of migraines. He was given a standard initial adult dose of the medication. Over a one-hour period, he was initially relieved of the headache, but then noted a new more severe headache, diaphoresis, and flushing. His vital signs showed progressive BP elevation to 210/130 and a relative bradycardia. Treatment over the next three hours was limited to elevation of the head of the bed and observation, during which his vital signs returned to baseline and he became asymptomatic. This experience reinforces the belief that sympathomimetic drugs in general, and isometheptene in particular, should be used in caution in patients with high-level SCI.

Adaptive equipment for C6 quadriplegia: an approach to effective, simple, and inexpensive devices.

Three simple and inexpensive devices were developed by a man with complete C6 quadriplegia to increase his independence: a reacher that allows him to lift and move objects ranging in size from ballpoint pens to beverage cans; a wrist splint that permits him to open pop-top cans, dial a telephone, open a drawer, and page through a book; and an implement holder that stabilizes small devices.

Rehabilitation for stroke: a review.

Survivors of stroke are often left with severe mental and physical disabilities, which create a major social and economic burden. Many investigators have attempted to assess the role of rehabilitation in reducing such disability. Few controlled studies provide accurate assessment and documentation of benefit. Because of the presence of multiple variables and inadequate measures of outcome, it is difficult to design studies evaluating the effectiveness of rehabilitation for stroke. It is unclear how early rehabilitation should begin and what aspects of rehabilitation are important. Intensive rehabilitation is an expensive and limited resource; thus, the ability to identify the subgroup of patients with stroke who are likely to benefit is a critical issue. Although preliminary guidelines for the selection of patients who are appropriate for rehabilitation are given, no uniform criteria reliably differentiate patients who need rehabilitation from those who will recover spontaneously or do poorly. Controlled studies in the practice of rehabilitation for stroke will provide much useful information for patient management.