The Interface of Clinical Decision-Making With Study Protocols for Knowledge Translation From a Walking Recovery Trial.

BACKGROUND AND PURPOSE: Despite efforts to translate knowledge into clinical practice, barriers often arise in adapting the strict protocols of a randomized, controlled trial (RCT) to the individual patient. The Locomotor Experience Applied Post-Stroke (LEAPS) RCT demonstrated equal effectiveness of 2 intervention protocols for walking recovery poststroke; both protocols were more effective than usual care physical therapy. The purpose of this article was to provide knowledge-translation tools to facilitate implementation of the LEAPS RCT protocols into clinical practice. METHODS: Participants from 2 of the trial's intervention arms: (1) early Locomotor Training Program (LTP) and (2) Home Exercise Program (HEP) were chosen for case presentation. The two cases illustrate how the protocols are used in synergy with individual patient presentations and clinical expertise. Decision algorithms and guidelines for progression represent the interface between implementation of an RCT standardized intervention protocol and clinical decision-making. OUTCOMES: In each case, the participant presents with a distinct clinical challenge that the therapist addresses by integrating the participant's unique presentation with the therapist's expertise while maintaining fidelity to the LEAPS protocol. Both participants progressed through an increasingly challenging intervention despite their own unique presentation. SUMMARY: Decision algorithms and exercise progression for the LTP and HEP protocols facilitate translation of the RCT protocol to the real world of clinical practice. The two case examples to facilitate translation of the LEAPS RCT into clinical practice by enhancing understanding of the protocols, their progression, and their application to individual participants.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A147).

Concordance and discordance between measured and perceived balance and the effect on gait speed and falls following stroke.

OBJECTIVE: To ascertain the existence of discordance between perceived and measured balance in persons with stroke and to examine the impact on walking speed and falls. DESIGN: A secondary analysis of a phase three, multicentered randomized controlled trial examining walking recovery following stroke. SUBJECTS: A total of 352 participants from the Locomotor Experience Applied Post-Stroke (LEAPS) trial. METHODS: Participants were categorized into four groups: two concordant and two discordant groups in relation to measured and perceived balance. Number and percentage of individuals with concordance and discordance were evaluated at two and 12 months. Walking speed and fall incidence between groups were examined. MAIN MEASURES: Perceived balance was measured by the Activities-Specific Balance Confidence scale, measured balance was determined by the Berg Balance Scale and gait speed was measured by the 10-meter walk test. RESULTS: Discordance was present for 35.8% of participants at two months post stroke with no statistically significant change in proportion at 12 months. Discordant participants with high perceived balance and low measured balance walked 0.09 m/s faster at two months than participants with concordant low perceived and measured balance (p < 0.05). Discordant participants with low perceived balance and high measured balance walked 0.15 m/s slower than those that were concordant with high perceived and measured balance (p ⩽ 0.0001) at 12 months. Concordant participants with high perceived and measured balance walked fastest and had fewer falls. CONCLUSIONS: Discordance existed between perceived and measured balance in one-third of individuals at two and 12 months post-stroke. Perceived balance impacted gait speed but not fall incidence.

Reliability, responsiveness, and validity of slow walking speed in community dwelling older adults.

BACKGROUND: Independent ambulation requires adaptability. Self-selected and maximum walking speeds are often both assessed to demonstrate the ability to adapt speed to different tasks and environments. However, purposefully walking at a slow speed (slowWS) could also be an appropriate adaptation in certain situations but has rarely been investigated. RESEARCH QUESTION: The purpose of this study was to assess the reliability, responsiveness, and concurrent validity of slowWS in community-dwelling older adults. METHODS: This was an observational, cross-sectional study of 110 community-dwelling older adults. Test-retest and inter-rater reliabilities of slowWS were assessed with intra-class correlation coefficients. Standard error of measurement (SEM) and minimal detectable change (MDC95) were calculated to determine responsiveness. Concurrent validity was assessed with Spearman rank-order correlations between slowWS and a battery of tests previously shown to be related to walking speed. RESULTS: Walking speed measurement for slowWS was shown to have excellent test-retest and interrater reliability (ICCs values of 0.971-0.997). Standard error of measurement value was small (0.015 m/sec) and MDC95 was 0.04 m/sec. SlowWS was not found to significantly correlate to any other study variable. SIGNIFICANCE: Walking speed, whether self-selected, maximum, or slow, can be measured reliably with a stopwatch and specific verbal commands. While slowWS could be beneficial for certain tasks or environments, walking slowly was not associated with age, sex, comorbidity, or measures of cognition, depression, strength, balance, disability, or life-space in this sample.

Fugl-Meyer assessment of sensorimotor function after stroke: standardized training procedure for clinical practice and clinical trials.

BACKGROUND AND PURPOSE: Outcome measurement fidelity within and between sites of multi-site, randomized, clinical trials is an essential element to meaningful trial outcomes. As important are the methods developed for randomized, clinical trials that can have practical utility for clinical practice. A standardized measurement method and rater training program were developed for the total Fugl-Meyer motor and sensory assessments; inter-rater reliability was used to test program effectiveness. METHODS: Fifteen individuals with hemiparetic stroke, 17 trained physical therapists across 5 regional clinical sites, and an expert rater participated in an inter-rater reliability study of the Fugl-Meyer motor (total, upper extremity, and lower extremity subscores) and sensory (total, light touch, and proprioception subscores) assessments. RESULTS: Intra-rater reliability for the expert rater was high for the motor and sensory scores (range, 0.95-1.0). Inter-rater agreement (intraclass correlation coefficient, 2, 1) between expert and therapist raters was high for the motor scores (total, 0.98; upper extremity, 0.99; lower extremity, 0.91) and sensory scores (total, 0.93; light touch, 0.87; proprioception, 0.96). CONCLUSIONS: Standardized measurement methods and training of therapist assessors for a multi-site, rehabilitation, randomized, clinical trial resulted in high inter-rater reliability for the Fugl-Meyer motor and sensory assessments. Poststroke sensorimotor impairment severity can be reliably assessed for clinical practice or rehabilitation research with these methods.