Group-based telerehabilitation intervention using Wii Fit to improve walking in older adults with lower limb amputation (WiiNWalk): A randomized control trial.

OBJECTIVE: Determine efficacy of the novel WiiNWalk intervention on walking-related outcomes in older adults with lower limb amputation. DESIGN: Multi-site, parallel, evaluator-masked randomized controlled trial. SETTING: Home-setting in three Canadian cities. PARTICIPANTS: Community-dwelling lower limb prosthesis users over 50 years of age. INTERVENTIONS: The WiiNWalk group (n = 38) used modified Wii Fit activities for prosthetic rehabilitation. The attention control group (n = 33) used Big Brain Academy: Wii Degree, comprising of cognitive activities. Both groups completed a 4-week supervised phase with three 1-h sessions/week in groups of three overseen by a clinician via videoconferencing and a 4-week unstructured and unsupervised phase. MAIN MEASURES: Primary outcome was walking capacity (2 min walk test); secondary outcomes were balance confidence (activities-specific balance confidence scale), dynamic balance (four-step square test), and lower limb functioning (short physical performance battery). Outcomes were compared across time points with repeated measures analysis of covariance, adjusting for baseline and age. RESULTS: Mean age was 65.0 (8.4) years, with 179.5 (223.5) months post-amputation and 80% transtibial amputation. No group difference in a 2 min walk test with an effect size: 1.53 95% CI [-3.17, 6.23] m. Activities balance confidence was greater in the WiiNWalk group by 5.53 [2.53, 8.52]%. No group difference in the four-step square test -0.16 [-1.25, 0.92] s, nor short physical performance battery 0.48 [-0.65, 1.61]. A post-hoc analysis showed the greatest difference in balance confidence immediately after an unsupervised phase. CONCLUSIONS: The WiiNWalk intervention improved balance confidence, but not walking-related physical function in older adult lower limb prosthesis users. Future rehabilitation games should be specific to the amputation context.Clinical Trial Registration number, NCT01942798.

Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective, Multicenter Cohort Study of Imaging Selection.

OBJECTIVE: The primary imaging modalities used to select patients for endovascular thrombectomy (EVT) are noncontrast computed tomography (CT) and CT perfusion (CTP). However, their relative utility is uncertain. We prospectively assessed CT and CTP concordance/discordance and correlated the imaging profiles on both with EVT treatment decisions and clinical outcomes. METHODS: A phase 2, multicenter, prospective cohort study of large-vessel occlusions presented up to 24 hours from last known well was conducted. Patients received a unified prespecified imaging evaluation (CT, CT angiography, and CTP with Rapid Processing of Perfusion and Diffusion software mismatch determination). The treatment decision, EVT versus medical management, was nonrandomized and at the treating physicians' discretion. An independent, blinded, neuroimaging core laboratory adjudicated favorable profiles based on predefined criteria (CT:Alberta Stroke Program Early CT Score ≥ 6, CTP:regional cerebral blood flow (<30%) < 70ml with mismatch ratio ≥ 1.2 and mismatch volume ≥ 10ml). RESULTS: Of 4,722 patients screened from January 2016 to February 2018, 361 patients were included. Two hundred eighty-five (79%) received EVT, of whom 87.0% had favorable CTs, 91% favorable CTPs, 81% both favorable profiles, 16% discordant, and 3% both unfavorable. Favorable profiles on the 2 modalities correlated similarly with 90-day functional independence rates (favorable CT = 56% vs favorable CTP = 57%, adjusted odds ratio [aOR] = 1.91, 95% confidence interval [CI] = 0.40-9.01, p = 0.41). Having a favorable profile on both modalities significantly increased the odds of receiving thrombectomy as compared to discordant profiles (aOR = 3.97, 95% CI = 1.97-8.01, p < 0.001). Fifty-eight percent of the patients with favorable profiles on both modalities achieved functional independence as compared to 38% in discordant profiles and 0% when both were unfavorable (p < 0.001 for trend). In favorable CT/unfavorable CTP profiles, EVT was associated with high symptomatic intracranial hemorrhage (sICH) (24%) and mortality (53%) rates. INTERPRETATION: Patients with favorable imaging profiles on both modalities had higher odds of receiving EVT and high functional independence rates. Patients with discordant profiles achieved reasonable functional independence rates, but those with an unfavorable CTP had higher adverse outcomes. Ann Neurol 2020;87:419-433.

Endovascular Thrombectomy for Mild Strokes: How Low Should We Go?

Background and Purpose- Endovascular thrombectomy (EVT) is effective for acute ischemic stroke with large vessel occlusion and National Institutes of Health Stroke Scale (NIHSS) ≥6. However, EVT benefit for mild deficits large vessel occlusions (NIHSS, <6) is uncertain. We evaluated EVT efficacy and safety in mild strokes with large vessel occlusion. Methods- A retrospective cohort of patients with anterior circulation large vessel occlusion and NIHSS <6 presenting within 24 hours from last seen normal were pooled. Patients were divided into 2 groups: EVT or medical management. Ninety-day mRS of 0 to 1 was the primary outcome, mRS of 0 to 2 was the secondary. Symptomatic intracerebral hemorrhage was the safety outcome. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, presentation NIHSS, time last seen normal to presentation, center, IV alteplase, Alberta Stroke Program early computed tomographic score, and thrombus location. We then performed propensity score matching as a sensitivity analysis. Results were also stratified by thrombus location. Results- Two hundred fourteen patients (EVT, 124; medical management, 90) were included from 8 US and Spain centers between January 2012 and March 2017. The groups were similar in age, Alberta Stroke Program early computed tomographic score, IV alteplase rate and time last seen normal to presentation. There was no difference in mRS of 0 to 1 between EVT and medical management (55.7% versus 54.4%, respectively; adjusted odds ratio, 1.3; 95% CI, 0.64-2.64; P=0.47). Similar results were seen for mRS of 0 to 2 (63.3% EVT versus 67.8% medical management; adjusted odds ratio, 0.9; 95% CI, 0.43-1.88; P=0.77). In a propensity matching analysis, there was no treatment effect in 62 matched pairs (53.5% EVT, 48.4% medical management; odds ratio, 1.17; 95% CI, 0.54-2.52; P=0.69). There was no statistically significant difference when stratified by any thrombus location; M1 approached significance ( P=0.07). Symptomatic intracerebral hemorrhage rates were higher with thrombectomy (5.8% EVT versus 0% medical management; P=0.02). Conclusions- Our retrospective multicenter cohort study showed no improvement in excellent and independent functional outcomes in mild strokes (NIHSS, <6) receiving thrombectomy irrespective of thrombus location, with increased symptomatic intracerebral hemorrhage rates, consistent with the guidelines recommending the treatment for NIHSS ≥6. There was a signal toward benefit with EVT only in M1 occlusions; however, this needs to be further evaluated in future randomized control trials.

A randomized controlled trial to evaluate the feasibility of the Wii Fit for improving walking in older adults with lower limb amputation.

OBJECTIVE: To assess the feasibility of Wii.n.Walk for improving walking capacity in older adults with lower limb amputation. DESIGN: A parallel, evaluator-blind randomized controlled feasibility trial. SETTING: Community-living. PARTICIPANTS: Individuals who were ⩾50 years old with a unilateral lower limb amputation. INTERVENTION: Wii.n.Walk consisted of Wii Fit training, 3x/week (40 minute sessions), for 4 weeks. Training started in the clinic in groups of 3 and graduated to unsupervised home training. Control group were trained using cognitive games. MAIN MEASURES: Feasibility indicators: trial process (recruitment, retention, participants' perceived benefit from the Wii.n.Walk intervention measured by exit questionnaire), resources (adherence), management (participant processing, blinding), and treatment (adverse event, and Cohen's d effect size and variance). Primary clinical outcome: walking capacity measured using the 2 Minute Walk Test at baseline, end of treatment, and 3-week retention. RESULTS: Of 28 randomized participants, 24 completed the trial (12/arm). Median (range) age was 62.0 (50-78) years. Mean (SD) score for perceived benefit from the Wii.n.Walk intervention was 38.9/45 (6.8). Adherence was 83.4%. The effect sizes for the 2 Minute Walk Test were 0.5 (end of treatment) and 0.6 (3-week retention) based on intention to treat with imputed data; and 0.9 (end of treatment) and 1.2 (3-week retention) based on per protocol analysis. The required sample size for a future larger RCT was deemed to be 72 (36 per arm). CONCLUSIONS: The results suggested the feasibility of the Wii.n.Walk with a medium effect size for improving walking capacity. Future larger randomized controlled trials investigating efficacy are warranted.

Reliability and validity of scores of a Chinese version of the Frenchay Activities Index.

OBJECTIVE: To develop a Chinese version of the Frenchay Activities Index (FAI-C) and evaluate the reliability and validity of its scores. DESIGN: A 2-week test-retest study. SETTING: Chinese community in Vancouver, BC, Canada. PARTICIPANTS: Data were collected using a convenience sample of Chinese immigrants living in Vancouver, BC, Canada. Of the 73 participants, data from 66 participants were included in the analysis. The total sample included 2 subsamples: community dwelling (n=32), and assisted-living (n=34). Participants were 65 years or older, lived in Canada for more than 5 years, and were able to read Chinese. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FAI-C scores. RESULTS: Test-retest reliability of the FAI-C scores assessed using an intraclass correlation coefficient was .86 (95% confidence interval [CI], .79-.92) for the total sample, .89 (95% CI, .78-.94) for the community-dwelling subsample, and .71 (95% CI, .50-.85) for the assisted-living subsample. The minimal detectable difference at the 95% CI was 8.64. Correlations between the FAI-C and the Reintegration to Normal Living Index (r=.61, P<.01), Activities-specific Balance Confidence Scale (r=.55, P<.01), and Timed Up & Go test (r=-.68, P<.01) were in the a priori hypothesized direction and magnitude. CONCLUSIONS: The FAI-C scores are reliable and there is support for validity. This tool enables us to measure social participation level in the Chinese-speaking population.

Walking while talking: validation in older adults with lower-limb amputation.

BACKGROUND: Walking while talking (WWT) is a dual-task (cognitive and motor) performance test that has not yet been validated in older adults with lower-limb amputation (LLA). WWT is composed of two sections: WWT-simple (walking while reciting every letter of the alphabet) and WWT-complex (walking while reciting every other letter of the alphabet). OBJECTIVE: To determine the validity, and provide normative data and a new scoring system for the WWT test in older adults with LLA. STUDY DESIGN: Baseline cross-sectional data were collected from 56 community-living older adults (≥50 years old) with LLA at rehabilitation hospitals in Vancouver, BC, London, ON, and Edmonton, AB, Canada. METHODS: Time and number of recited letters and errors during both sections were recorded. A new score was developed based on all these variables. Correlations of the recorded times with the Activities-specific Balance Confidence (ABC) scale and the 2-Minute Walk Test (2MWT) score were used to evaluate the validity of the WWT test. RESULTS: As hypothesized, the times for both sections of the WWT were negatively correlated with both the ABC and 2MWT scores. Positive correlations were observed between the scores developed for both WWT sections with the 2MWT score. CONCLUSION: Times taken to complete each section of the WWT test were correlated with the 2MWT and the ABC scale scores, providing evidence for the validity of the WWT test. We also provided a scoring method that is more objective and in line with the dual-task nature of the test.

Validity of measures for life space mobility and physical activity in older adults with lower-limb amputation.

BACKGROUND: Older adults with lower-limb amputations (LLAs) often experience lack of confidence and poor balance, which limits their mobility. There are few validated measures for assessing these outcomes in the LLA population. OBJECTIVES: To assess the validity of the Life Space Assessment (LSA) and the Physical Activity Scale for the Elderly (PASE) for older adults with LLA. STUDY DESIGN: Secondary analyses of cross-sectional data. METHODS: Sixty-eight older adults with LLA across Canada were recruited to complete the LSA and the PASE. Validity was assessed via correlations with the Activities-specific Balance Confidence (ABC), Four-Square Step Test (FSST), and Two-Minute Walk Test (2-MWT). RESULTS: As hypothesized, the LSA was positively correlated with the ABC (ρ = 0.36, 95% confidence interval [CI] [0.17, 0.62]) and 2-MWT (r = 0.49, 95% CI [0.27, 0.70]) and negatively correlated with FSST (ρ = -0.39, 95% CI [-0.56, -0.10]). The PASE was positively correlated with the ABC (ρ = 0.34, 95% CI [0.10, 0.56]) and 2-MWT (ρ = 0.32, 95% CI [0.05, 0.52]), and negatively correlated with FSST (ρ = -0.36, 95% CI [-0.53, -0.07]). CONCLUSIONS: The LSA has validity in measuring life space mobility. The PASE captures the physical activity with weaker support of validity in older adults with LLA. CLINICAL RELEVANCE: The LSA and PASE are quick low-cost tools for clinicians to assess mobility-related functional health and physical activity, respectively, in older adults with LLA. However, the PASE may contain activities that are not common among older adults with LLA.

Self-directed usage of an in-home exergame after a supervised telerehabilitation training program for older adults with lower-limb amputation.

BACKGROUND: While home-based exergames help overcome accessibility barriers to rehabilitation, it is unclear what constitutes effective intervention design in using exergames to support self-efficacy and engagement. OBJECTIVE: Examine usage of an in-home exergame, compared to control, unsupervised after supervised training by older persons with lower-limb amputation. STUDY DESIGN: Secondary analysis of a multi-site parallel evaluator-masked randomized control trial. METHODS: WiiNWalk uses the WiiFit and teleconferencing for in-home group-based exergame therapy with clinical supervision. Participants engaged in a 4-week supervised training phase followed by a 4-week unsupervised phase in experimental (WiiNWalk) and attention control groups. Usage between phases and between groups was compared using unsupervised/supervised ratio of session count (over 4 weeks) and session time (mean min/session over 4 weeks) for each phase. RESULTS: Participants: n=36 experimental, n=28 control, unilateral lower-limb amputation, age > 50 years, prosthesis usage ≥ 2 hours/day. Session count ratio unsupervised/supervised, median and interquartile range (IQR), was less than parity (p<0.01) for experimental (0.25, IQR 0.00 -0.68) and control (0.18, IQR 0.00 -0.67) groups, with no different between groups (p=0.92). Experimental session time unsupervised/supervised showed consistency (1.12, IQR 0.80 -1.41) between phases (p=0.24); control showed lower (0.76, IQR 0.57 -1.08) ratios compared to experimental (p=0.027). CONCLUSIONS: Unsupervised exercise duration remained consistent with supervised, but frequency was reduced. Social and clinical guidance features may remain necessary for sustained lower-limb amputation exergame engagement at home. CLINICAL RELEVANCE: This study provides context regarding when prosthesis users are more likely to use exergames such as Wii Fit for exercise therapy. Clinicians may consider our results when applying exergames in their practice or when developing new exergame intervention strategies.

Lower Limb Prosthetic Rehabilitation in Canada: A Survey Study.

Purpose: This study describes prosthetic rehabilitation services provided to individuals who have had a lower limb amputation in Canada. Method: This cross-sectional survey study used an online survey to collect data from facilities that provide lower limb prosthetic rehabilitation; it included questions about approaches and types of service, therapies, focus of service, and health care providers. One representative from each facility was asked to complete the survey. Results: Of the 65 identified eligible facilities, 59 completed the survey (response rate = 90.8%). The majority of facilities (n = 39; 66.1%) indicated that they provided both in-patient and outpatient prosthetic rehabilitation services. All facilities provided balance, coordination, and gait training as well as prosthetic fit education. Most facilities indicated that they had a physical therapist (n = 58; 93.8%), an occupational therapist (n = 52; 88.1%), and a prosthetist (n = 52; 88.1%) on their team. Conclusions: The majority of the facilities surveyed provided both in-patient and outpatient services and had specialized health care provider teams. Future surveys are required to collect more specific information about prosthetic rehabilitation in Canada.

Objectif : décrire les services de réadaptation avec prothèse du Canada pour les personnes amputées des membres inférieurs. Méthodologie : une étude transversale en ligne a permis d'amasser des données auprès d'établissements qui offrent une réadaptation avec prothèse des membres inférieurs. Elle incluait des questions sur les approches et les types de services, les traitements, l'objet des services et les professionnels de la santé. Un représentant de chaque établissement était invité à remplir le sondage. Résultats : des 65 établissements admissibles répertoriés, 59 ont rempli le sondage (taux de réponse = 90,8 %). La majorité des établissements (n = 39, 66,1 %) a indiqué qu'il offrait des services de réadaptation avec prothèse aux patients hospitalisés et ambulatoires. Tous les établissements offraient un entraînement sur l'équilibre, la coordination et la démarche et de l'information sur l'ajustement des prothèses. La plupart des établissements indiquaient qu'ils comptaient un physiothérapeute (n = 58, 93,8 %), un ergothérapeute (n = 52, 88,1 %) et un prothésiste (n = 52, 88,1 %) au sein de leur équipe. Conclusions : la majorité des établissements sondés offraient à la fois des services aux patients hospitalisés et ambulatoires et étaient dotés d'équipes soignantes spécialisées. Il faudra réaliser d'autres sondages pour colliger de l'information plus précise sur la réadaptation avec prothèse au Canada.

Outcomes of Endovascular Thrombectomy vs Medical Management Alone in Patients With Large Ischemic Cores: A Secondary Analysis of the Optimizing Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) Study.

IMPORTANCE: The efficacy and safety of endovascular thrombectomy (EVT) in patients with large ischemic cores remains unknown, to our knowledge. OBJECTIVE: To compare outcomes in patients with large ischemic cores treated with EVT and medical management vs medical management alone. DESIGN, SETTING, AND PARTICIPANTS: This prespecified analysis of the Optimizing Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT) trial, a prospective cohort study of imaging selection that was conducted in 9 US comprehensive stroke centers, enrolled patients between January 2016 and February 2018, and followed them up for 90 days. Patients with moderate to severe stroke and anterior circulation large-vessel occlusion presenting up to 24 hours from the time they were last known to be well were eligible for the cohort. Of these, patients with large ischemic cores on computed tomography (CT) (Alberta Stroke Program Early CT Score <6) or CT perfusion scanning (a volume with a relative cerebral blood flow <30% of ≥50 cm3) were included in analyses. EXPOSURES: Endovascular thrombectomy with medical management (MM) or MM only. MAIN OUTCOMES AND MEASURES: Functional outcomes at 90 days per modified Rankin scale; safety outcomes (mortality, symptomatic intracerebral hemorrhage, and neurological worsening). RESULTS: A total of 105 patients with large ischemic cores on either CT or CT perfusion images were included: 71 with Alberta Stroke Program Early CT Scores of 5 or less (EVT, 37; MM, 34), 74 with cores of 50 cm3 or greater on CT perfusion images (EVT, 39; MM, 35), and 40 who had large cores on both CT and CT perfusion images (EVT, 14; MM, 26). The median (interquartile range) age was 66 (60-75) years; 45 patients (43%) were female. Nineteen of 62 patients (31%) who were treated with EVT achieved functional independence (modified Rankin Scale scores, 0-2) vs 6 of 43 patients (14%) treated with MM only (odds ratio [OR], 3.27 [95% CI, 1.11-9.62]; P = .03). Also, EVT was associated with better functional outcomes (common OR, 2.12 [95% CI, 1.05-4.31]; P = .04), less infarct growth (44 vs 98 mL; P = .006), and smaller final infarct volume (97 vs 190 mL; P = .001) than MM. In the odds of functional independence, there was a 42% reduction per 10-cm3 increase in core volume (adjusted OR, 0.58 [95% CI, 0.39-0.87]; P = .007) and a 40% reduction per hour of treatment delay (adjusted OR, 0.60 [95% CI, 0.36-0.99]; P = .045). Of 10 patients who had EVT with core volumes greater than 100 cm3, none had a favorable outcome. CONCLUSIONS AND RELEVANCE: Although the odds of good outcomes for patients with large cores who receive EVT markedly decline with increasing core size and time to treatment, these data suggest potential benefits. Randomized clinical trials are needed.

A clinical survey about commercial games in lower limb prosthetic rehabilitation.

BACKGROUND: Despite the popularity of commercial games in lower limb prosthetic rehabilitation, data about their prevalence of use as well as therapists' perspectives about these games are still lacking. OBJECTIVES: To learn about the prevalence of use of commercial games in lower limb prosthetic rehabilitation and therapists' perspectives about these games. STUDY DESIGN: Cross-sectional. METHODS: An online survey was sent to physical and occupational therapists across prosthetic rehabilitation facilities in Canada. The survey had questions about the use of commercial games and therapists' perspectives. RESULTS: Data were collected from 82 therapists. Overall, 46.3% (38/82) reported that they use commercial games; of those, 94.7% (36/38) used the Nintendo Wii Fit. The most reported perceived benefits were the Wii Fit helping to improve weight shifting ( n = 76/82, 92.7%) and balance ( n = 75/82, 91.5%), and being motivating and complementing traditional therapy ( n = 75/82, 91.5%). The most reported perceived barriers/challenges were lack of time and familiarity with the games ( n = 58/82, 70.7%). CONCLUSION: Commercial games, particularly the Wii Fit, are commonly used in lower prosthetic rehabilitation in Canada. Most of the queried therapists view the Wii Fit positively. Knowledge translation activities and developing standard treatment protocols would be helpful in minimizing the barriers identified in this study. Clinical relevance The Wii Fit is prevalent in lower limb prosthetic rehabilitation in Canada and it is viewed positively by therapists as having the potential to improve balance and weight bearing, making rehabilitation more motivating, and complementing traditional therapy. Future studies should investigate the efficacy of the Wii Fit in prosthetic rehabilitation.

Incidence of lower limb amputation in Canada.

OBJECTIVES: To determine the Canadian age-adjusted incidence rates of lower limb amputation (LLA) by province, sex, level, and cause of amputation. METHODS: Data on all hospital discharges associated with LLA from April 1, 2006, to March 31, 2012, were obtained from the Canadian Institute for Health Information's Discharge Abstract Database. National and provincial age-adjusted rates were calculated per 100 000 individuals by sex, level, and cause of LLA using the direct method of standardization. The relative risk of LLA in people with diabetes was calculated. RESULTS: There were a total of 44 430 LLAs performed in Canada over the study years. The number of LLAs increased from 7331 in 2006 to 7708 in 2011. Mean (SD) age was 65.7 (16.6) years, and 68.8% were males. Sixty-five percent of the LLA cases were due to diabetes. The average age-adjusted rate of LLA in Canada was 22.9 per 100 000 individuals. The age-adjusted rates declined over the study years. The relative risk of diabetes-related LLAs was 28.9. CONCLUSION: This study provided the first Canadian national and provincial age-adjusted incidence rates of LLA and a baseline for monitoring and evaluation in the future. Understanding the incidence of LLA is essential to managing preventive and rehabilitation services for this population. Although the age-adjusted LLA incidence rates have decreased, the number of new LLAs has increased. The increase in the number of LLAs has important implications for social and health care costs.

Standardized Patients versus Volunteer Patients for Physical Therapy Students' Interviewing Practice: A Pilot Study.

PURPOSE: To compare the use of standardized patients (SPs) and volunteer patients (VPs) for physical therapy students' interviewing practice in terms of students' perception and overall costs. METHODS: Students in the Master of Physical Therapy programme (n=80) at a Canadian university were divided into 20 groups of 4 and were randomly assigned to interview either an SP (10 groups) or a VP (10 groups). Students completed a survey about their perception of the usefulness of the activity and the ease and depth of information extraction. Survey responses as well as costs of the interview exercise were compared between SP and VP groups. RESULTS: No statistically significant between-groups difference was found for the majority of survey items. The cost of using an SP was $148, versus $50 for a VP. CONCLUSIONS: Students' perceptions of the usefulness of the activity in helping them to develop their interview skills and of the ease and depth of extracting information were similar for both SPs and VPs. Because the cost of using an SP is about three times that of using a VP, using VPs seem to be a more cost-effective option.

Objet : Comparer le recours aux patients normalisés (PN) et aux patients bénévoles (PB) par des étudiants en physiothérapie qui s'exercent à réaliser des entrevues en ce qui concerne la perception des étudiants et les coûts généraux. Méthodes : Des étudiants à la maîtrise en physiothérapie (n=80) d'une université canadienne ont été divisés en 20 groupes de 4 personnes et on leur a aléatoirement attribué soit un PN (n=10 groupes), soit un PB (n=10 groupes) à interviewer. Les étudiants ont répondu à un sondage sur leur perception de l'utilité de cette activité, de la facilité avec laquelle l'information avait été obtenue et du niveau de détail de l'information obtenue. Les réponses au sondage ainsi que les coûts de l'exercice d'entrevue ont été comparés entre les groupes de PN et de PB. Résultats : Aucune différence importante sur le plan statistique entre les deux groupes n'a été relevée pour la majorité des points du sondage. Le cours du recours à un PN était de 148 $, tandis qu'il était de 50 $ pour un PB. Conclusions : La perception des étudiants en ce qui concerne l'utilité de l'activité pour les aider à parfaire leurs techniques d'entrevue ainsi que la facilité d'obtenir de l'information et le niveau de détail de l'information obtenue était similaire pour les patients normalisés et les patients bénévoles. Puisque le coût du recours à un PN est environ trois fois celui du recours à un PB, les patients bénévoles semblent être un choix plus rentable.

Virtual reality rehabilitation from social cognitive and motor learning theoretical perspectives in stroke population.

Objectives. To identify the virtual reality (VR) interventions used for the lower extremity rehabilitation in stroke population and to explain their underlying training mechanisms using Social Cognitive (SCT) and Motor Learning (MLT) theoretical frameworks. Methods. Medline, Embase, Cinahl, and Cochrane databases were searched up to July 11, 2013. Randomized controlled trials that included a VR intervention for lower extremity rehabilitation in stroke population were included. The Physiotherapy Evidence Database (PEDro) scale was used to assess the quality of the included studies. The underlying training mechanisms involved in each VR intervention were explained according to the principles of SCT (vicarious learning, performance accomplishment, and verbal persuasion) and MLT (focus of attention, order and predictability of practice, augmented feedback, and feedback fading). Results. Eleven studies were included. PEDro scores varied from 3 to 7/10. All studies but one showed significant improvement in outcomes in favour of the VR group (P < 0.05). Ten VR interventions followed the principle of performance accomplishment. All the eleven VR interventions directed subject's attention externally, whereas nine provided training in an unpredictable and variable fashion. Conclusions. The results of this review suggest that VR applications used for lower extremity rehabilitation in stroke population predominantly mediate learning through providing a task-oriented and graduated learning under a variable and unpredictable practice.

Health promotion and disease prevention strategies in older adults with intellectual and developmental disabilities.

The rapid growth in the number of individuals living with intellectual and developmental disabilities (IDD) along with their increased longevity present challenges to those concerned about health and well-being of this unique population. While much is known about health promotion and disease prevention in the general geriatric population, far less is known about those in older adults with IDD. Effective and efficient health promotion and disease prevention strategies need to be developed and implemented for improving the health and quality of life of older adults living with IDD. This is considered to be challenging given the continued shrinkage in the overall health care and welfare system services due to the cut in the governmental budget in some of the western countries. The ideal health promotion and disease prevention strategies for older adults with IDD should be tailored to the individuals' health risks, address primary and secondary disease prevention, and prevent avoidable impairments that cause premature institutionalization. Domains of intervention should include cognitive, mental and physical health, accommodations, workplace considerations, assistive technology, recreational activities, and nutrition.

A Telehealth Intervention Using Nintendo Wii Fit Balance Boards and iPads to Improve Walking in Older Adults With Lower Limb Amputation (Wii.n.Walk): Study Protocol for a Randomized Controlled Trial.

BACKGROUND: The number of older adults living with lower limb amputation (LLA) who require rehabilitation for improving their walking capacity and mobility is growing. Existing rehabilitation practices frequently fail to meet this demand. Nintendo Wii Fit may be a valuable tool to enable rehabilitation interventions. Based on pilot studies, we have developed "Wii.n.Walk", an in-home telehealth Wii Fit intervention targeted to improve walking capacity in older adults with LLA. OBJECTIVE: The objective of this study is to determine whether the Wii.n.Walk intervention enhances walking capacity compared to an attention control group. METHODS: This project is a multi-site (Vancouver BC, London ON), parallel, evaluator-blind randomized controlled trial. Participants include community-dwelling older adults over the age of 50 years with unilateral transtibial or transfemoral amputation. Participants will be stratified by site and block randomized in triplets to either the Wii.n.Walk intervention or an attention control group employing the Wii Big Brain cognitive software. This trial will include both supervised and unsupervised phases. During the supervised phase, both groups will receive 40-minute sessions of supervised group training three times per week for a duration of 4 weeks. Participants will complete the first week of the intervention in groups of three at their local rehabilitation center with a trainer. The remaining 3 weeks will take place at participants' homes using remote supervision by the trainer using Apple iPad technology. At the end of 4 weeks, the supervised period will end and the unsupervised period will begin. Participants will retain the Wii console and be encouraged to continue using the program for an additional 4 weeks' duration. The primary outcome measure will be the "Two-Minute Walk Test" to measure walking capacity. Outcome measures will be evaluated for all participants at baseline, after the end of both the supervised and unsupervised phases, and after 1-year follow up. RESULTS: Study staff have been hired and trained at both sites and recruitment is currently underway. No participants have been enrolled yet. CONCLUSIONS: Wii.n.Walk is a promising in-home telehealth intervention that may have useful applications for older adults with LLA who are discharged from rehabilitation or live in remote areas having limited or no access to existing rehabilitation programs. TRIAL REGISTRATION: Clinicaltrial.gov NCT01942798; http://clinicaltrials.gov/ct2/show/NCT01942798 (Archived by WebCite at http://www.webcitation.org/6V0w8baKP).

Feasibility of the Nintendo WiiFit™ for improving walking in individuals with a lower limb amputation.

OBJECTIVES: To evaluate the feasibility of the Nintendo WiiFit™ as an adjunct to usual therapy in individuals with a lower limb amputation. METHODS: The study was a Multiple Baseline (AB) Single Subject Research Design. Subjects were ≥19 years old, had their first unilateral transtibial or transfemoral amputation ≤12 months ago, and were participating in prosthetic training. WiiFit training was provided for 30 min, 5 times a week, for a minimum of 2 and a maximum of 6 weeks in addition to usual therapy. Feasibility indicators were safety, post-intervention fatigue and pain levels, adherence, and subject's acceptability of the program as measured by the Short Feedback Questionnaire-modified (SFQ-M). The primary clinical outcome was walking capacity assessed by the 2 Minute Walk Test (2MWT). The secondary clinical outcomes were the Short Physical Performance Battery, L-test, and Activities-Specific Balance Confidence. RESULTS: Subjects (4 transtibial; 2 transfemoral) had a median age of 48.5 years (range = 45-59 years). No adverse events associated with the intervention occurred. Median pain and fatigue levels were 1.3 (range = 0.5-3.5) and 3.1 (range = 1.4-4.1), respectively. Median adherence was 80%. Subjects found the WiiFit enjoyable and acceptable (median SFQ-M = 35). Five subjects showed statistical improvement on the 2MWT and four on the secondary outcomes (p < 0.05). CONCLUSION: The WiiFit intervention was found to be feasible in individuals with unilateral lower limb amputation. This research provides the foundation for future clinical research investigating the use of the WiiFit as a viable adjunctive therapy to improve outcomes in individuals with unilateral lower limb amputation who are participating in prosthetic training.

The relationship of pre-sarcopenia (low muscle mass) and sarcopenia (loss of muscle strength) with functional decline in individuals with intellectual disability (ID).

The aim was to determine the association between loss of muscle mass, loss of muscle strength, and physical ability in individuals with ID. Upper and lower extremity strength, muscle mass and muscle quality (MQ) were calculated. Physical ability was measured according to the Katz activities of daily living (ADL), stair climb test, and sit-to-stand test. We found a strong correlation between quadriceps strength and physical ability in ADL (r=0.92 for males, and r=0.88 for females), and a low-moderate correlation between hand grip strength and physical ability in ADL (r=0.40 for males, and r=0.46 for females). MQ showed a strong relationship between pre-sarcopenia and sarcopenia. Quadriceps strength is a promising measure of age-related muscle changes and it is strongly associated with physical and functional decline.

Inflammation and oxidative stress as biomarkers of premature aging in persons with intellectual disability.

The decline in cognitive ability and physical performance in older adults with intellectual disabilities (ID) is accompanied by less participation in social activities and a sedentary lifestyle; however the pathogenesis is not clear yet. It was recently suggested that chronic disease, adverse drug reactions, and aging create a cascade of events that can be best characterized as an asymptomatic inflammatory process. This cascade of events is mediated by cytokine interleukins 1 and 6 (IL-1α, and IL-6), nitric oxide (NO) and total oxidative stress (OS). Our hypothesis was that chronic inflammation in the bloodstream of persons with ID contributes to their "premature aging". To test this hypothesis, we measured and compared the levels of inflammatory molecules in persons with and without ID. Fifteen adults with, and 15 adults without ID (control group) participated in this study. The levels of NO metabolites (NOx), IL-1α, and IL-6 were obtained from participants' serum. OS markers were drawn from participants' capillary. Western blot, RT-PCR and specific chemical analysis were used as measurement tools. The levels of inflammatory molecules and OS were significantly higher in persons with ID compared to the control group. Asymptomatic inflammation in the bloodstream of the older adults with ID might explain the "premature aging" of these individuals. Monitoring the levels of inflammatory molecules could serve as biomarkers of "premature aging" which may allow early diagnosis and intervention, and improve the quality of care for persons with ID.