Does the addition of virtual reality training to a standard program of inpatient rehabilitation improve sitting balance ability and function after stroke? Protocol for a single-blind randomized controlled trial.

BACKGROUND: Sitting ability and function are commonly impaired after stroke. Balance training has been shown to be helpful, but abundant repetitions are required for optimal recovery and patients must be motivated to perform rehabilitation exercises repeatedly to maximize treatment intensity. Virtual reality training (VRT), which allows patients to interact with a virtual environment using computer software and hardware, is enjoyable and may encourage greater repetition of therapeutic exercises. However, the potential for VRT to promote sitting balance has not yet been explored. The objective of this study is to determine if supplemental VRT-based sitting balance exercises improve sitting balance ability and function in stroke rehabilitation inpatients. METHODS/DESIGN: This is a single-site, single-blind, parallel-group randomized control trial. Seventy six stroke rehabilitation inpatients who cannot stand independently for greater than one minute but can sit for at least 20 minutes (including at least one minute without support) are being recruited from a tertiary-care dedicated stroke rehabilitation unit. Participants are randomly allocated to experimental or control groups. Both participate in 10-12 sessions of 30-45 minutes of VRT performed in sitting administered by a single physiotherapist, in addition to their traditional therapy. The experimental group plays five games which challenge sitting balance while the control group plays five games which minimize trunk lean. Outcome measures of sitting balance ability (Function in Sitting Test, Ottawa Sitting Scale, quantitative measures of postural sway) and function (Reaching Performance Scale, Wolf Motor Function Test, quantitative measures of the limits of stability) are administered prior to, immediately following, and one month following the intervention by a second physiotherapist blind to the participant's group allocation. DISCUSSION: The treatment of sitting balance post-stroke with VRT has not yet been explored. Results from the current study will provide important evidence for the use of low-cost, accessible VRT as an adjunct intervention to increase sitting balance in lower-functioning patients receiving inpatient rehabilitation. The motivating and enjoyable attributes of VRT may increase exercise dosage, leading to improved function and optimal results from rehabilitation. TRIAL REGISTRATION: https://clinicaltrials.gov/; Identifier: NCT02285933. Registered 06 November 2014. Funded by the Heart & Stroke Foundation of Canada and a generous donation from Tony & Elizabeth Graham.

Standardized standing pelvis-to-floor photographs for the assessment of lower-extremity alignment.

OBJECTIVES: The objective of this cross-sectional study was to assess the intra-rater, inter-rater and test-retest reliability and concurrent validity of lower-extremity alignment estimated from a photograph [photographic alignment (PA) angle]. METHODS: A convenience sample of participants was recruited from the community. Radiopaque stickers were placed over participants' anterior superior iliac spines. One radiograph and one photograph were taken with the participant standing in a standardized position. The stickers were removed. After 30 min they were reapplied and a second photograph was taken. The hip-knee-ankle (HKA) angle was measured from each radiograph using customized imaging analysis software. The same software was used by three readers to measure the PA angle from each photograph from the first set twice, at least 2 weeks apart. One reader measured the PA angle from the second set of photographs. Reliability was tested using intraclass correlation coefficients (ICC(2,1)), Bland-Altman analyses and the minimal detectable change (MDC95). Concurrent validity was tested using a Pearson's correlation coefficient and Bland-Altman analysis. RESULTS: Fifty adults participated (mean age 41.8 years; mean body mass index 24.7 kg/m(2)). The PA angle was 4.5° more varus than the HKA angle; these measures were highly correlated (r = 0.92). Intra-rater (ICC(2,1) > 0.985), inter-rater (ICC(2,1) = 0.988) and test-retest reliability (ICC(2,1) = 0.903) showed negligible bias (<0.20°). The MDC95 was 2.69°. CONCLUSIONS: The PA angle may be used in place of the HKA angle if a bias of 4.5° is added. A difference of 3° between baseline and follow-up would be considered a true difference.

Validity and sensitivity to change of three scales for the radiographic assessment of knee osteoarthritis using images from the Multicenter Osteoarthritis Study (MOST).

OBJECTIVES: The purpose of this study was to assess the concurrent validity and sensitivity to change of three knee osteoarthritis (OA) grading scales. The Kellgren-Lawrence (KL) and the Osteoarthritis Research Society International (OARSI) joint space narrowing (JSN) grading scales are well-established. The third scale, the compartmental grading scale for OA (CG) is a novel scale which grades JSN, femoral osteophytes, tibial erosion and subluxation to create a total score. METHODS: One sample of 72 posteroanterior (PA) fixed-flexion radiographs displaying mild to moderate knee OA was selected from the Multicenter Osteoarthritis Study (MOST) to study validity. A second sample of 75 radiograph pairs, which showed an increase in OA severity over 30 months, was selected to study sensitivity to change. The three radiographic grading scales were applied to each radiograph in both samples. Spearman's rank correlation coefficients were used to correlate the radiographic grades and the change in grades over 30 months with a Whole-organ Magnetic Resonance Imaging Score (WORMS)-based composite score which included five articular features of knee OA. RESULTS: Correlations between the KL, OARSI JSN and CG grading scales and the magnetic resonance image (MRI)-based score were 0.836, 0.840 and 0.773 (P < 0.0001) respectively while correlations between change in the radiographic grading scales and change in the MRI-based score were 0.501, 0.525 and 0.492 (P < 0.0001). CONCLUSIONS: All three radiographic grading scales showed high validity and are suitable to assess knee OA severity. They showed moderate sensitivity to change; therefore caution should be taken when using ordinal radiographic grading scales to monitor knee OA over time.

Does measurement of the anatomic axis consistently predict hip-knee-ankle angle (HKA) for knee alignment studies in osteoarthritis? Analysis of long limb radiographs from the multicenter osteoarthritis (MOST) study.

OBJECTIVE: Researchers commonly use the femoral shaft-tibial shaft angle (FS-TS) from knee radiographs to estimate the hip-knee-ankle angle (HKA) in studies examining risk factors for knee osteoarthritis (OA) incidence and progression. The objective of this study was to determine the relationship between HKA and FS-TS, depending on the method of calculating FS-TS and the direction and degree of knee deformity. METHODS: 120 full-length digital radiographs were assigned, with 30 in each of four alignment groups (0.0°-4.9°, and ≥5.0° of varus and valgus), from a large cohort of persons with and at risk of knee OA. HKA and five measures of FS-TS (using progressively shorter shaft lengths) were obtained using Horizons Analysis Software, Orthopaedic Alignment & Imaging Systems Inc. (OAISYS). The offsets between HKA and the different versions of FS-TS were calculated, with 95% confidence intervals (CIs). Pearson correlations were calculated. RESULTS: In varus limbs use of a shorter shaft length increased the offset between HKA and FS-TS from 5.1° to 7.0°. The opposite occurred with valgus limbs (from 5.0° to 3.7°). Correlations between HKA and FS-TS for the whole sample of 120 individuals were excellent (r range 1.00-0.88). However, correlations for individual alignment groups were low to moderate, especially for the shortest-shaft FS-TS (r range 0.41-0.66). CONCLUSIONS: The offsets obtained using the shorter FS-TS measurements vary depending on direction and degree of knee deformity, and therefore may not provide reliable predictions for HKA We recommend that full-length radiographs be used whenever an accurate estimation of HKA is required, although broad categories of alignment can be estimated with FS-TS.

The utility of external performance measurement tools in program evaluation.

Many rehabilitation hospitals use formal measurement tools to evaluate program performance. A potential advantage to using the Functional Independence Measure instrument through the Uniform Data System for Medical Rehabilitation (UDSMR) is that it provides information that allows an institution to compare its level of performance to those of other facilities. To assess whether joining UDSMR, along with an institution's continuous quality improvement efforts, could be associated with improved program performance, the records of a rehabilitation hospital's internal inpatient Program Evaluation System (PES) were reviewed for 6 fiscal years (1990-1995). Quality improvement efforts during 1995 (during which a 51% improvement in length of stay efficiency was noted) included education for staff, feedback on team performance, and efforts to formulate clinical pathways. Although external measures of performance do not have a direct effect on quality improvement, they could help identify areas of potential improvement that might not be appreciated when internal assessment systems are used alone.