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Present interventions utilized in musculoskeletal rehabilitation are guided, in large part, by a biomedical model where peripheral structural injury is believed to be the sole driver of the disorder. There are, however, neurophysiological changes across different areas of the peripheral and central nervous systems, including peripheral receptors, dorsal horn of the spinal cord, brain stem, sensorimotor cortical areas, and the mesolimbic and prefrontal areas associated with chronic musculoskeletal disorders, including chronic low back pain, osteoarthritis, and tendon injuries. These neurophysiological changes appear not only to be a consequence of peripheral structural injury but also to play a part in the pathophysiology of chronic musculoskeletal disorders. Neurophysiological changes are consistent with a biopsychosocial formulation reflecting the underlying mechanisms associated with sensory and motor findings, psychological traits, and perceptual changes associated with chronic musculoskeletal conditions. These changes, therefore, have important implications in the clinical manifestation, pathophysiology, and treatment of chronic musculoskeletal disorders. Musculoskeletal rehabilitation professionals have at their disposal tools to address these neuroplastic changes, including top-down cognitive-based interventions (eg, education, cognitive-behavioral therapy, mindfulness meditation, motor imagery) and bottom-up physical interventions (eg, motor learning, peripheral sensory stimulation, manual therapy) that induce neuroplastic changes across distributed areas of the nervous system and affect outcomes in patients with chronic musculoskeletal disorders. Furthermore, novel approaches such as the use of transcranial direct current stimulation and repetitive transcranial magnetic stimulation may be utilized to help renormalize neurological function. Comprehensive treatment addressing peripheral structural injury as well as neurophysiological changes occurring across distributed areas of the nervous system may help to improve outcomes in patients with chronic musculoskeletal disorders.

Study Design Cross-sectional. Introduction Pain severity, sensory and motor impairment, and psychological (distress and anxiety) and social factors have previously been related to self-reported disability in persons with wrist and hand pain. Purpose of the study The purpose of this study to determine the relative contribution of pain severity, measures of impairment (sensory and motor function), psychosocial factors, and pain interference on self-reported disability experienced by persons with heterogeneous orthopedic injuries and conditions of the wrist and hand. Methods Measures of disability and pain severity as well as measures of sensory (pressure pain thresholds, joint position sense), motor (grip strength, Purdue pegboard), and cognitive performance (Stroop test) and psychosocial variables related to pain and participation (West Haven-Yale Multidimensional Pain Inventory) were administered to 60 participants with wrist and hand pain. Pearson product correlations controlled for age and sex, and multiple linear regression was performed to determine the relationship between measures of impairment, pain severity, psychosocial variables, and pain interference with self-reported disability assessed with the Disability of Arm, Shoulder and Hand (DASH) questionnaire. Results The best-fitting regression model with DASH scores entered as the dependent variable (F4,50 = 28.8, P Conclusion Pain interference appears to be an important factor explaining the link between impairment, pain severity, and self-reported disability. Addressing pain interference may be important to improve outcomes in this population.

Background Exergames have the potential to provide an accessible, remote approach for poststroke upper extremity (UE) rehabilitation. However, the use of exergames without any follow-up by a health professional could lead to compensatory movements during the exercises, inadequate choice of difficulty level, exercises not being completed, and lack of motivation to pursue exercise programs, thereby decreasing their benefits. Combining telerehabilitation with exergames could allow continuous adjustment of the exercises and monitoring of the participant’s completion and adherence. At present, there is limited evidence regarding the feasibility or efficacy of combining telerehabilitation and exergames for stroke rehabilitation. Objective This study aims to (1) determine the preliminary efficacy of using telerehabilitation combined with exergames on UE motor recovery, function, quality of life, and motivation in participants with chronic stroke, compared with conventional therapy (the graded repetitive arm supplementary program; GRASP); (2) examine the feasibility of using the technology with participants diagnosed with stroke at home; and (3) identify the obstacles and facilitators for its use by participants diagnosed with stroke and stroke therapists and understand the shared decision-making process. Methods A mixed methods study protocol is proposed, including a randomized, blinded feasibility trial with an embedded multiple case study. The intervention consists of the provision of a remote rehabilitation program, during which participants will use the Jintronix exergame for UE training and the Reacts Application to conduct videoconferenced sessions with the therapists (physical or occupational therapists). We plan to recruit 52 participants diagnosed with stroke, randomly assigned to a control group (n=26; 2-month on-paper home exercise program: the GRASP with no supervision) and an experimental group (n=26; 2-month home program using the technology). The primary outcome is the Fugl-Meyer UE Assessment, a performance-based measure of UE impairment. The secondary outcomes are self-reported questionnaires and include the Motor Activity Log-28 (quality and frequency of use of the UE), Stroke Impact Scale-16 (the quality of life), and Treatment Self-Regulation Questionnaire (motivation). Feasibility data include process, resources, management, and scientific outcomes. Qualitative data will be collected by interviews with both participants and therapists. Results At present, data collection was ongoing with one participant who had completed the exergame- telerehabilitation based intervention. We expect to collect preliminary efficacy data of this technology on the functional and motor recovery of the UE, following a stroke; collect feasibility data with users at home (adherence, safety, and technical difficulties); and identify the obstacles and facilitators for the technology use and understand the shared decision-making process. Conclusions This paper describes the protocol underlying the study of a telerehabilitation-exergame technology to contribute to understanding its feasibility and preliminary efficacy for UE stroke rehabilitation. Trial Registration ClinicalTrials.gov NCT03759106; http://clinicaltrials.gov/show/NCT03759106. International Registered Report Identifier (IRRID) DERR1-10.2196/14629

Loss of arm function occurs in up to 85% of stroke survivors. Home-based telerehabilitation is a viable approach for upper limb training post-stroke when rehabilitation services are not available. Method: A costing analysis of a telerehabilitation program was conducted under several scenarios, alongside a single-blind two-arm randomized controlled trial with participants randomly allocated to control (N=25) or intervention group (N=26). Detailed analysis of the cost for two different scenarios for providing telerehabilitation were conducted. The fixed costs of the telerehabilitation are an important determinant of the total costs of the program. The detailed breakdown of the costs allows for costs of future proposed telerehabilitation programs to be easily estimated. The costs analysis found that a program supplying all required technology costs between CAD$475 per patient and CAD$482 per patient, while a program supplying only a camera would have total costs between CAD$242 per patient and $245 per patient. The findings of this study support the potential implementation of telerehabilitation for stroke survivors for improving accessibility to rehabilitation services. This cost-analysis study will facilitate the implementation and future research on cost-effectiveness of such interventions.

Despite limited scientific evidence, there is an increasing interest in soft robotic gloves to optimize hand- and finger-related functional abilities following a neurological event. This review maps evidence on the effects and effectiveness of soft robotic gloves for hand rehabilitation and, whenever possible, patients’ satisfaction. A systematized search of the literature was conducted using keywords structured around three areas: technology attributes, anatomy, and rehabilitation. A total of 272 titles, abstracts, and keywords were initially retrieved, and data were extracted out of 13 articles. Six articles investigated the effects of wearing a soft robotic glove and eight studied the effect or effectiveness of an intervention with it. Some statistically significant and meaningful beneficial effects were confirmed with the 29 outcome measures used. Finally, 11 articles also confirmed users’ satisfaction with regard to the soft robotic glove, while some articles also noticed an increased engagement in the rehabilitation program with this technology. Despite the heterogeneity across studies, soft robotic gloves stand out as a safe and promising technology to improve hand- and finger-related dexterity and functional performance. However, strengthened evidence of the effects or effectiveness of such devices is needed before their transition from laboratory to clinical practice.

Introduction Suite a un accident vasculaire cerebrale (AVC), les personnes ont une atteinte de la coordination intersegmentaire qui entrave la fonction. L’hypothese posee est que la coordination inter-membres (inter-cotes) est aussi modifiee. L’objectif etait de quantifier la coordination inter-membres des forces lors de poussees bilaterales maximales des membres superieurs. Materiel et methode Dix sujets chronique post-AVC (56 ± 15 ans) et 17 controles ont realise des poussees maximales statiques bilaterales en position assise, pieds au sol, les mains posees sur des poignees positionnees a mi-amplitude d’un mouvement d’atteinte. Les capteurs aux poignees, aux pieds et sous l’assise (sous chacune des cuisses) ont permis la quantification des forces de reaction du sol sur toute la duree de la poussee a effort maximal bilateral (2 essais). Des tests statistiques ont permis de comparer l’amplitude et le profil des forces inter-membres des deux groupes. Resultats En comparaison a la position controle (mains sur les poignees sans effort) ou seules les forces verticales a l’assise et aux pieds differaient entre les groupes (p Discussion/conclusion La coordination inter-membres est deficiente lors de poussees bilaterales. Les analyses ulterieures permettront de comprendre l’impact de ces resultats sur la readaptation des personnes avec atteinte neurologique.

Introduction L’evaluation en milieu reel ou ecologique momentanee (EMEM) permet d’obtenir des informations uniques et differentes de l’evaluation traditionnelle en milieu clinique ou en laboratoire. Les musees sont des environnements riches pour la comprehension du comportement humain. Leurs vastes espaces requierent de bonnes capacites de mobilite et de navigation pour une participation experientielle optimale. Notre projet vise a caracteriser la mobilite dans un environnement ecologique, le musee des Beaux-Arts de Montreal (MBAM), en mettant en commun des donnees multiples sur la posture, l’equilibre et la locomotion et les facteurs qui les influencent, comme la cognition. Materiel et methode Ce projet consiste a explorer la faisabilite de collecter des donnees issues de plusieurs sous-projets de recherche, lors d’une journee de visite reguliere du MBAM. Cent soixante-neuf membres VIP du musee seront recrutes. Ils seront aleatoirement attribues a un des sous-projets tenus simultanement. Des mesures de faisabilite seront recoltees a l’aide d’observations, de questionnaires et d’entrevues semi-structurees aupres des chercheurs, participants et employes du musee. L’agregation de ces donnees multiples et leur analyse permettra de juger de la faisabilite du projet et la validite des donnees des sous-projets. Resultats attendus/Discussion Les resultats immediats de l’etude devraient fournir des recommandations specifiques conduisant a des modifications du protocole de sorte a pouvoir plus facilement tenir ce type de collectes a l’avenir. Les produits livrables a court et moyen termes comprendront des solutions concretes benefiques pour les autres jours de collectes, les autres groupes de visiteurs evalues (ex. visiteurs post-accident neurologique) et rendront a terme le MBAM et d’autres sites similaires des environnements de collectes de donnees de type EMEM concevables.

Objective: to evaluate the effects of excitatory repetitive transcranial magnetic stimulation (rTMS) of the international 10-20 system P3 point (intraparietal sulcus region) in chronic patients with a frontal lesion and parietal sparing due to stroke on the impaired upper (UL) and lower limb (LL) as measured by Fugl-Meyer Assessment (FMA). Methods: three patients (C1: 49.83/2.75, C2: 53.17/3.83, C3: 63.33/3.08 years-old at stroke/ years post-stroke, respectively) received two weeks (five days/ week) of rTMS at 10 Hz of P3. A patient was treated in similar conditions with a sham coil (S1: 56.58/4.33). No complimentary therapy was delivered during the study. Patients were evaluated before, after- and two months post-treatment (A1, A2 and A3, respectively). Results: we found increased scores for LL in motor function subsection for C1 and C3 and in sensory function for C2 by A2 that remained at A3. We also found an increased score for UL motor function for C2 and C3, but the score decreased by A3 for C2. C3 score for UL range of motion increased by A3 compared to A1 and A2. Conclusion: In a variable way, P3 excitatory rTMS increased FMA scores in different upper and lower limb subsections of our three treated patients.

1) Objective: to evaluate the effects of excitatory transcranial magnetic stimulation of the anterior intraparietal area in chronic patients with a frontal lesion and parietal sparing due to stroke on the impaired upper (UL) and lower limb (LL) as measured by Fugl-Meyer Assessment (FMA). 2) Methods: three patients (P1: 49.83/2.75, P2: 53.17/3.83, P3:63.33/3.08 years-old at stroke/years post-stroke, respectively) received two weeks (five days/ week) of rTMS at 10 Hz of the left anterior intraparietal area (AIP). A patient was treated in similar conditions with a sham coil (56.58/4.33) No complimentary therapy was delivered during the study. Patients were evaluated before, after- and two-months post-treatment (A1, A2 and A3, respectively). 3) Results: We found increased scores for lower limb in motor function subsection for P1 and P3 and in sensory function for P2 by A2 that remained at A3. We also found an increased score for upper limb motor function for P2 and P3, but the score decreased by A3 for P2. P3 score for upper limb ROM increased by A3 compared to A1 and A2. 4) Conclusion: AIP excitatory rTMS increased the FMA scores for lower and upper limb function, showing a broader effect when compared to M1 stimulation.

Clinical approach to surgical patients has evolved to include previous patients as part of the treating team in the role of "patient-advisors". Knowing that compliance to rehabilitation protocols is significant for a successful functional hand replantation, we set out to quantify functional patient-reported outcomes in individuals enrolled in a Patient-Advisor Program (PAP). We performed a prospective cohort pilot study of all patients admitted for a finger replantation between July 2015 to January 2016. All patients were offered to partake in the PAP, or else they would constitute the control group. Primary endpoints were functional outcomes as reported by patients at 6-8weeks and 4-6months of follow-up. Secondary endpoints were patient-reported pain and quality of life questionnaires. In total, 62 patients were admitted for finger replantation in the studied period, in which 50 agreed to participate in the study, including 7 in the patient-advisors group and 43 in the control group. Patients from the patient-advisors group fared better on mean scores of the Disabilities of the Arm, Shoulder and Hand than controls (29.6 vs 34.8 respectively at 4-6months). Improvements in the McGill Pain Questionnaire were also greater in the studied group (19.9 vs 33.3 at 4-6months). Replantation patients benefiting from the PAP demonstrated superior functional outcomes on self-reported questionnaires, which could be explained by a better understanding of rehabilitation protocols and compliance when previous patients are active members of the treating team.

The Left Right Judgement Task (LRJT) involves determining if an image of the body part is of the left or right side. The LRJT has been utilized as part of rehabilitation treatment programs for persons with pain associated with musculoskeletal injuries and conditions. Although studies often attribute changes and improvement in LRJT performance to an altered body schema, imaging studies suggest that the LRJT implicates other cortical regions. We hypothesized that cognitive factors would be related to LRJT performance of hands and feet and that sensory, motor, and pain related factors would be related to LRJT in the affected hand of participants with wrist/hand pain. In an observational cross-sectional study, sixty-one participants with wrist/hand pain participated in a study assessing motor imagery ability, cognitive (Stroop test), sensory (Two-Point Orientation Discrimination, pressure pain thresholds), motor (grip strength, Purdue Pegboard Test), and pain related measures (West Haven Yale Multidimensional Pain Inventory) as well as disability (Disability of the Arm, Shoulder and Hand). Multiple linear regression found Stroop test time and motor imagery ability to be related to LRJT performance. Tactile acuity, motor performance, participation in general activities, and the taking of pain medications were predictors of LRJT accuracy in the affected hand. Participants who took pain medications performed poorly in both LRJT accuracy (p=0.001) and reaction time of the affected hand (p=0.009). These participants had poorer cognitive (p=0.013) and motor function (p=0.002), and higher pain severity scores (p=0.010). The results suggest that the LRJT is a complex mental task that involves cognitive, sensory, motor, and behavioural processes. Differences between persons with and without pain and improvement in LRJT performance may be attributed to any of these factors and should be considered in rehabilitation research and practice utilizing this task.

This study determined test–retest reliability and minimum detectable change in longitudinal median nerve excursion during upper limb neurodynamic tests (ULNTs). Seven participants with unilateral or bilateral carpal tunnel syndrome and 11 healthy participants were randomly tested with two ULNTs ( i.e ., tensioner and slider). Each ULNT was performed three times each at 45° and 90° of shoulder abduction on two separate visits. Video sequences of median nerve excursion, recorded by a physical therapist using ultrasound imaging, were quantified using computer software. The generalizability theory, encompassing a G-Study and a D-study, measured the dependability coefficient (Φ) along with standard error of measurement (SEM) accuracy and allowed various testing protocols to be proposed. The highest reliability (Φ = 0.84) and lowest minimal measurement error (SEM = 0.58 mm) of the longitudinal median nerve excursion were reached during the ULNT-slider performed with 45° of shoulder abduction and when measures obtained from three different image sequences recorded during a single visit were averaged. It is recommended that longitudinal median nerve excursion measures computed from three separate image sequences recorded during a single visit be averaged in clinical practice. Ideally, adding a second visit (six image sequences) is also suggested in research protocols.

Objective Existing screening tools for HIV-Associated Neurocognitive Disorders (HAND) may lack the accuracy required for clinical use. We hypothesized that the diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) as a screening tool for HAND might be improved with a stronger scoring methodology. Design Two hundred HIV-positive participants aged 18-65 years completed the MoCA and a battery of neuropsychological tests. Methods HAND diagnosis was established according to the Frascati criteria, and an NPZ-8 score was also calculated. Rasch analysis was applied to the MoCA items to create a quantitative score. Results The optimal cut-off on the quantitative MoCA for detecting impairment as per Frascati criteria yielded a sensitivity of 0.74 and a specificity of 0.68. Overall accuracy was 0.79 (95% CI: 0.73-0.85), an improvement over standard scoring methods. However, whether cognition was quantified with the quantitative MoCA or with NPZ-8, there was substantial overlap between diagnostic categories; several individuals categorized as impaired had better overall cognitive function as assessed by NPZ-8 or quantitative MoCA than those classified as normal using standard criteria. Conclusion Quantifying performance on MoCA items through Rasch analysis improves its accuracy as a screening tool for HAND, and demonstrates that cognition can be measured as a unidimensional construct in HIV, at least at the level of precision of bedside testing. However, the current categorical diagnostic approach to HAND is poorly aligned with summary measures of cognitive ability. Measuring cognition as a quasi-continuous construct may be more relevant than conventional HAND diagnostic categories for many clinical purposes.

Manual action verbs modulate the right-hand grip force in right-handed subjects. However, to our knowledge, no studies demonstrate the ability to accomplish this modulation during bimanual tasks nor describe their effect on left-hand behavior in unimanual and bimanual tasks. Using load cells and word playlists, we evaluated the occurrence of grip force modulation by manual action verbs in unimanual and symmetrical bimanual tasks across the three auditory processing phases. We found a significant grip force increase for all conditions compared to baseline, indicating the occurrence of modulation. When compared to each other, the grip force variation from baseline for the three phases of both hands in the symmetrical bimanual task was not different from the right-hand in the unimanual task. The left-hand grip force showed a lower amplitude for auditory phases 1 and 2 when compared to the other conditions. The right-hand grip force modulation became significant from baseline at 220 ms after the word onset in the unimanual task. This moment occurred earlier for both hands in bimanual task (160 ms for the right-hand and 180 for the left-hand). It occurred later for the left-hand in unimanual task (320 ms). We discuss the hypothesis that Broca’s area and Broca’s homologue area likely control the left-hand modulation in a unilateral or a bilateral fashion. These results provide new evidence for understanding the linguistic function processing in both hemispheres.

Introduction/Background Rehabilitation of the upper limb post-stroke represents a significant challenge with only 5% of severely affected individuals fully recovering function of their arm and hand. This study used a newly designed instrumented bimanual exerciser to assess the effects of an error augmentation (EA) protocol on upper limb bilateral coordination post-stroke. Material and method Twenty participants, 10 individuals post-stroke (median age; time post-stroke 60.5 years; 4 months) able to hold a handle (median Chedoke hand 4/7) and 10 healthy controls, volunteered to participate. They were assessed on the bimanual exerciser using an EA protocol (baseline with symmetrical resisted movement at 30% (1 min) and 15% (1 min); adaptation with asymmetrical resistance (15% and 30%: 6 min) and post-adaptation at 15% resistance (3 min). The effects of the EA protocol on bilateral synchronisation when initiating pushing movements were determined. Results Stroke and healthy participants took the same time to execute the baseline 15% pushing task (median 0.8–1 s). The movement amplitude for the non-paretic arm was greater than for the paretic one (34 cm vs. 30 cm). Stroke participants produced a maximal symmetrical pushing force 25% lower on the paretic side while healthy participants had symmetrical values (7% difference). For both groups, the asymmetric resistance (adaptation) modified the bilateral coordination with increasing onset delays between arms (median values: healthy: 6.4% (55 ms); Stroke: 9.4% (89 ms)). The delays were reversed and differed from baseline at the beginning of the post-adaptation period (post-effects). The large between-subject variability prevented the detection of a difference between groups although the delays were greater overall in post-stroke participants during the adaptation period. Conclusion Preliminary findings suggest that the EA protocol could modify the timing between movements of the two arms during a bimanual task. Additional data is currently analysed to further understand the potential benefits of training patients with the bimanual exerciser on inter-limb coordination.

Background and Objectives: Language-induced grip force modulation (LGFM) can be used to better understand the link between language and motor functions as an expression of embodied language. However, the contribution of each brain hemisphere to LGFM is still unclear. Using six different action verbs as stimuli, this study evaluated the grip force modulation of the left hand in a unimanual task to characterize the left and right hemispheres&rsquo, contributions. Materials and Methods: Left-hand LGFM of 20 healthy and consistently right-handed subjects was evaluated using the verbs &ldquo, to write&rdquo, &ldquo, to hold&rdquo, to pull&rdquo, (left-lateralized central processing actions), &ldquo, to draw&rdquo, to tie&rdquo, and &ldquo, to drive&rdquo, (bihemispheric central processing actions) as linguistic stimuli. The time between the word onset and the first interval of statistical significance regarding the baseline (here as reaction time, RT) was also measured. Results: The six verbs produced LGFM. The modulation intensity was similar for the six verbs, but the RT was variable. The verbs &ldquo, whose central processing of the described action is bihemispheric, showed a longer RT compared to the other verbs. Conclusions: The possibility of a given manual action being performed by the left hand in consistent right-handers does not interfere with the occurrence of LGFM when the descriptor verb of this action is used as a linguistic stimulus, even if the possibility is remote. Therefore, LGFM seems to mainly rely on the left hemisphere, while a greater activation of the right hemisphere in action processing appears to slow the increase in LGFM intensity.

There is a growing body of evidence of changes in corticospinal excitability associated with musculoskeletal disorders, however there is a lack of knowledge of how these changes relate to measures of pain, motor performance and disability. An exploratory study was performed utilizing Transcranial Magnetic Stimulation to investigate differences in corticospinal excitability in the Abductor Pollicis Brevis (APB) between 15 pain-free subjects and 15 subjects with chronic wrist/hand pain and to determine how corticospinal excitability was associated with measures of pain (visual analog scale, AUSCAN™), hand motor performance (isometric and key pinch strength, Purdue Pegboard Test), disability (AUSCAN™), and spinal motoneuronal excitability. Input-output curves demonstrated increased corticospinal excitability of the APB in the affected hand of subjects with chronic pain (p

Research in rehabilitation has grown from a rare phenomenon to a mature science and clinical trials are now common. The purpose of this study is to estimate the extent to which questions posed and methods applied in clinical trials published in Clinical Rehabilitation have evolved over three decades with respect to accepted standards of scientific rigour. Studies were identified by journal, database, and hand searching for the years 1986 to 2016. A total of 390 articles whose titles suggested a clinical trial of an intervention, with or without randomization to form groups, were reviewed. Questions often still focused on methods to be used (57%) rather than what knowledge was to be gained. Less than half (43%) of the studies delineated between primary and secondary outcomes; multiple outcomes were common; and sample sizes were relatively small (mean 83, range 5 to 3312). Blinding of assessors was common (72%); blinding of study subjects was rare (19%). In less than one-third of studies was intention-to-treat analysis done correctly; power was reported in 43%. There is evidence of publication bias as 83% of studies reported either a between-group or a within-group effect. Over time, there was an increase in the use of parameter estimation rather than hypothesis testing and there was evidence that methodological rigour improved. Rehabilitation trialists are answering important questions about their interventions. Outcomes need to be more patient-centred and a measurement framework needs to be explicit. More advanced statistical methods are needed as interventions are complex. Suggestions for moving forward over the next decades are given.

This paper presents an innovative model of care, which brings patients who have already been through a similar experience of illness (patient advisors) directly to the bedside of patients, where they are viewed as full-fledged members of the clinical team. As part of a pilot project, three patient advisors were recruited and met with patients who had sustained a traumatic amputation and were admitted to the only center of expertise in replantation of the upper limb in Canada. Several individual interviews and focus groups with patients and patient advisors have revealed very promising results. Indeed, patients have expressed tremendous appreciation for their meetings and interactions with patient advisors. They have stated feeling less isolated, having a better morale and increased hopefulness regarding the outcome of the care pathway. Patient advisors also felt a positive impact of their involvement. A larger study needs to be conducted to determine the impact of this model of care on patient adherence to treatment and on members of the health care team.

Objective: To develop a comprehensive measure of Early Physical Functioning (EPF) post-stroke quantified through Rasch analysis and conceptualized using the International Classification of Functioning Disability and Health (ICF). Design: An observational cohort study. Subjects: A cohort of 262 subjects (mean age 71.6 (standard deviation 12.5) years) hospitalized post-acute stroke. Methods: Functional assessments were made within 3 days of stroke with items from valid and reliable indices commonly utilized to evaluate stroke survivors. Information on important variables was also collected. Principal component and Rasch analysis confirmed the factor structure, and di mensionality of the measure. Rasch analysis combined items across ICF components to develop the measure. Items were deleted iteratively, those retained fit the model and were re lated to the construct; reliability and validity were assessed. Results: A 38-item unidimensional measure of the EPF met all Rasch model requirements. The item difficulty matched the person ability (mean person measure: –0.31; standard error 0.37 logits), reliability of the person-item-hierarchy was excellent at 0.97. Initial validity was adequate. Conclusion: The 38-item EPF measure was developed. It expands the range of assessment post acute stroke; it covers a broad spectrum of difficulty with good initial psychometric properties that, once revalidated, can assist in planning and evaluating early interventions.

To assess the psychometric properties of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) for pressure ulcer (PU) risk assessment during inpatient rehabilitation.Prospective cohort.Tertiary rehabilitation centers.Individuals (N=759) participating in inpatient spinal cord injury rehabilitation between January 3, 2012, and April 23, 2014.Not applicable.Admission SCIPUS scores and the corresponding risk stratification, PU incidence, intraclass correlation coefficient (ICC) for interrater reliability, sensitivity, specificity, and likelihood ratios (LRs). Receiver operating characteristic analysis was performed to calculate the area under the curve (AUC).Mean SCIPUS scores were higher for individuals who developed PUs than for those who did not (mean SCIPUS score, 9.8±2.5 vs 8.5±2.6). Interrater reliability was excellent for SCIPUS composite scores (ICC=.91) and very good for risk stratification (ICC=.86). Using the existing cutoff value of ≥6 for "high risk" category, sensitivity and specificity were estimated to be .97 and .12, respectively, with an LR of 1.1. A cutoff value of ≥8 yielded a better balance between sensitivity and specificity (.85 and .38, respectively). The AUC equaled .64 with an LR of 1.4. Results were similar when the analysis was confined to PUs of stage II or greater.The psychometric properties of the SCIPUS do not currently support its routine use as a measure of PU risk in individuals with spinal cord injury undergoing inpatient rehabilitation. LRs of2 indicate that stratification as high risk or very high risk does not substantially increase the likelihood of identifying individuals who develop PUs beyond chance alone. AUCs were also below the desired cutoff value of 0.7.

Background and Purpose. The Stroke Rehabilitation Assessment of Movement (STREAM) is a relatively new measure of voluntary movement and basic mobility. The main objectives of this study were: (1) to examine the relationship of the STREAM to other measures of impairment and disability and (2) to compare its usefulness for evaluating effects of stroke and rehabilitation and for assessing change over time with that of other measures of impairment and disability. Subjects and Methods. The performance of 63 patients with acute stroke on the STREAM and other measures of impairment and disability was evaluated during the first week after stroke and 4 weeks and 3 months later. Results. Scores on the STREAM were associated with scores on the Box and Block test, Balance Scale, Barthel Index, gait speed, and the Timed “Up & Go” Test (with Pearson correlation coefficients ranging from .57 to .80) and were associated with categories of the Barthel Index and Balance Scale. The STREAM's ability to predict discharge destination from the acute care hospital, as well as to predict gait speed and Barthel Index scores at 3 months poststroke, was comparable to that of other commonly used measures. Standardized response mean estimates provided supporting evidence for the ability of the STREAM to reflect change over time. Discussion and Conclusion. The results obtained with the STREAM, as compared with other measures of impairment and disability in people with stroke, suggest that it may be useful in clinical practice and research.

Background Dupuytren’s contracture is a progressive, fibroproliferative disorder that causes fixed finger contractures and can lead to disability. With the advances of new therapeutic interventions, the necessity to assess the functional repercussions of this condition using valid, reliable and sensitive outcome measures is of growing interest. The Disabilities of the Arm, Shoulder and Hand (DASH) is one frequently used patient-reported outcome measure but its reliability and validity have never been demonstrated specifically for a population affected with Dupuytren’s contracture. The objective of this study was to evaluate the psychometric properties of the DASH, with focus on validity evidence using the Rasch measurement model. Methods Secondary analysis was performed on data collected as part of a randomised clinical trial. One hundred fifty-three participants diagnosed with Dupuytren’s contracture completed the DASH at four time points (pre-op, 3, 6 and 12 months post-op). Baseline data were analysed using traditional analysis and to test whether they adhered to the expectations of the Rasch model. Post-intervention data were subsequently included and analyzed to determine the effect of the intervention on the items. Results DASH scores demonstrated large ceiling effects at all time points. Initial fit to the Rasch model revealed that the DASH did not adhere to the expectations of the Rasch partial credit model (χ2 = 119.92; p

Objective: To report the theoretical foundation of generic patient-reported outcomes for measuring functioning related to upper extremity musculoskeletal disorders and perform content coverage analysis and content comparison using the International Classification of Functioning, Disability and Health (ICF). Methods: A literature search was performed to identify commonly used patient-reported outcomes. A comparison of their theoretical foundations and a linking exercise between the measures’ meaningful concepts and the ICF and Brief ICF Core Set for Hand Conditions was accomplished based on established rules. Results: Fifteen measures were selected. Multiple theoretical foundations were identified, and only 7 measures were developed based on a known conceptual model. Six measures were chosen for the linking process with 232 meaningful concepts retrieved and linked to 54 ICF categories. No concept was linked to the Body Structures component and two measures stood out for their Activity and Participation coverage. No measure covered all Brief ICF Core Set for Hand Conditions recommended categories. Conclusion: Some heterogeneity was observed with regards to the theoretical foundations on which the identified measures are based. The results of the linking process should help reduce these inconsistencies. They enable easy identification of content coverage and content comparison between measures using a common framework and can be used as a reference when selecting the most appropriate patient-reported outcome measure.

Stroke is the most disabling chronic condition, newly affecting 35000 persons in Canada each year. Because of declining fatality, a growing number of persons will have to cope with stroke-related disability. The purpose of this paper is to describe the disabilities experienced by persons with stroke during the first year and explore the evolution of impairment, disability, handicap and health-related quality of life.The data for this paper come from a series of longitudinal and cross-sectional studies, collectively known as the McGill Stroke Rehabilitation Research Program.Within the first week post-stroke, getting out of bed and walking over a short distance, even with assistance, was a strong predictor of discharge home. Most of the improvement in measures of impairment and disability occurred during the first month and, by 3 months, there was still considerable room for improvement in all measures: 85% of persons were still impaired on gait speed, 78% had not reached age-specific norms for upper extremity function, 68% still demonstrated slow physical mobility, 37% needed some assistance with basic activities of daily living and 29% were still impaired on balance. By 1 year, 73% of persons scored the maximum for basic activities of daily living but 51 and 67% of persons reported their physical health and mental health to be lower than expected. Among a hardy group of stroke survivors, still living in the community 1 year post-stroke, the most striking area of difficulty was endurance, as measured by the 6 minute walk test. Those subjects well enough to complete this task (50% of sample) were able to walk, on average, only 250 metres, equivalent to 40% of their predicted ability. This series of snapshots taken at different points in time suggests that much of the improvement in impairment and disability occurs during the first month and then reaches a plateau. Handicap and quality of life continue to be issues later. Rehabilitation strategies need to consider the multifaceted nature of disablement, which in itself changes with time post-stroke.

Les techniques de readaptation en neurologie ont montre leurs efficacites pour la recuperation motrice et fonctionnelle du membre superieur apres un AVC. Cependant, elles demandent souvent un minimum de fonction motrice du membre paretique. Les stimulations sensorimotrices induites par vibrations musculaires permettent, chez les sujets n’ayant aucune capacite motrice de creer des illusions de mouvement. De plus, elles generent une activite neuronale proche de celle liee a la realisation des mouvements volontaires [1] . On sait egalement que les illusions generees peuvent etre associees a la perception de mouvements complexes : lettres, formes [2] . Cette etude pilote propose d’evaluer la perception des illusions de mouvement complexes induites par vibrations musculaires multiples chez une population de sujets sains et hemiparetiques. Les criteres d’inclusions pour les patients etaient : un score inferieur a 66 au test de Fugl-Meyer [3] pour la partie membre superieur, une absence de troubles cognitifs importants : score superieur a 26/30 au Montreal Cognitive Assessment [4] , une absence d’heminegligence importante [5] . Six vibrateurs Techno-concept VB 115 ont ete places en regard des tendons des antagonistes aux mouvements souhaites pour creer des illusions de mouvement en flexion/extension du coude, et en flexion/extension/abduction/adduction de l’epaule. Treize patrons de vibrations bases sur la cinematique du geste ont ete crees selon differentes combinaisons de hauteur, profondeur et lateralite. Les participants etaient en position assise, les yeux fermes, le bras stimule maintenu en suspension. L’ordre des 13 patrons de stimulations etait determine de maniere aleatoire. Chaque patron de vibration etait applique 4 fois de suite. Les mesures ont ete realisees sur le membre superieur non dominant des sujets sains, et le membre paretique et sain des patients. La consigne etait de reproduire la position percue a la fin de chaque stimulation par le membre superieur oppose ou fonctionnel. La collecte de donnees s’est fait par des capteurs places sur les bras et enregistre par des cameras infrarouges type NDI OPTOTRAK. Les amplitudes mesurees ont ete normalisees par rapport a l’amplitude maximale pour chaque axe. La clarte de l’illusion etait cotee de 1 a 5 d’apres l’echelle utilisee pour le KVIQ [6] . Seul l’essai ayant la meilleure cotation etait conserve. Des statistiques descriptives ont ete utilisees pour analyser les positions finales relatives et la clarte de l’illusion. Dix-neuf sujets ont participe a l’etude (12 sains et 7 patients), âges de 23 a 62 ans. Un sujet a ete exclu. La moyenne des perceptions des illusions chez les patients est de 3,1/5 [1 ;5] et 4,1 [3,5 ;4,5] pour les sujets sains. L’amplitude ressentie sur l’axe medio-lateral est de 38 cm ± 27 pour le cote hemiparetique, 43 cm ± 17, pour le cote sain et 57 cm ± 14 pour les sujets sains. Elle est de 32 cm ± 31 pour l’axe antero-posterieur et 27 cm ± 25 pour l’axe vertical ressenties lors de la stimulation du bras hemiparetique. Les resultats ( Fig. 1 , Fig. 2 ) nous informent que les sujets percoivent des mouvements complexes avec une clarte assez bonne. Les directions de mouvements sont percues en adequation avec la direction des patrons crees pour des amplitudes correctes. La variabilite inter-sujet est assez elevee. Prenant en compte la clarte des essais et la variabilite des resultats, cela nous encourage a poursuivre les travaux afin de mieux controler les illusions dans un objectif d’application a la clinique.

Introduction. Repetitive transcranial magnetic stimulation (rTMS) is a promising technique for promoting rehabilitation of arm function after stroke. The feasibility and impact of rTMS as an adjunct to traditional task-oriented training to improve arm function have not yet been demonstrated.Objective. Evaluate the feasibility of a randomized controlled trial aimed at determining the efficacy of rTMS as an adjunct to task-oriented therapy in facilitating restoration of arm function after stroke.Methods. Stratified block-randomized controlled trial set in the general community. Eleven stroke persons with mild to severe arm deficits were recruited and randomized to receive 8 sessions ofreal-rTMS orsham-rTMS followed by ninety minutes of arm tasks designed to improve function.Results. Medium to large, statistically significant effect sizes (0.49 to 1.63) were observed in both groups on several measures of arm function at the postintervention evaluation. Three out of four subjects in thereal-TMS condition showed increased levels of corticomotor excitability after the first stimulation session.Conclusions. Preliminary evidence suggests that an rTMS protocol potent enough to induce transient increases in cortical excitability of the lesioned hemisphere is feasible but did not show promising results as an adjunct to task-specific training. This trial is registration with Clinical Trials.govNCT00850408.

Purpose: Patient advisors are peer volunteers who have already been through a digit replantation. They are fully trained and viewed as full-fledged members of the care team. This proof-of-concept study was aimed at describing a model of care that brings patient advisors directly to the patient’s bedside. In this model, the patients’ perception of disability, the adherence to the rehabilitation process, and overall satisfaction were reported. Methods: A prospective pilot study was conducted from July 2014 to June 2015. All patients admitted to a center of expertise were offered the option to interact with patient advisor at bedside. Meetings were generally brief (15-30 minutes) and were proposed on the fifth day postsurgery as well as 8 and 16 weeks following surgery. The Disabilities of the Arm, Shoulder and Hand (DASH; 30 items scored 1-5) questionnaire was completed at 8 and 16 weeks follow-up as a measure of self-rated upper extremity disability and symptoms. All patients who had at least 1 interaction with a patient advisor were interviewed by telephone after study completion. The purpose of the interviews was to understand their expectations, the contribution of the patient advisor in their own care, and any possible reluctance or difficulty encountered (particularly when interactions were conducted via videoconferencing). Adherence to the rehabilitation process was also recorded and later compared to an estimate of 35% adherence generated from our Institution. Results: Based on an average of 9 patients, the DASH score completed at week 16 (27.6) showed a decrease of 33.8% when compared with that of week 8 (41.7). Adherence to treatment plan was respected in 55% of patients with patient advisor’s interaction, which was higher than estimations. Several key roles of the patient advisors emerged from the 18 interviews conducted on patients. Patient advisor is perceived as a care team member who will listen and support the patient, simplify the information conveyed by the care team, and finally break the patients’ loneliness, increasing their motivation toward the rehabilitation process. Conclusion: This study underlines the potential of patient advisors to improve the perception of disability and the adherence to the rehabilitation process in patients who have undergone digits replantation. Measurements of hand strength, range of motion, and sensibility as well as self-reported pain, posttraumatic stress disorder, and self-esteem were also performed; analyses are ongoing at present time. Further researches are required before widespread dissemination of the usefulness of patient advisors.

Objective: To develop an adaptive measure, the Stroke Arm Ladder, to parsimoniously quantify upper extremity function post stroke. Setting: Various studies conducted in Montreal and elsewhere in Canada. Subjects: A total of 4058 persons with stroke who participated in various studies were assessed on different occasions post stroke. Assessments spanned from 3 days to 1 year post stroke. Main measures: A calibrated bank containing 49 items from tests and indices designed to assess global motor recovery of the upper extremity, upper extremity function and activities involving the upper extremity was used. Data including all testing occasions were analysed to test whether they adhered to the expectations of the Rasch partial credit model and whether item hierarchy remained stable across testing occasions. Results: Fifteen items did not meet the requirements of the Rasch model and were deleted. An adaptive measure of upper extremity function, the Stroke Arm Ladder, containing 34 items was created. The easiest item was partially executing the bilateral task of tying a scarf around one’s neck, while the hardest item was being able to transfer more than 60 blocks on the Box and Block Test. The items’ difficulty thresholds cover a wide range of difficulty levels from −7.4 to 6.2 and the global fit statistics (χ2: 331; probability: 0.18), confirmed content validity. Conclusion: The Stroke Arm Ladder demonstrates adequate initial psychometric properties. Further testing of the measure in its adaptive format is necessary before it can be used clinically.

Background: The field of geriatric medicine has identified a need for an evaluative tool that can rapidly quantify global cognitive ability and accurately monitor change over time in patients with a wide range of impairments. We hypothesized that the development of an adaptive test approach to cognitive measurement would help to meet that need. This study aimed to provide evidence for the interpretability of scores obtained from a novel, adaptive approach to cognitive assessment, called the Geriatric Rapid Adaptive Cognitive Estimate (GRACE) method.Methods: An adaptive method for cognitive assessment was developed using data from 185 patients referred for geriatric cognitive assessment, and pilot tested in an additional 137 patients. Correlations between test scores and between rank orders of patients were computed to examine the reliability and validity of cognitive ability scores obtained by (1) administering test questions out of their usual order, (2) administering only a subset of questions, and (3) administering questions adaptively using simplified selection rules based on the most difficult question passed.Results: Cognitive ability scores obtained with the GRACE method correlated highly with the Montreal Cognitive Assessment (MoCA) scores (r = 0.93) and ranked patients similarly in order of ability (r > 0.87). A simplified adaptive testing algorithm for pencil-and-paper assessment demonstrated moderately high correlations with scores obtained from administering the full set of MMSE and MoCA items as well as the MoCA items alone.Conclusions: Scores from the GRACE method can be obtained easily in 5–10 minutes, reducing test burden. The resulting numeric score quantifies cognitive ability, allowing clinicians to compare patients and monitor change in global cognition over time. The adaptive nature of this method allows for evaluation of persons across a broader range of cognitive ability levels than currently available tests.

Objective To create and illustrate the development of a method to parsimoniously and hierarchically assess upper extremity function in persons after stroke. Design Data were analyzed using Rasch analysis. Setting Re-analysis of data from 8 studies involving persons after stroke. Subjects Over 4000 patients with stroke who participated in various studies in Montreal and elsewhere in Canada. Methods Data comprised 17 tests or indices of upper extremity function and health-related quality of life, for a total of 99 items related to upper extremity function. Tests and indices included, among others, the Box and Block Test, the Nine-Hole Peg Test and the Stroke Impact Scale. Data were collected at various times post-stroke from 3 days to 1 year. Results Once the data fit the model, a bank of items measuring upper extremity function with persons and items organized hierarchically by difficulty and ability in log units was produced. Conclusion This bank forms the basis for eventual computer adaptive testing. The calibration of the items should be tested further psychometrically, as should the interpretation of the metric arising from using the item calibration to measure the upper extremity of individuals.

Finch LE, Higgins J, Wood-Dauphinee SL, Mayo NE. A measure of physical functioning to define stroke recovery at 3 months: preliminary results. Objective To develop a physical functioning measure through Rasch analysis conceptualized using the International Classification of Functioning, Disability and Health (ICF). Design Observational cohort study. Setting Acute-hospital and community-based study. Participants Subjects (N=235) hospitalized with postacute stroke and reassessed in the community at 3-months (mean age, 71.6±12.9y). Interventions None. Main Outcome Measures Functional assessments 3 months poststroke included self-report and observational indices and tests commonly used to evaluate stroke survivors. Sociodemographic information was also collected. Rasch analysis assisted in combining the items across ICF components to develop the measure. Items were retained based on fit to the model and relationship to the construct; reliability and validity were assessed. Results The best 44 items formed the Physical Functioning Measure at 3 months (F3m) measure of functioning evaluating limb movement, balance, activities of daily living, and participation. All Rasch model assumptions were met. Both item and person reliably (.96) indicated a stable hierarchy, while precision varied from .51 to 1.2 logits. Early evidence for construct validity is adequate. Conclusions The F3m combines patient reported and observed ratings of performance items into a single measure quantifying functioning with good preliminary psychometric properties that with further testing can assist in directing and evaluating interventions and recovery.

To develop a parsimonious measure of functioning for persons after stroke.A sub-set of 206 community-dwelling subjects with a first stroke from a larger cohort was interviewed within 9 months using 39 items from five indices assessing functioning. Information was collected on influencing variables: age, stroke type and severity, and previous health. Two statistical methods, factor analysis and Rasch analysis, confirmed the item structure, hierarchy and dimensionality of the measure. Statistics confirmed fit to the model; internal consistency was also assessed. Items were deleted iteratively based on fit and relationship to the construct.The subjects were predominately male (63%) aged on average 68-years-old. A 12-item unidimensional functioning measure was developed. All items and persons fit the Rasch model with stable item-person reliability indices of 0.98 and 0.91, respectively. Item precision (standard errors) ranged from 0.14-0.37 logits. Gaps in measurement occurred at the extremes of the measure and there was a small ceiling effect.A 12-item measure captured the concept of functioning that could be used as a prototype to quantify recovery post-stroke. These items could form the basis for a measure of functioning.

Objective: To evaluate the efficacy of a task-oriented intervention in enhancing arm function in people with stroke. Design: Two-centre, observer-blinded, stratified, block-randomized controlled trial. Setting: General community. Patients: Ninety-one individuals within one year of a first or recurrent stroke consented to participate between May 2000 and February 2003. Interventions: The experimental intervention involved practice of functional, unilateral and bilateral tasks that were designed to improve gross and fine manual dexterity whereas the control intervention was composed of walking tasks. Members in both groups participated in three sessions a week for six weeks. Main outcome measure(s): The primary test of arm function was the Box and Block Test. Secondary tests included the Nine-Hole Peg Test, maximal grip strength, the Test d'Evaluation des Membres supé rieurs des Personnes Agées (TEMPA) and the Stroke Rehabilitation Assessment of Movement. Results: Results are for the more affected arm. Baseline performance on the Box and Block Test was an average of 26 blocks (standard deviation (SD=16) in the experimental group (n=47) and 26 blocks (Sd=18) in the control group (n=44). These values represent approximately 40% of age-predicted values. Values for the postintervention evaluation were an average of 28 (SD=17) and 28 (SD=19) blocks for the experimental and control group respectively. No meaningful change on other measures of arm function was observed. Conclusions: A task-oriented intervention did not improve voluntary movement or manual dexterity of the affected arm in people with chronic stroke.

Objective: The purpose of this proof-of-concept study was to assess the feasibility of using a generic health measure to create coded functional status indicators and compare the characterization of a stroke population using coded functional indicators and using health-related quality-of-life summary measures alone. Design: multiple raters assigned International Classification of Functioning, Disability, and Health (ICF) codes to the items of the 12-Item Short Form Health Survey (SF-12). Data for comparing the information from the SF-12 and from ICF codes were derived from the Montreal Stroke Cohort Study that was set up to examine the long-term impact of stroke. Available for analysis were data from 604 persons with stroke, average age 69 years, and 488 controls, average age 62 years. Measurement: The SF-12 provides two summary scores, one for physical health and one for mental health. Domains of the ICF are coded to three digits, before the decimal; specific categorizations of impairments, activity limitations, and participation restrictions are coded to four digits before the decimal. Results: Persons with stroke scored, on average, approximately 10 points lower than controls on physical and mental health. The ICF coding indicated that this was attributed, not surprisingly, to greater difficulty in doing moderate activities including housework, climbing stairs, and working and was not attributed to differences in pain. Differences in mental health were attributed most strongly to greater fatigue (impairment in energy), but all areas of mental health were affected to some degree. Conclusion: The ICF coding provided enhanced functional status information in a format compatible with the structure of administrative health databases.

The Stroke Rehabilitation Assessment of Movement (STREAM) is a relatively new measure of voluntary movement and basic mobility. The main objectives of this study were: (1) to examine the relationship of the STREAM to other measures of impairment and disability and (2) to compare its usefulness for evaluating effects of stroke and rehabilitation and for assessing change over time with that of other measures of impairment and disability.The performance of 63 patients with acute stroke on the STREAM and other measures of impairment and disability was evaluated during the first week after stroke and 4 weeks and 3 months later.Scores on the STREAM were associated with scores on the Box and Block test, Balance Scale, Barthel Index, gait speed, and the Timed "Up Go" Test (with Pearson correlation coefficients ranging from .57 to .80) and were associated with categories of the Barthel Index and Balance Scale. The STREAM's ability to predict discharge destination from the acute care hospital, as well as to predict gait speed and Barthel Index scores at 3 months poststroke, was comparable to that of other commonly used measures. Standardized response mean estimates provided supporting evidence for the ability of the STREAM to reflect change over time.The results obtained with the STREAM, as compared with other measures of impairment and disability in people with stroke, suggest that it may be useful in clinical practice and research.

Salbach NM, Mayo NE, Higgins J, Ahmed S, Finch LE, Richards CL. Responsiveness and predictability of gait speed and other disability measures in acute stroke. Arch Phys Med Rehabil 2001;82;1204-12. Objectives: To identify the most responsive method of measuring gait speed, to estimate the responsiveness of other outcome measures, and to determine whether gait speed predicts discharge destination in acute stroke. Design: A prospective cohort study. Setting: Five acute-care hospitals. Patients: Fifty subjects with residual gait deficits after a first-time stroke. Interventions: Five- (5mWT) and 10-meter walk tests (10mWT) at comfortable and maximum speeds, with 2 evaluations conducted an average ± standard deviation (SD) of 8 ± 3 and 38 ± 5 days poststroke. Main Outcome Measure: Standardized response mean (SRM = mean change/SD of change) was used to estimate responsiveness for each walk test, the Berg Balance Scale, the Barthel Index, the Stroke Rehabilitation Assessment of Movement (STREAM), and the Timed Up and Go (TUG). Results: The SRMs were 1.22 and 1.00 for the 5mWT, and .92 and .83 for the 10mWT performed at a comfortable and maximum pace, respectively. The SRMs for the Berg Balance Scale, the Barthel Index, the STREAM, and the TUG were 1.04, .99, .89, and .73, respectively. The probability of discharge to a rehabilitation center for persons walking at ≤ 0.3m/s or > 0.6m/s at the first evaluation was .95 and .22, respectively. Conclusions: The 5mWT at a comfortable pace is recommended as the measure of choice for clinicians and researchers who need to detect longitudinal change in walking disability in the first 5 weeks poststroke. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

This study evaluates stroke patients with upper-limb (UL) motor deficits using measures of impairment and "activity limitation" to quantify recovery of UL function poststroke and to identify predictors of UL function and predictors of UL recovery following stroke. The study also compares the recovery of UL function with that of the lower limb (LL). Measures of impairment and "activity limitation" of the UL and LL improved over the first 5 weeks. The Box and Block Test performance improved the most over 5 weeks (standardized response mean [SRM] = 1.34), followed closely by the 5-meter walk test (SRM = 0.97). Performances on measures of UL "activity limitation" measured at 1 week poststroke were the most important predictors of UL function 5 weeks poststroke. The results of this study do not support the belief that recovery of LL function is faster than that of UL.

Background Musculoskeletal rehabilitative care and research have traditionally been guided by a structural pathology paradigm and directed their resources towards the structural, functional, and biological abnormalities located locally within the musculoskeletal system to understand and treat Musculoskeletal Disorders (MSD). However the structural pathology model does not adequately explain many of the clinical and experimental findings in subjects with chronic MSD and, more importantly, treatment guided by this paradigm fails to effectively treat many of these conditions. Discussion Increasing evidence reveals structural and functional changes within the Central Nervous System (CNS) of people with chronic MSD that appear to play a prominent role in the pathophysiology of these disorders. These neuroplastic changes are reflective of adaptive neurophysiological processes occurring as the result of altered afferent stimuli including nociceptive and neuropathic transmission to spinal, subcortical and cortical areas with MSD that are initially beneficial but may persist in a chronic state, may be part and parcel in the pathophysiology of the condition and the development and maintenance of chronic signs and symptoms. Neuroplastic changes within different areas of the CNS may help to explain the transition from acute to chronic conditions, sensory-motor findings, perceptual disturbances, why some individuals continue to experience pain when no structural cause can be discerned, and why some fail to respond to conservative interventions in subjects with chronic MSD. We argue that a change in paradigm is necessary that integrates CNS changes associated with chronic MSD and that these findings are highly relevant for the design and implementation of rehabilitative interventions for this population. Summary Recent findings suggest that a change in model and approach is required in the rehabilitation of chronic MSD that integrate the findings of neuroplastic changes across the CNS and are targeted by rehabilitative interventions. Effects of current interventions may be mediated through peripheral and central changes but may not specifically address all underlying neuroplastic changes in the CNS potentially associated with chronic MSD. Novel approaches to address these neuroplastic changes show promise and require further investigation to improve efficacy of currents approaches.

Background Adherence to treatment in children with juvenile idiopathic arthritis (JIA) is associated with better outcomes. Assessing patient adherence in JIA, as well as attitudes and beliefs about prescribed treatments, is important for the clinician in order to optimize patient management. The objective of the current study was to evaluate the psychometric properties of the Parent (proxy-report) Adherence Report Questionnaires (PARQ), which assesses beliefs and behaviors related to adherence to treatments prescribed for JIA. Methods A Rasch analysis was conducted on data collected with parents of children with JIA from two studies in which the PARQ was used as a measure of adherence. Results The PARQ showed preliminary evidence of multidimensionality with two factors, accounting for 38 % and 27 % of the variance respectively. The PARQ in its original version does not adhere to expectations of the Rasch model. A transformed version of the PARQ obtained by deletion of the general adherence scale and modification of visual analog scales into 5-point likert scales improved fit to the model and showed preliminary evidence of unidimensionality. Conclusions The PARQ was transformed based on the results of the Rasch analysis. The transformed version of the PARQ shows preliminary evidence of unidimensionality and may allow computation of a total score, although further testing is needed to verify these findings.

Objective Repetitive transcranial magnetic stimulation (rTMS) is a promising technique for enhancing rehabilitation of upper extremity function after stroke. The objective of this study is to evaluate the feasibility of conducting a randomized controlled trial aimed at determining the efficacy of rTMS as an adjunct to task-oriented therapy in facilitating restoration of arm and hand function after stroke. Methods Eleven individuals living in the community (Montreal, Canada) with mild to severe arm deficits following a stroke were recruited and randomized. The experimental intervention consisted in a session of real-rTMS immediately followed by ninety minutes of arm and hand functional tasks designed to improve function. The control intervention involved a session of sham-rTMS followed by ninety minutes of arm and hand functional tasks. Subjects in both groups attended sessions twice weekly for four weeks. The main outcome measures were: The Box and Block Test (BBT), the Wolf Motor Function Test (WMFT), the Stroke Impact Scale (SIS) and neurophysiological measures. Results Medium to large, statistically significant effect sizes (0.49 to 1.63) were observed in both groups on the BBT, the SIS and the functional score of the WMFT at the post-intervention evaluation. Three out of four subjects in the real-TMS condition showed an increase in baseline levels of corticomotor excitability after the first stimulation session. Conclusion It is possible to conduct a study comprising two ninety-minute therapy sessions weekly for arm function. However, preliminary evidence suggests that an rTMS protocol potent enough to induce transient increases in cortical excitability of the lesioned hemisphere did not show promising results as an adjunct to task-oriented training for improving upper extremity function.