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Accepted Mar 7, 2013; Epub ahead of print Jun 24, 2013IntRoductIonAfter stroke, 64% of survivors regain independent walking (1). However, post-stroke hemiplegic gait is often characterized by impaired standing balance on the paretic leg, reduced propul-sion at paretic push-off, and decreased hip, knee and ankle AH[LRQ GXULQJ WKH SDUHWLF VZLQJ SKDVH UHVXOWLQJ LQ LQDGHTXDWH foot clearance. these stroke-related balance and gait impair-ments are important risk factors for falling (2). In addition, community-dwelling people in the chronic phase after stroke PRVW IUHTXHQWO\ PHQWLRQ ZDONLQJ DV WKH DFWLYLW\ DVVRFLDWHG with falling (2).For independent and safe community ambulation, one needs to be able to adjust gait to environmental demands and constraints (e.g. while walking in crowded environments or on uneven terrain). Previous studies have demonstrated that gait adaptability is often impaired in people after stroke (3–9). this includes impairments in anticipatory control, as evidenced by placement of the affected lead foot closer to the obstacle before clearance (3), as well as impaired motor control of the leg to execute online step adjustments (e.g. more errors in avoiding a sudden obstacle) (4–6). Furthermore, people after stroke demonstrated different movement strategies, presumably WR FRPSHQVDWH IRU GLI?FXOWLHV LQ EDODQFH FRQWURO GXULQJ WKH execution of a step adjustment (10). Gait adaptations impose large demands on balance control, and nonnekes et al. (7) have demonstrated previously that reduced balance capacity LQ SHRSOH DIWHU VWURNH VLJQL?FDQWO\ XQGHUOLHV WKHLU LQDELOLW\ WR perform accurate online step adjustments. In their study, par-ticipants stepped to a target that could suddenly jump medially RU ODWHUDOO\ ZKLOH WKH VWHSSLQJ IRRW ZDV LQ WKH DLU UHTXLULQJ D mid-step adjustment. this so-called target-Stepping task was executed both with and without external body support. People with stroke were found to suppress mid-step adjustments of foot placement when balance demands were greatest. Hence WKH\ VDFUL?FHG WDVN SHUIRUPDQFH IRU VWDELOLW\ ZKHUHDV WKH healthy controls hardly ever needed to do so. )URP WKH DERYH LW IROORZV WKDW WDVN VSHFL?F JDLW WUDLQLQJ focusing on gait adaptability may be an important target for improving safe community ambulation in people after stroke. Although there is convincing evidence that gait training in the chronic phase after stroke can improve walking velocity (11–16), RQO\ D IHZ VWXGLHV KDYH VSHFL?FDOO\ HYDOXDWHG WUDLQLQJ RI JDLW adaptability and associated dynamic balance demands (12, 15, 17), and none of these studies have evaluated training effects

Contains fulltext : 116831.pdf (Publisher’s version ) (Open Access) Aim To investigate the validity and reliability of the revised Video-Observation Aarts and Aarts module: Determine Developmental Disregard (VOAA-DDD-R). Method Upper-limb capacity and performance were assessed in children with unilateral spastic cerebral palsy (CP) by measuring overall duration of affected upper-limb use and the frequency of specific behaviours during a task in which bimanual activity was demanded (stringing beads) and stimulated (decorating a muffin). Developmental disregard was defined as the difference in duration of affected upper-limb use between both tasks. Raters were two occupational and one physical therapist who received 3 hours of training. Construct validity was determined by comparing children with CP with typically developing children. Intrarater, interrater, and testretest reliability were determined using the intraclass correlation coefficient. Standard errors of measurement and smallest detectable differences were also calculated. Results Twenty-five children with CP (15 females, 10 males; mean age 4y 9mo [SD 1y 7mo], range 2y 9mo8y; Manual Ability Classification System levels IIII) scored lower on capacity (p=0.052) and performance (p

Item does not contain fulltext Startle pathways may contribute to rapid accomplishment of postural stability. Here we investigate the possible influence of a startling auditory stimulus (SAS) on postural responses. We formulated four specific questions: (1) can a concurrent SAS shorten the onset of automatic postural responses?; and if so (2) is this effect different for forward versus backward perturbations?; (3) does this effect depend on prior knowledge of the perturbation direction?; and (4) is this effect different for low- and high-magnitude perturbations? Balance was perturbed in 11 healthy participants by a movable platform that suddenly translated forward or backward. Each participant received 160 perturbations, 25% of which were combined with a SAS. We varied the direction and magnitude of the perturbations, as well as the prior knowledge of perturbation direction. Perturbation trials were interspersed with SAS-only trials. The SAS accelerated and strengthened postural responses with clear functional benefits (better balance control), but this was only true for responses that protected against falling backwards (i.e. in tibialis anterior and rectus femoris). These muscles also demonstrated the most common SAS-triggered responses without perturbation. Increasing the perturbation magnitude accelerated postural responses, but again with a larger acceleration for backward perturbations. We conclude that postural responses to backward and forward perturbations may be processed by different neural circuits, with influence of startle pathways on postural responses to backward perturbations. These findings give directions for future studies investigating whether deficits in startle pathways may explain the prominent backward instability seen in patients with Parkinson's disease and progressive supranuclear palsy. 12 p.

Contains fulltext : 127317.pdf (Publisher’s version ) (Closed access) Dysphagia is reported in advanced stages of Duchenne muscular dystrophy (DMD). The population of DMD is changing due to an increasing survival. We aimed to describe the dysphagia in consecutive stages and to assess the underlying mechanisms of dysphagia in DMD, in order to develop mechanism based recommendations for safe swallowing. In this cross-sectional study, participants were divided into: early and late ambulatory stage (AS, n = 6), early non-ambulatory stage (ENAS, n = 7), and late non-ambulatory stage (LNAS, n = 11). Quantitative oral muscle ultrasound was performed to quantify echo intensity. Swallowing was assessed with a video fluoroscopic swallow study, surface electromyography (sEMG) of the submental muscle group and tongue pressure. Differences in outcome parameters among the three DMD stages were tested with analysis of variance. Oral muscles related to swallowing were progressively affected, starting in the AS with the geniohyoid muscle. Tongue (pseudo) hypertrophy was found in 70 % of patients in the ENAS and LNAS. Oral phase problems and post-swallow residue were observed, mostly in the LNAS with solid food. sEMG and tongue pressure data of swallowing solid food revealed the lowest sEMG amplitude, the longest duration and lowest tongue pressure in the LNAS. In case of swallowing problems in DMD, based on the disturbed mechanisms of swallowing, it is suggested to (1) adjust meals in terms of less solid food, and (2) drink water after meals to clear the oropharyngeal area.

Item does not contain fulltext Postural instability, one of the cardinal symptoms of Parkinson's disease (PD), has devastating consequences for affected patients. Better strategies to prevent falls are needed, but this calls for an improved understanding of the complex mechanisms underlying postural instability. We must also improve our ability to timely identify patients at risk of falling. Dynamic posturography is a promising avenue to achieve these goals. The latest moveable platforms can deliver 'real-life' balance perturbations, permitting study of everyday fall circumstances. Dynamic posturography studies have shown that PD patients have fundamental problems in scaling their postural responses in accordance with the need of the actual balance task at hand. On-going studies evaluate the predictive ability of impaired posturography performance for daily life falls. We also review recent work aimed at exploring balance correcting steps in PD, and the presumed interaction between startle pathways and postural responses.

OBJECTIVE: To evaluate the effectiveness of individually tailored cognitive behavioral therapy (CBT) for reducing depressive symptoms with or without anxiety post stroke.DESIGN: Multi-center, assessor-blinded, randomized controlled trial.SETTING: Six ambulatory rehabilitation settings in The Netherlands.PARTICIPANTS: Patients who had a Hospital Anxiety and Depression Scale - subscale Depression (HADS-D) score > 7 at least three months post stroke.INTERVENTIONS: Sixty-one participants were randomly allocated to either augmented CBT or computerized cognitive training (CCT). The CBT intervention was based on the principles of recognizing, registering, and altering negative thoughts and cognitions. CBT was augmented with goal-directed real-life activity training given by an occupational or movement therapist.MAIN OUTCOME MEASURES: HADS-D was the primary outcome and measures of participation and quality of life were secondary outcomes. Outcome measurements were performed at baseline, directly post treatment, and at four and eight months follow-up. Analysis was performed with linear mixed models using group (CBT vs CCT) as between-subjects factor and time (4 assessments) as within-subjects factor.RESULTS: Mixed model analyses showed a significant and persistent time effect for HADS-D (MD:-4.6, 95%CI=-5.7;-3.75, pCONCLUSIONS: Our augmented CBT intervention was not superior to computerized cognitive training for the treatment of mood disorders after stroke. Future studies should determine whether both interventions are better compared to natural history.

Background and Purpose— The purpose of this systematic review and meta-analysis was to investigate the effects of exercise training on balance capacity in people in the chronic phase after stroke. Furthermore, we aimed to identify which training regimen was most effective. Methods— Electronic databases were searched for randomized controlled trials evaluating the effects of exercise therapy on balance capacity in the chronic phase after stroke. Studies were included if they were of moderate or high methodological quality (PEDro score ≥4). Data were pooled if a specific outcome measure was reported in at least 3 randomized controlled trials. A sensitivity analysis and consequent subgroup analyses were performed for the different types of experimental training (balance and/or weight-shifting training, gait training, multisensory training, high-intensity aerobic exercise training, and other training programs). Results— Forty-three randomized controlled trials out of 369 unique hits were included. A meta-analysis could be conducted for the Berg Balance Scale (28 studies, n=985), Functional Reach Test (5 studies, n=153), Sensory Organization Test (4 studies, n=173), and mean postural sway velocity (3 studies, n=89). A significant overall difference in favor of the intervention group was found for the Berg Balance Scale (mean difference 2.22 points (+3.9%); 95% confidence interval [CI], 1.26–3.17; P I 2 =52%), Functional Reach Test (mean difference=3.12 cm; 95% CI, 0.90–5.35; P I 2 =74%), and Sensory Organization Test (mean difference=6.77 (+7%) points; 95% CI, 0.83–12.7; P =0.03; I 2 =0%). Subgroup analyses of the studies that included Berg Balance Scale outcomes demonstrated a significant improvement after balance and/or weight-shifting training of 3.75 points (+6.7%; 95% CI, 1.71–5.78; P I 2 =52%) and after gait training of 2.26 points (+4.0%; 95% CI, 0.94–3.58; P I 2 =21, whereas no significant effects were found for other training regimens. Conclusions— This systematic review and meta-analysis showed that balance capacities can be improved by well-targeted exercise therapy programs in the chronic phase after stroke. Specifically, balance and/or weight-shifting and gait training were identified as successful training regimens.

Item does not contain fulltext Roosink M, Van Dongen RT, Buitenweg JR, Renzenbrink GJ, Geurts AC, IJzerman MJ. Multimodal and widespread somatosensory abnormalities in persistent shoulder pain in the first 6 months after stroke: an exploratory study. OBJECTIVE: To explore the role of multimodal and widespread somatosensory abnormalities in the development of persistent poststroke shoulder pain (pPSSP) in the first 6 months after stroke. DESIGN: Prospective inception cohort study. SETTING: Stroke units of 2 teaching hospitals. PARTICIPANTS: The data of a strict selection of patients (N=31) with a clinical diagnosis of stroke were analyzed. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The development of pPSSP within the first 6 months after stroke. Bilateral sensation and pain thresholds at 3 (t1) and 6 (t2) months, and conditioned pain modulation (CPM) at 3 months after stroke. Clinical examination within 2 weeks after stroke (t0), at t1, and at t2. RESULTS: pPSSP (n=9) was associated with increased sensation and pain threshold ratios at the affected side (t1, t2), and with reduced cold pain tolerance at the unaffected side (t1). CPM was not different from patients without pPSSP (n=22). Notably, in patients with pPSSP reporting increased sensation on clinical examination, multiple body sites across multiple stimulus modalities were involved, and increased sensation persisted from t1 to t2. CONCLUSIONS: pPSSP in the first 6 months after stroke was associated with somatosensory loss to both innocuous and noxious stimuli (affected side). In addition, pPSSP was associated with sensitization to cold pain (unaffected side) and with widespread sensitization to multimodal innocuous stimuli (affected side). The results support the notion that central somatosensory sensitization could play an important role in the development of pPSSP, the maintenance of pPSSP, or both.

Roorda LD, Green JR, Houwink A, Bagley PJ, Smith J, Molenaar IW, Geurts AC. The Rivermead Mobility index allows valid comparisons between subgroups of patients undergoing rehabilitation after stroke who differ with respect to age, sex, or side of lesion. Arch Phys Med Rehabil 2012;93:1086-90.Objective: To investigate differential item functioning or item bias of the Rivermead Mobility Index (RMI) and its impact on the drawing of valid comparisons with the RMI between subgroups of patients after stroke who differ with respect to age, sex, or side of lesion.Design: Cross-sectional study.Setting: A rehabilitation center in the Netherlands and 2 stroke rehabilitation units and the wider community in the United Kingdom.Participants: The RMI was completed for patients undergoing rehabilitation after stroke (N=620; mean age +/- SD, 69.2 +/- 12.5y; 297 [48%] men; 269 [43%] right hemisphere lesion, and 304 [49%] left hemisphere lesion).Interventions: Not applicable.Main Outcome Measures: Mokken scale analysis was used to investigate differential item functioning of the RMI between subgroups of patients who differed with respect to age (young vs older), sex (men vs women), and side of stroke lesion (right vs left hemisphere).Results: No differential item functioning was found for any of the comparison subgroups.Conclusions: The RMI allows valid comparisons to be made between subgroups of patients undergoing rehabilitation after stroke who differ with respect to age, sex, or side of lesion.

Item does not contain fulltext Decreased tongue strength (TS) might herald bulbar involvement in patients with amyotrophic lateral sclerosis (ALS) well before dysarthria or dysphagia occur, and as such might be prognostic of short survival. The purpose of this study was to investigate the prognostic value of a decreased TS, in addition to other prognostic factors, such as site of onset, bulbar symptoms, bulbar signs, age, sex, maximum phonation time, time from symptoms to diagnosis, and gastrostomy, for survival time in patients with ALS. TS was measured in four directions in 111 patients who attended the diagnostic outpatient motor neuron clinic of our university hospital. Of these patients, 54 were diagnosed with ALS. TS was considered abnormal if the strength in minimally one direction was at least two standard deviations below the reference values obtained from comparable age category and sex-groups of healthy controls (n = 119). Twenty of the patients with ALS had a decreased TS. Multivariable analysis showed that, in addition to age, TS was an independent prognostic factor for survival time in patients with ALS.

Geurtsen GJ, van Heugten CM, Martina JD, Rietveld AC, Meijer R, Geurts AC. Three-year follow-up results of a residential community reintegration program for patients with chronic acquired brain injury. Arch Phys Med Rehabil 2012;93:908-11. Objective: To evaluate outcomes of a residential community reintegration program 3 years after treatment on independent living, societal participation, emotional well-being, and quality of life in patients with chronic acquired brain injury and psychosocial problems hampering societal participation. Design: A follow-up assessment 3 years after treatment was compared with the 1-year follow-up assessment in a prospective cohort study. Setting: A tertiary rehabilitation center for acquired brain injury. Participants: Of the 67 patients assessed at the 1-year follow-up, 63 subjects (94%; 42 men; mean age at admission to treatment 24.7y; mean time postonset 5.1y) were available at the 3-year follow-up and taken into account in the analyses. Intervention: A structured residential treatment program directed at improving independence in domestic life, work, leisure time, and social interactions. Main Outcome Measures: Community Integration Questionnaire, Employability Rating Scale, living situation, school, work situation, work hours, Center for Epidemiological Studies-Depression scale, and the World Health Organization Quality of Life Scale Abbreviated (5 scales). Results: There were no significant differences for any of the outcome measures between the 1-year and 3-year follow-up assessment. Conclusions: These results indicate that the established significant and clinically relevant improvements after a residential community reintegration program remain stable in the long term

Spruit-van Eijk M, Zuidema SU, Buijck BI, Koopmans RT, Geurts AC. To what extent can multimorbidity be viewed as a determinant of postural control in stroke patients? Objective To investigate the determinants of postural imbalance after stroke in geriatric patients admitted for low-intensity rehabilitation in skilled nursing facilities (SNFs), particularly the role of multimorbidity. Design Cross-sectional study design. Setting Fifteen SNFs. Participants All patients who were admitted for rehabilitation after stroke in one of the participating SNFs (N=378) were eligible. Interventions Not applicable. Main Outcome Measures The Berg Balance Scale (BBS) was selected as a measure of standing balance and the Functional Ambulation Categories (FAC) as a measure of walking balance. Results Multimorbidity was present in 34% of the patients. The patients with multimorbidity differed from the patients without multimorbidity with respect to age, proprioception, and vibration sense, but not for any of the cognitive tests, muscle strength, or sitting balance. Patients with multimorbidity had, on average, lower scores on both outcome measures. In linear regression analyses, both the BBS and FAC were best explained by multimorbidity, muscle strength, and the interaction between muscle strength and static sitting balance (overall explained variance 66% and 67%, respectively), while proprioception added only to the variance of the FAC. Conclusions Multimorbidity was independently related to postural imbalance after stroke in patients admitted for rehabilitation in SNFs. Muscle strength and the interaction of muscle strength with static sitting balance were important determinants of both standing and walking balance, indicating these factors as essential targets for rehabilitation.

Background Walking ability of people with foot drop in the chronic phase after stroke is better with functional electrical stimulation (FES) of the peroneal nerve than without an orthotic device. However, the literature is not conclusive on whether peroneal FES also is better than an ankle-foot orthosis (AFO) in this regard. Objective This study aimed to identify potential benefits of peroneal FES over an AFO with respect to the ability to negotiate a sudden obstacle. Design The study design was a within-subject comparison between FES and AFO using repeated measures. Methods Twenty-four community-dwelling people with stroke (mean age=52.6 years, SD=12.7) who regularly used a polypropylene AFO were fitted with a transcutaneous FES device. The participants' obstacle avoidance ability was tested after 2 and 8 weeks. They had to avoid 30 obstacles that were suddenly dropped on a treadmill in front of the affected leg while walking with either FES or an AFO. The obstacle avoidance success rates were determined. Results Success rates were higher with FES than with an AFO, especially after adjustment for individual leg muscle strength. Participants with relatively low muscle strength (Motricity Index score Limitation Further work is needed to determine whether the results may be generalized to other groups of people with stroke. Conclusions Peroneal FES seems to be superior to an AFO with regard to obstacle avoidance ability in community-dwelling people with stroke. The observed gains in obstacle avoidance ability appear to be clinically most relevant in the people with relatively low leg muscle strength.

Item does not contain fulltext de Niet M, Latour H, Hendricks H, Geurts AC, Weerdesteyn V. Short-latency stretch reflexes do not contribute to premature calf muscle activity during the stance phase of gait in spastic patients. OBJECTIVE: To identify whether a relationship exists between stretch and activity of the calf muscles during the stance phase of gait in patients with upper motor neuron syndrome (UMNS), while taking into account the physiologic phase shift between these entities. DESIGN: Survey. SETTING: Ambulatory care and general community. PARTICIPANTS: Patients with UMNS (n=15; 9 patients with stroke, 6 patients with hereditary spastic paraparesis) with premature calf muscle activity during the stance phase of gait and healthy controls (n=13). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Timing of optimal association (phase shift) between the lengthening velocity of the gastrocnemius muscle and its electromyographic activity as revealed by cross-correlation analyses. RESULTS: Although premature calf muscle activity was evident in the patient groups, the phase shift between calf muscle stretch and its activity did not correspond with the monosynaptic stretch reflex latency (40- to 80-ms time window). However, there was a main effect of group on the phase shifts (F(3,33)=3.23, P=.035). Post hoc analysis revealed that in the paretic leg of stroke patients, the electromyographic activity preceded the lengthening velocity by 9+/-54ms, whereas in the control group, the electromyographic activity followed the pattern of the muscle-lengthening velocity with a delay of 61+/-54ms (P=.029). CONCLUSIONS: Short-latency stretch reflexes do not significantly contribute to premature calf muscle activity in the stance phase of (spastic) gait. This notion questions the validity of the clinical assessment of hyperreflexia and clonus of the calf as a predictor of calf muscle spasticity during gait.

OBJECTIVE: To investigate the prevalence and course of neuropsychiatric symptoms (NPS) in geriatric patients admitted to skilled nursing facilities (SNFs) for rehabilitation after stroke. METHODS: This was a longitudinal multicenter study within 15 SNFs in the Netherlands. NPS were assessed in 145 patients with stroke through the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) with measurements on admission and at discharge. The prevalence and course of NPS were described in terms of cumulative prevalence (symptoms either on admission or at discharge), conversion (only symptoms at discharge), remission (only symptoms on admission), and persistence (symptoms both on admission and at discharge) for patients who were discharged to an independent living situation within one year after admission and patients who had to stay in the SNF for long term care. RESULTS: Eighty percent had a first-ever stroke and 74% could be successfully discharged. Overall, the most common NPS were depression (33%), eating changes (18%), night-time disturbances (19%), anxiety (15%), irritability (12%), and disinhibition (12%). One year after admission, the patients who were still in the SNF showed significantly more hallucinations (p = 0.016), delusions (p = 0.016), agitation (p = 0.004), depression (p = 0.000), disinhibition (p = 0.004), irritability (p = 0.018), and night-time disturbances (p = 0.001) than those who had been discharged. DISCUSSION: The overall prevalence of NPS in this study was lower than reported by other studies in different settings. There was a high prevalence of NPS in patients that could not be successfully discharged. CONCLUSIONS: The findings suggest that NPS should be optimally treated to improve outcome of rehabilitation.

BACKGROUND: Ultrasound is a non-invasive method to quantitatively measure various muscle parameters. Purpose of this study was to assess the feasibility of ultrasound of lower leg and foot muscles and to obtain reference values for muscle thickness (MT) and echo intensity (EI). METHODS: Ultrasound measurements of leg and foot muscles were performed in 60 healthy adults. MT and EI were quantitatively determined for the abductor hallucis (AH), extensor digitorum brevis (EDB), extensor hallucis longus (EHL) and peroneus longus (PER) muscles. Influence of age, height, weight and sex was determined using a multiple linear regression analysis. RESULTS: All muscles except the AH could easily be visualized with ultrasound. EI tended to be increased above 60 years and MT was significantly higher in men compared to women, necessitating age- and sex-dependent reference values. CONCLUSIONS: This study shows that muscle ultrasound is capable of visualizing lower leg and foot muscles and reference values for MT and EI can be obtained. Future research will focus on the use of these reference values to evaluate muscle abnormalities caused by neuromuscular disorders like hereditary motor and sensory neuropathy.

The purpose of this article was to describe a child-friendly modified constraint-induced movement therapy protocol that is combined with goal-directed task-specific bimanual training (mCIMT-BiT). This detailed description elucidates the approach and supports various research reports. This protocol is used in a Pirate play group setting and aims to extend bimanual skills in play and self-care activities for children with cerebral palsy and unilateral spastic paresis of the upper limb. To illustrate the content and course of treatment and its effect, a case report of a two-year-old boy is presented. After the eight-week mCIMT-BiT intervention, the child improved the capacity of his affected arm and hand in both quantitative and qualitative terms and his bimanual performance in daily life as assessed by the Assisting Hand Assessment, ABILHAND-Kids, Video Observations Aarts and Aarts Module Determine Developmental Disregard, Canadian Occupational Performance Measure and Goal Attainment Scaling. It is argued that improvement of affected upper-limb capacity in a test situation may be achieved and retained relatively easily, but it may take a lot more training to stabilize the results and automate motor control of the upper limb. Future studies with groups of children should elaborate on these intensity and generalization issues.

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is the neuropsychologist. AbstractPurpose: Post-stroke fatigue is a common and debilitating complaint, which has only recently received attention in clinical rehabilitation. Until now, no evidence-based treatments have been available for the condition. Therefore, a new treatment was designed to reduce post-stroke fatigue complaints: Cognitive and Graded Activity Training (COGRAT). Rationale: Following the premise that post-stroke fatigue is primarily caused by brain damage, the treatment aims to prevent fatigue and to manage existing fatigue symptoms. The purpose of the added graded activity programme is to reduce fatigue by changing cognitions and enhancing physical fitness. Theory into practice: COGRAT consists of a cognitive treatment and graded activity programme in small groups over 12 weeks. In the cognitive treatment, patients receive education on post-stroke fatigue and register their activities and fatigue to gain insight into their daily agenda and fatigability. Patients are then taught several compensation strategies. Cognitive behavioural therapy is used to diminish anxiety, facilitate behavioural change and manage fatigue symptoms. The graded activity programme consists of walking on a treadmill, strength training and home work assignments. Maximum heart rate and strength are increased from 40% at the beginning of the training to a maximum of 70%. Considerations for future improvements: COGRAT is currently being evaluated in outpatients with severe post-stroke fatigue in a multicentre randomized controlled trial. Preliminary data suggest both positive short- and long-term effects. Adaptations for other neurological patient groups suffering from fatigue are suggested.

Roorda LD, Houwink A, Smits W, Molenaar IW, Geurts AC. Measuring upper limb capacity in poststroke patients: development, fit of the monotone homogeneity model, unidimensionality, fit of the double monotonicity model, differential item functioning, internal consistency, and feasibility of the Stroke Upper Limb Capacity Scale, SULCS. Objectives To develop an easy-to-use scale that measures upper limb capacity, according to the International Classification of Functioning, Disability and Health definition, in patients after stroke, and to investigate certain psychometric properties of this scale. Design Cohort study. Setting Inpatient department of a rehabilitation center. Participants Patients (N=546; mean age ± SD, 60.1±11.2y; 56% men) undergoing rehabilitation after stroke. Interventions Not applicable. Main Outcome Measures Mokken scale analysis was used to investigate the following psychometric properties: (1) fit of the monotone homogeneity model, indicating that the items form a scale; (2) unidimensionality, indicating that the items measure only 1 concept (or construct); (3) fit of the double monotonicity model, indicating invariant (hierarchical) item ordering; (4) differential item functioning (DIF), indicating the validity of comparison between subgroups; and (5) internal consistency, indicating the degree of interrelatedness of the items. The mean time needed to complete the scale was calculated to indicate (6) feasibility. Results The Stroke Upper Limb Capacity Scale (SULCS) was developed on the basis of interviews with experts. Ten of 15 items had (1) good fit of the monotone homogeneity model (coefficient H =.88), were (2) unidimensional, and had (3) good fit of the double monotonicity model (coefficient H T =.71), (4) absence of DIF (C rit -values ρ =.96). When applying start-and-stop rules, the (6) feasibility of the SULCS was good (6min). Conclusions The SULCS is an easy-to-use, unidimensional, hierarchical, and internally consistent scale that assesses upper limb capacity in patients after stroke.

Contains fulltext : 90137.pdf (Publisher’s version ) (Closed access) Motor imagery (MI) refers to the mental rehearsal of a movement without actual motor output. MI training has positive effects on upper limb recovery after stroke. However, until now it is unclear whether this effect is specific to the trained task or a more general motor skill improvement. This study was set up to advance our insights into the efficacy of MI training and the specificity of its effects. We investigated whether MI training affected the trained hand exclusively, or both hands. Four stroke participants received a 15-min MI training four times a week for 3 weeks. Hand function was measured before and after the training using three measurements of increasing complexity. Hand function improved after MI training, thus confirming the earlier studies. Second, we found specific effects of the MI training for two of the three measurements. These results suggest that MI specificity is dependent on the complexity of the hand function task.

Item does not contain fulltext Importance: Gait impairments are common in patients with chronic supratentorial upper motor neuron lesions and are a source of disability. Clinical management aimed at improving the gait pattern in these patients is generally perceived as a challenging task because many possible abnormalities may interact. Moreover, a multitude of treatment options exist, ranging from assistive devices and muscle stretching to pharmacologic and surgical interventions, but evidence is inconclusive for most approaches and clear treatment guidelines are lacking. Observations: Gait deviations in adults with a chronic supratentorial upper motor neuron lesion can approximately be reduced to the following 3 groups of primary deficits: (1) imbalance of muscle strength, length, and activity around the ankle and tarsal joints leading to pes equinovarus or pes equinus; (2) calf muscle weakness; and (3) overactivity of proximal leg muscles. Conclusions and Relevance: A stepwise treatment algorithm emphasizes medical-technical interventions, which are based on evidence when available and otherwise reflect practice-based experience.

Contains fulltext : 87495.pdf (Publisher’s version ) (Closed access) Asymmetry in performance and an association with non-lateralized attention are often mentioned as two important aspects of the clinical manifestation of visuospatial neglect. Both these aspects were investigated in 21 left (LH) and 24 right hemisphere (RH) stroke patients and in 20 healthy subjects. The letter and star cancellation subtests of the Behavioural Inattention Task (BIT) and a computerized visual reaction time task (CVRT) with stimuli presented either left, central or right in extrapersonal space were administered. In LH patients, the calculation of BIT asymmetry scores allowed a better distinction between patients with and without neglect than raw omission scores. However, in RH patients, raw and asymmetry scores led to similar classifications. In the CVRT, raw and asymmetry scores for the number of omissions also produced identical classifications. Thus, the computation of asymmetry scores for omissions did not substantially refine the diagnosis of neglect. On the other hand, more patients were classified as neglect patients by using CVRT reaction time (RT) asymmetry scores than by using BIT or CVRT omission scores. Ipsilesional RT's were chosen as a measure of general, non-lateralized attention. The ipsilesional RT's of the LH and RH patients did not differ from the healthy subjects' lateral RT's. However, within the RH group, patients with both RT asymmetries and BIT scores above cut-off level showed longer ipsilesional RT's than patients with defective RT asymmetries but normal BIT scores. This supports the idea of an interaction between lateralized and non-lateralized attentional components in neglect, in which the presence of general attentional deficits exacerbates the severity of neglect symptoms. RT tasks may contribute to the detection of asymmetries in visuospatial attention in patients with subclinical neglect symptoms, who might compensate for their lateralized deficit in paper-and-pencil tasks employing intact general attention. 01 mei 2010

Contains fulltext : 88752.pdf (Publisher’s version ) (Closed access) BACKGROUND: In children with unilateral spastic cerebral palsy (CP), there is only limited evidence for the effectiveness of modified constraint-induced movement therapy (mCIMT). OBJECTIVE: To investigate whether 6 weeks of mCIMT followed by 2 weeks of bimanual task-specific training (mCIMT-BiT) in children with unilateral spastic CP improves the spontaneous use of the affected limb in both qualitative and quantitative terms more than usual care (UC) of the same duration. METHODS: Children with unilateral spastic CP with Manual Ability Classification System (MACS) scores I, II, or III and aged 2.5 to 8 years were recruited and randomly allocated to either the mCIMT-BiT group (three 3-hour sessions per week: 6 weeks of mCIMT, followed by 2 weeks of task-specific training in goal-directed bimanual play and self-care activities) or to 1.5 hours of more general physical or occupational weekly plus encouragement to use the affected hand for the UC group. Primary outcome measures were the Assisting Hand Assessment and the ABILHAND-Kids. Secondary outcomes were the Melbourne Assessment of Unilateral Upper Limb Function, the Canadian Occupational Performance Measure, and the Goal Attainment Scale. RESULTS: Twenty-eight children were allocated to mCIMT-BiT and 24 to UC. Except for the Melbourne, all primary and secondary outcome measures demonstrated significant improvements in the mCIMT-BiT group. CONCLUSION: mCIMT followed by task-specific training of goal-directed bimanual play and self-care activities is an effective intervention to improve the spontaneous use of the more affected upper limb in children with relatively good baseline upper extremity function.

In The Netherlands, a web application for speech training, E-learning-based speech therapy (EST), has been developed for patients with dysarthria, a speech disorder resulting from acquired neurological impairments such as stroke or Parkinson's disease. In this report, the EST infrastructure and its potentials for both therapists and patients are elucidated. EST provides patients with dysarthria the opportunity to engage in intensive speech training in their own environment, in addition to undergoing the traditional face-to-face therapy. Moreover, patients with chronic dysarthria can use EST to independently maintain the quality of their speech once the face-to-face sessions with their speech therapist have been completed. This telerehabilitation application allows therapists to remotely compose speech training programs tailored to suit each individual patient. Moreover, therapists can remotely monitor and evaluate changes in the patient's speech. In addition to its value as a device for composing, monitoring, and carrying out web-based speech training, the EST system compiles a database of dysarthric speech. This database is vital for further scientific research in this area.

Contains fulltext : 89786.pdf (Publisher’s version ) (Closed access) PURPOSE: To explore the association between perceived spasticity and psychological factors (pain sensations, coping strategies, and illness cognitions) in chronic spinal cord injured (SCI) patients. METHODS: Cross-sectional study using a set of questionnaires was designed for chronic complete patients with SCI and with self-reported leg spasticity. Outcome measures were Visual Analogue Scale for average perceived leg spasticity (VAS(Spasticity)), VAS(Pain) for average perceived pain sensations in the leg, Utrecht Coping List (UCL) including its seven subscales, and Illness Cognition Questionnaire (ICQ) with its three subscales. Psychological factors with a bivariate correlation with VAS(Spasticity) of p < 0.2 were selected for regression analyses. RESULTS: Nineteen patients with SCI (response rate 86%) participated. Bivariate correlations of p < 0.2 were found between VAS(Spasticity) and VAS(Pain), UCL(Active approach), UCL(Seeking social support), UCL(Reassuring thoughts), ICQ(Acceptation), and ICQ(Helplessness). Only UCL(Reassuring) (thoughts) (Beta -0.59, p = 0.01) and ICQ(Helplessness) (Beta 0.50, p = 0.02) were retained in the multivariate model, explaining 44% of the variance in VAS(Spasticity) (R(2)(adjusted)). CONCLUSIONS: Perceived spasticity appeared associated with psychological factors in complete patients with SCI: Those with higher levels of reassuring thoughts and lower levels of helplessness reported relatively lower levels of perceived spasticity. Large prospective cohort studies are recommended.

Contains fulltext : 88697.pdf (Publisher’s version ) (Open Access) OBJECTIVE: As a Web application for speech training, e-learning-based speech therapy (EST) is assumed to have potential for neurological patients who aim at independent speech training in their home environment. This article reports a case study of a patient with dysarthric speech due to Parkinson's disease (PD) who enrolled in a 4-week intensive speech training through EST. The primary goal was to investigate the feasibility and the potential efficacy of EST as a Web application for speech training in dysarthric patients with PD. MATERIALS AND METHODS: The participant used EST, following a speech training program containing parts of the pitch limiting voice treatment for patients with PD. The feasibility of EST for independent speech training in the home environment was verified through a questionnaire. The questionnaire addressed the participant's individual experiences with EST as well as the extent of satisfaction with technological features of EST, the content of the speech training, and the suitability of the home training environment. The potential efficacy of EST as a device to improve speech intelligibility was investigated using a repeated measures with randomized blocks design. The proportion of correct orthographic transcriptions of semantically unpredictable sentences as well as ratings of perceived intelligibility on a 10-point scale were used as measures for speech intelligibility. RESULTS: Outcomes of the questionnaire resulted in recommendations to enhance EST feasibility. Speech intelligibility, as measured by transcription scores, improved significantly after EST training. This improvement was maintained for 2 weeks after completing the EST training, whereas considerably lower scores were observed after 11 weeks without training. Subjective ratings of intelligibility did not show significant differences across time. CONCLUSIONS: The results of this case study confirm the potential of EST for patients with PD.

Contains fulltext : 88191.pdf (Publisher’s version ) (Closed access) OBJECTIVE: Spinal cord-injured (SCI) individuals demonstrate an increased baseline leg vascular resistance (LVR). In addition, despite the lack of sympathetic control, an increase in LVR is observed during orthostatic challenges. On the basis of the vasoconstrictive characteristics of angiotensin II, we examined the hypothesis that angiotensin II contributes to the LVR at baseline and during head-up tilt (HUT) in SCI individuals. METHODS: Supine baseline leg and forearm blood flow were measured using venous occlusion plethysmography and leg blood flow during 30 degrees HUT using duplex ultrasound. Measurements were performed before and 4 h after an angiotensin II antagonist (irbesartan, 150 mg) administered in eight SCI individuals and eight age-matched and sex-matched able-bodied controls. Vascular resistance was calculated as the arterial-venous pressure gradient divided by blood flow. RESULTS: Angiotensin II blockade significantly decreased baseline LVR in SCI individuals (P = 0.02) but not in controls, whereas no changes in forearm vascular resistance were found in both groups. Angiotensin II blockade did not alter the increase in LVR during HUT in SCI individuals nor in controls. CONCLUSION: Our results indicate that angiotensin II contributes to the increased baseline LVR in SCI individuals. As angiotensin II does not contribute to forearm vascular resistance, the contribution to LVR may relate to the extreme inactivity of the legs in SCI individuals. Angiotensin II does not contribute to the increase in LVR during HUT in SCI individuals nor in controls. 01 oktober 2010

Contains fulltext : 80082.pdf (Publisher’s version ) (Closed access) BACKGROUND: Ankle-foot orthoses are often provided to improve walking in stroke patients, although the evidence of effects on walking and balance control is still inconsistent. This could be caused by a lack of insight into the influence of orthoses on the underlying impairments. These impairments can be assessed with dual plate posturography to determine the relative contribution of each lower limb to balance control and weight-bearing. This study examined the effects of ankle-foot orthoses on functional balance, static and dynamic weight-bearing asymmetry and dynamic balance control of the paretic and non-paretic lower limbs. METHODS: Twenty stroke subjects (time since stroke 5-127 months) completed the study. Subjects were assessed with and without ankle-foot orthosis. Functional balance was assessed using the Berg Balance Scale, Timed Up & Go test, Timed Balance Test, 10-m walking test and Functional Ambulation Categories. Weight-bearing asymmetry and dynamic balance control were assessed with force plates on a movable platform. FINDINGS: No significant effects of ankle-foot orthoses were found for weight-bearing asymmetry and dynamic balance control, but significant differences in favour of ankle-foot orthosis use were found for most functional tests. INTERPRETATION: Although ankle-foot orthoses had no effect on weight-bearing asymmetry or dynamic balance contribution of the paretic lower limb, functional tests were performed significantly better with orthoses. Apparently, improvements at functional level cannot be readily attributed to a greater contribution of the paretic lower limb to weight-bearing or balance control. This finding suggests that ankle-foot orthoses influence compensatory mechanisms.

Contains fulltext : 80322.pdf (Publisher’s version ) (Closed access) Peripherally induced movement disorders are relatively rare. Here, we present 3 patients who suffered a lesion of the brachial plexus because of neuralgic amyotrophy and developed involuntary movements of their shoulder muscles. The nature of the involuntary movements, which did not easily comply with classic descriptions of hyperkinetic movement disorders, is probably best referred to as dystonia.

Contains fulltext : 81487.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To compare stimulus-response characteristics of both motor evoked potentials (MEP) and silent periods (SP) induced by transcranial magnetic stimulation (TMS) in proximal and distal upper-extremity muscles. METHODS: Stimulus-response curves of MEPs and SPs were obtained from the biceps brachii (BB) and abductor digiti minimi (ADM) muscles in 15 healthy participants. A nonlinear mixed model was used to fit the stimulus-response curves to a sigmoid Boltzmann function. RESULTS: Small residuals of the function were found for MEPs and SPs in both muscles. Higher maximal MEP amplitudes were found for the BB compared to the ADM (p

Contains fulltext : 70296.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To investigate the cross-cultural validity of international Dutch-English comparisons when using the Dutch Rivermead Mobility Index (RMI), and the intra-test reliability and construct validity of the Dutch RMI. METHODS: Cross-cultural validity was studied in a combined data-set of Dutch and English patients undergoing rehabilitation after stroke, who were assessed with the Dutch version of the RMI and the original English RMI, respectively. Mokken scale analysis was used to investigate unidimensionality, monotone homogeneity model fit, and differential item functioning between the Dutch and the English RMI. Intra-test reliability and construct validity were studied in the Dutch patients by calculating the reliability coefficient and correlating the Dutch RMI and the Dutch Barthel Index. RESULTS: The RMI was completed for Dutch (n = 200) and English (n = 420) patients after stroke. The unidimensionality and monotone homogeneity model fit of the RMI were excellent: combined Dutch-English data-set (coefficient H = 0.91); Dutch data-set (coefficient H = 0.93); English data-set (coefficient H = 0.89). No differential item functioning was found between the Dutch and the English RMI. The intra-test reliability of the Dutch RMI was excellent (coefficient rho = 0.97). In a sub-sample of patients (n = 91), the Dutch RMI correlated strongly with the Dutch Barthel Index (Spearman's correlation coefficient rho = 0.84). CONCLUSION: The Dutch RMI allows valid international Dutch-English comparisons, and has excellent intra-test reliability and construct validity.

Physiotherapy (PT) and occupational therapy (OT) are key professions providing treatment for the arm after stroke; however, knowledge about the content of these treatments is scant. Detailed data are needed to replicate interventions, evaluate their effective components, and evaluate PT and OT practice. This paper describes PT and OT treatment for the severely affected arm in terms of duration, content according to components and categories of the International Classification of Human Functioning, Disability and Health, and to analyze differences between professions.Design: This is a retrospective analysis of randomized trial data.46 patients after stroke with poor arm motor control recruited from inpatient neurological units from three rehabilitation centers in the Netherlands.PTs and OTs recorded duration and content of arm treatment interventions for 8 weeks using a bespoke treatment schedule with 15 International Classification of Human Functioning, Disability and Health categories.PTs and OTs spent on average 4-7 min per treatment session (30 min) on arm treatment. OTs spent significantly more time providing arm treatment and treatment at the activities level than PTs. PTs spent 79% of their arm treatment time on body functions, OTs 41%. OTs spent significantly more time on "moving around using transportation," "self care," and "household tasks" categories.Patients after stroke with a severely affected arm and an unfavorable prognosis for arm motor recovery receive little arm-oriented PT and OT. Therapists spent most arm treatment time on body functions. There was a considerable overlap in the content of PT and OT in 12 of the 15 categories. Results can be generalized only to patients with poor arm motor control and may not represent practice in other countries.

Item does not contain fulltext OBJECTIVE: To estimate the relative contribution of psychological factors next to sociodemographic and premorbid/stroke-related factors to the risk of developing symptoms of depression and anxiety after stroke. DESIGN: Multicenter, longitudinal cohort study. SETTING: Patients after stroke from 6 general hospitals. PARTICIPANTS: Patients (N=331) were included at stroke onset and followed up 2 and 12 months after stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sociodemographic and premorbid/stroke-related information was recorded during hospital admission, whereas psychological characteristics were determined with postal questionnaires 2 months poststroke. Symptoms of depression and anxiety were assessed with the Hospital Anxiety and Depression Scale (HADS) 2 and 12 months poststroke. Multivariable logistic analysis was performed to analyze the influence of sociodemographic, premorbid/stroke-related, and psychological characteristics on depressive symptoms (depression subscale of HADS >7) and symptoms of anxiety (anxiety subscale of HADS >7) 1 year after stroke. RESULTS: Early depression, stroke severity, posterior cerebral artery stroke, and neuroticism independently explained the variance of depressive symptoms 1 year poststroke (discriminative power, 83%; adjusted R(2) value, 36%). Neuroticism and early anxiety independently explained the variance of symptoms of anxiety 1 year poststroke (discriminative power, 88%; adjusted R(2) value, 44%). Based on these predictive models, nomograms were constructed to visually reflect the individual contribution of each risk factor to the development of long-term mood disorders after stroke. CONCLUSIONS: Psychological characteristics are important risk factors for poststroke symptoms of depression and anxiety.

Contains fulltext : 53011.pdf (Publisher’s version ) (Closed access) The primary goal of this study was to identify secondary functional changes in the peripheral motor units of the paretic upper extremity (UE) in patients with severe ischemic stroke and to determine how these changes develop during the first weeks after stroke. An inception cohort of 27 consecutive patients with an acute ischemic supratentorial stroke and an initial UE paralysis was compared with 10 healthy control subjects. The ulnar nerve was electrically stimulated proximal to the wrist and electromyographic recordings were obtained from the abductor digiti minimi muscle. Hemiparetic side mean values of the compound muscle action potential (CMAP) 1 and 3 weeks after stroke were compared with the nonparetic side and with CMAP values obtained from healthy control subjects. The mean CMAP amplitude in patients was significantly lower on the paretic side compared with the nonparetic side and with control subjects. Decrease in CMAP amplitude was observed in more than half of the stroke patients, sometimes as early as 4 days after stroke, and persisted in most cases. Whenever present, it was accompanied by absence of motor recovery at that specific time after stroke. Decreased CMAP amplitude in the abductor digiti minimi muscle can be seen already in the very acute phases after stroke unrelated to peripheral neuropathy, radiculopathy, or plexopathy, and it is accompanied by absence of UMN recovery. This knowledge is important for interpreting electrophysiological data in stroke patients.

Contains fulltext : 167738.PDF (Publisher’s version ) (Open Access) INTRODUCTION: StartReact is the acceleration of reaction time by a startling acoustic stimulus (SAS). The SAS is thought to release a pre-prepared motor program. Here, we investigated whether the StartReact effect is applicable to the very first trial in a series of repeated unpractised single-joint movements. METHODS: Twenty healthy young subjects were instructed to perform a rapid ankle dorsiflexion movement in response to an imperative stimulus. Participants were divided in two groups of ten. Both groups performed 17 trials. In one group a SAS (116 dB) was given in the first trial, whereas the other group received a non-startling sound (70 dB) as the first imperative stimulus. In the remaining 16 trials, the SAS was given as the imperative stimulus in 25% of the trials in both groups. The same measurement was repeated one week later, but with the first-trial stimuli counterbalanced between groups. RESULTS: When a SAS was given in the very first trial, participants had significantly shorter onset latencies compared to first-trial responses to a non-startling stimulus. Succeeding trials were significantly faster compared to the first trial, both for trials with and without a SAS. However, the difference between the first and succeeding trials was significantly larger for responses to a non-startling stimulus compared to responses triggered by a SAS. SAS-induced acceleration in the first trial of the second session was similar to that in succeeding trials of session 1. DISCUSSION: The present results confirm that the StartReact phenomenon also applies to movements that have not yet been practiced in the experimental context. The excessive SAS-induced acceleration in the very first trial may be due to the absence of integration of novel context-specific information with the existing motor memory for movement execution. Our findings demonstrate that StartReact enables a rapid release of motor programs in the very first trial also without previous practice, which might provide a behavioural advantage in situations that require a rapid response to a potentially threatening environmental stimulus. 11 p.

Contains fulltext : 167887.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To reach multidisciplinary European consensus on the assessment tools for impairments and activity limitations in patients with hand conditions. DESIGN: Electronic Delphi method. SUBJECTS: Thirty experts from European societies for hand therapy, hand surgery, and physical and rehabilitation medicine. METHODS: In 3 rounds, participants were asked which of 13 preselected categories of the Brief International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions should be assessed. In addition, they were asked to choose which of 55 preselected instruments they preferred for each category by confirming or rejecting instrument-specific statements. RESULTS: All 13 preselected ICF categories were considered relevant. Consensus was based on >/= 75% agreement. After 3 rounds, 9 instruments were selected: Shape Texture Identification Test, Semmes Weinstein Monofilament Test, Visual Analogue Scale for pain, goniometer, Jamar Dynamometer, Pinch Gauge Device, Cold Intolerance Symptom Severity questionnaire, Canadian Occupational Performance Measure, and Disabilities of the Arm, Shoulder and Hand Questionnaire. It remained undecided whether to use the Nine-Hole Pegboard Test or the Purdue Pegboard Test. CONCLUSION: In this European Delphi study, multidisciplinary consensus was reached on 9 assessment tools for impairments and activity limitations in patients with hand conditions addressing 13 categories of the Brief ICF Core Set for Hand Conditions.

Item does not contain fulltext OBJECTIVE: To investigate the effects of aerobic exercise training (AET) and cognitive-behavioral therapy (CBT), directed towards an increase in daily physical activity, on the progression of fatty infiltration and edema in skeletal muscles of patients with facioscapulohumeral muscular dystrophy (FSHD) type 1 by T2 MRI. METHODS: Quantitative T2 MRI (qT2 MRI) and fat-suppressed T2 MRI of the thigh were performed at 3T on 31 patients, 13 of whom received usual care (UC), 9 AET, and 9 CBT. Muscle-specific fat fractions (%), derived from qT2 MRI, were recorded pretreatment and posttreatment. Intervention effects were analyzed by comparing fat fraction progression rates of the UC with the treated groups using Mann-Whitney tests, and intermuscle differences by a linear mixed model. Edematous hyperintense lesions were identified on the fat-suppressed T2 MRI. RESULTS: The intraclass correlation coefficient for reproducibility of qT2 MRI fat assessment was 0.99. In the UC group, the fat fraction increased by 6.7/year (95% confidence interval [CI] 4.3 to 9.1). This rate decreased to 2.9/year (95% CI 0.7 to 5.2) in the AET (p = 0.03) and 1.7/year (95% CI -0.2 to 3.6) in the CBT group (p = 0.00015). The treatment effect differed among individual muscles. Fewer new edematous lesions occurred after therapy. CONCLUSIONS: Fat fraction derived from qT2 MRI is a reproducible and sensitive biomarker to monitor the effects of increased physical activity in individual muscles. This biomarker reports a favorable effect of AET and CBT on the rate of muscular deterioration in FSHD as reflected in decelerated fat replacement. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that for patients with FSHD type 1, both AET and CBT decrease the rate of fatty infiltration in muscles.

Background: Falls in the elderly are a major health problem. Although exercise programs have been shown to reduce the risk of falls, the optimal exercise components, as well as the working mechanisms that underlie the effectiveness of these programs, have not yet been established. Objective: To test whether the Nijmegen Falls Prevention Program was effective in reducing falls and improving standing balance, balance confidence, and obstacle avoidance performance in community-dwelling elderly people. Methods: A total of 113 elderly with a history of falls participated in this study (exercise group, n = 79; control group, n = 28; dropouts before randomization, n = 6). Exercise sessions were held twice weekly for 5 weeks. Pre- and post-intervention fall monitoring and quantitative motor control assessments were performed. The outcome measures were the number of falls, standing balance and obstacle avoidance performance, and balance confidence scores. Results: The number of falls in the exercise group decreased by 46% (incidence rate ratio (IRR) 0.54, 95% confidence interval (CI) 0.36–0.79) compared to the number of falls during the baseline period and by 46% (IRR 0.54, 95% CI 0.34–0.86) compared to the control group. Obstacle avoidance success rates improved significantly more in the exercise group (on average 12%) compared to the control group (on average 6%). Quiet stance and weight-shifting measures did not show significant effects of exercise. The exercise group also had a 6% increase of balance confidence scores. Conclusion: The Nijmegen Falls Prevention Program was effective in reducing the incidence of falls in otherwise healthy elderly. There was no evidence of improved control of posture as a mechanism underlying this result. In contrast, an obstacle avoidance task indicated that subjects improved their performance. Laboratory obstacle avoidance tests may therefore be better instruments to evaluate future fall prevention studies than posturographic balance assessments.

Contains fulltext : 48139.pdf (Publisher’s version ) (Closed access) Whereas several animal studies have indicated the important role of the motor cortex in the control of voluntary gait modifications, little is known about the effects of cortical lesions on gait adaptability in humans. Obstacle avoidance tasks provide an adequate paradigm to study the adaptability of the stepping pattern under controlled, experimental conditions. In the present study, an exploratory assessment was made of the failure rate, the preferred stepping strategies (step lengthening vs step shortening), and the spatiotemporal stride characteristics (percentage increases in stride length, duration, and velocity of the crossing and postcrossing strides) during obstacle avoidance in 11 hemiplegic stroke patients and seven healthy controls. Patients were less successful in avoiding obstacles than controls (14% failure rate vs 0.5% in controls), independent of whether the affected or the unaffected leg led the obstacle avoidance. The number of failed trials increased systematically when the available response time became shorter. During successful trials, lengthening of the step was generally preferred over shortening. This bias towards step lengthening was more pronounced in stroke patients (step lengthening in 91% of the trials vs 75% in controls), irrespective of the side of obstacle presentation. For both groups, overall strategy preference did not adhere to a principle of minimal foot displacement, since step lengthening was used even if it would be more spatially efficient to shorten the step. No statistically significant group differences were found for the increases in length, duration, and velocity of the crossing and postcrossing strides. However, for a subgroup of more slowly walking patients, large percentage increases were found in crossing stride length, duration, and velocity. Similar results were obtained for the postcrossing stride, indicating that, for this subgroup of patients, restoration of the normal walking cadence was more difficult. Overall, no systematic differences were found between the affected and the unaffected leg in stroke patients with respect to failure rates, stepping strategies, or spatiotemporal measures of obstacle avoidance. The present findings suggest that the ability to adequately modify the stepping pattern in response to imposed spatiotemporal constraints is impaired in persons with stroke, especially when modifications have to be performed under time pressure. In addition, the stepping strategies employed by subjects with stroke are different from those found in controls, possibly to reduce the complexity of the avoidance maneuver and to enhance safety. Finally, unilateral cortical damage results in an impaired ability to avoid obstacles on both sides of the body, suggesting that the reduced ability of stroke patients to negotiate obstacles may be related to problems of a more general coordinative nature.

Contains fulltext : 48825.pdf (Publisher’s version ) (Closed access) Recently, interest in the mechanisms underlying balance recovery following stroke has grown, because insight into these mechanisms is necessary to develop effective rehabilitation strategies for different types of stroke. Studies dealing with the recovery of standing balance from stroke are, however, limited to rehabilitation inpatients with a unilateral supratentorial brain infarction or haemorrhage. In most of these patients, stance stability improves in both planes as well as the ability to compensate for external and internal body perturbations and to control posture voluntarily. Although there is evidence of true physiological recovery of paretic leg muscle functions in postural control, particularly during the first three months post-stroke, substantial balance recovery also occurs in patients when there are no clear signs of improved support functions or equilibrium reactions exerted through the paretic leg. This type of recovery probably takes much longer than 3 months. Apparently, mechanisms other than the restoration of paretic leg muscle functions may determine the standing balance recovery in patients after severe stroke. No information is available about the role of stepping responses as an alternative to equilibrium reactions for restoring the ability to maintain upright stance after stroke. The finding that brain lesions involving particularly the parieto-temporal junction are associated with poor postural control, suggests that normal sensory integration is critical for balance recovery. Despite a considerable number of intervention studies, no definitive conclusions can be drawn about the best approach to facilitate the natural recovery of standing balance following stroke.

Contains fulltext : 57782.pdf (Publisher’s version ) (Closed access) The short-term effects of whole-body vibration as a novel method of somatosensory stimulation on postural control were investigated in 23 chronic stroke patients. While standing on a commercial platform, patients received 30-Hz oscillations at 3 mm of amplitude in the frontal plane. Balance was assessed four times at 45-min intervals with a dual-plate force platform, while quietly standing with the eyes opened and closed and while performing a voluntary weight-shifting task with visual feedback of center-of-pressure movements. Between the second and third assessments, four repetitions of 45-sec whole-body vibrations were given. The results indicated a stable baseline performance from the first to the second assessment for all tasks. After the whole-body vibration, the third assessment demonstrated a reduction in the root mean square (RMS) center-of-pressure velocity in the anteroposterior direction when standing with the eyes closed (P < 0.01), which persisted during the fourth assessment. Furthermore, patients showed an increase in their weight-shifting speed at the third balance assessment (P < 0.05) while their precision remained constant. No adverse effects of whole-body vibration were observed. It is concluded that whole-body vibration may be a promising candidate to improve proprioceptive control of posture in stroke patients.

de Haart M, Geurts AC, Huidekoper SC, Fasotti L, van Limbeek J. Recovery of standing balance in postacute stroke patients: a rehabilitation cohort study. Arch Phys Med Rehabil 2004;85:886–95. Objective To identify and interrelate static and dynamic characteristics of the restoration of quiet standing balance in a representative sample of stroke survivors in the Netherlands during their inpatient rehabilitation. Design Exploratory study using an inception cohort with findings related to reference values from healthy elderly persons. Setting Rehabilitation center. Participants Thirty-seven inpatients (mean age, 61.6y; mean time poststroke, 10.0wk) with a first hemispheric intracerebral infarction or hematoma who were admitted to retrain standing balance and walking. Intervention Individualized therapy. Main outcome measures Center of pressure fluctuations were registered under each foot and in the sagittal and frontal planes separately by using a dual-plate force platform. The first balance measurements took place as soon as patients were able to stand unassisted for at least 30 seconds as well as 2, 4, 8, and, 12 weeks later. Quiet standing was assessed under 4 conditions: with and without a visual midline reference, with the eyes closed, and while performing a concurrent arithmetic task. Results The stroke patients showed excessive postural sway and instability, particularly in the frontal plane, compared with reference values. Frontal plane balance was, however, also most responsive to the effects of balance training and recovery ( P P P P P P Conclusions Balance recovery in postacute stroke inpatients is characterized by a reduction in postural sway and instability as well as by a reduction in visual dependency, particularly with regard to frontal plane balance. These restoration characteristics may be important factors underlying the relearning of independent standing and walking abilities. The clear lack of normalization for measures reflecting static and dynamic aspects of postural asymmetry suggests that the functional improvements in balance and gait must be more related to other mechanisms than to the restoration of support functions and equilibrium reactions of the paretic leg.

Objectives: To test if a combined stimulation-training program can improve selected hand functions and impairments of chronic stroke survivors. Design: Pretest-Posttest, multi-site 5-week training program. Stroke survivors ( N =7 7) with chronic upper limb paresis completed a home-based stimulation program combining activation of the wrist-fingers flexors and extensors with functional grasp, hold and release training. Subjects trained 2-3 times each day, 7 days a week. Outcome measures included: the Jebsen-Taylor simulated feeding (S-feed); light object lift (J-T light); heavy object lift (J-T heavy); Box and Blocks test (BB Nine-Hole Peg (9-HP); Ashworth scale (Spasticity); Visual analog scale-VAS (Pain). Paired t-tests ( α< 0.01) were performed on each study outcome. Results: Simulated feeding time decreased from 39.1 ± 30.9 sec to 25.5 ± 23.3 sec (34.8% improvement). The task time of the J-T light decreased by 13.3 sec and the J-T heavy by 11.5 sec (44.9% and 40.9% improvement respectively). The number of blocks moved increased from 19.4 ± 11.6 to 24.5 ± 12.5 (26.3% improvement) and the time to complete the 9-HP decreased from 178.8 ± 170.8 to 105.0 ± 117.1 sec (58.7% improvement). Mean reduction of spasticity was 0.87 and 0.78 points at the elbow and wrist respectively. Patients with persistent pain ( N =3 3) reported mean reduction from 3.5 ± 2.5 to 1.9 ± 1.8. Conclusions: Five weeks of daily home training with a task-specific stimulation program improved selected hand functions and upper limb impairments associated with chronic post-stroke paresis.

The goal of this study was to compare young and elderly healthy individuals and elderly stroke patients in their capacity to use visual CP feedback (VF) in controlling both quiet standing and weight shifting and to assess their sensory re-weighing when this VF is withdrawn. A total of 40 participants were involved in this study. Participants were asked to either quietly stand on a force platform for a period of 45 s with eyes open (EO), using visual feedback (VF) or without visual feedback (No VF) or to perform a dynamic weight shifting task while using VF or No VF. During the quiet standing trials with VF, only the young (YO) were able to decrease the amplitude and increase the frequency of their sway in either plane. Removal of the VF resulted in a 'destabilizing' effect in both healthy elderly (EL) and stroke patients (ST) in the sagittal plane. With regard to the dynamic task, both the YO and EL were generally more successful at weight shifting in terms of speed and control when compared to the ST. Yet, when VF was removed, only the YO were able to largely maintain speed and precision of control. Hence, providing or removing visual CP feedback during quiet standing or removing VF during visually controlled weight shifting can discriminate healthy young participants from healthy elderly, but does not clearly discriminate healthy elderly from stroke patients in the same age group. Results revealed that sagittal plane imbalance in healthy elderly and stroke patients may be largely due to the effects of aging, whereas frontal plane imbalance is much more specific for the postural problems associated with stroke.

Item does not contain fulltext PURPOSE: The aims of this review were (1) to provide insight into the natural course of upper-extremity (UE) impairments and UE activity limitations associated with facioscapulohumeral dystrophy (FSHD) and limb-girdle muscular dystrophies (LGMD), and (2) to provide an overview of outcome measures used to evaluate UE function and activity in patients with FSHD and LGMD. METHODS: Scientific literature databases (PubMed, MEDLINE, EMBASE, CINAHL and Cochrane) were searched for relevant publications. INCLUSION CRITERIA: (1) studies that included persons with a diagnosis of FSHD or LGMD; and (2) studies that reported the natural course of the UE functions and/or activity with outcome measures at these levels. RESULTS: 247 publications were screened, of which 16 fulfilled the selection criteria. Most studies used manual muscle testing (MMT) to evaluate UE function and the Brooke Scale to evaluate UE mobility activities. The clinical picture of UE impairments and limitations of UE activities in FSHD and LGMD patients was highly variable. In general, FSHD and LGMD patients experience difficulty elevating their upper extremities and the execution of tasks takes considerably longer time. CONCLUSIONS: The clinical course of UE impairments and activity limitations associated with FSHD and LGMD is difficult to predict due to its high variability. Although measures like MMT and the Brooke Scale are often used, there is a lack of more specific outcome measures to assess UE function and UE capacity and performance in daily life. Measures such as 3D motion analysis and electromyography (EMG) recordings are recommended to provide additional insight in UE function. Questionnaires like the Abilhand are recommended to assess UE capacity and accelerometry to assess UE performance in daily life. IMPLICATIONS FOR REHABILITATION: There is a need for specific outcome measures on the level of UE activity. Both the level of capacity and performance should be assessed. Possible outcome measures include 3D motion analysis to assess UE function, questionnaires like the Abilhand to assess UE capacity and accelerometry to assess performance of UE activities in daily life.

Item does not contain fulltext PURPOSE: To investigate whether an implantable functional electrical stimulation (FES) system of the common peroneal nerve (ActiGait(R)) improves relevant aspects of gait in chronic stroke patients with a drop foot typically using an ankle-foot orthosis (AFO). METHODS: Ten community-dwelling patients participated, of whom eight patients could be analysed. Gait quality (kinematic, kinetic, and spatiotemporal characteristics) during a 10-meter comfortable walk test, normalised net energy expenditure during a 6-minute walk test, participation (physical activity and stroke impact) and user satisfaction were tested before implantation and at various moments after FES-system activation up to 26 weeks. RESULTS: Walking with FES yielded increased maximum paretic ankle plantarflexion (FES: -0.12; AFO: -4.79 degrees , p < 0.01), higher paretic peak ankle power (FES: 1.46; AFO: 0.98 W/kg, p < 0.05) and better step length symmetry (FES: 14.90; AFO: 21.45% , p < 0.05). User satisfaction was higher for FES, but was unrelated to objective gait improvements. Energy expenditure and participation did not change. CONCLUSION: Implantable FES improved the use of residual ankle plantarflexion motion, ankle power of the paretic leg and step length symmetry compared to using an AFO, however, not resulting in decreased energy expenditure or improved participation. User satisfaction was highest with FES, but this was not related to the observed gait improvements.

Contains fulltext : 155131.pdf (Publisher’s version ) (Open Access) BACKGROUND: Chronic fatigue is present in more than 60% of the patients with a neuromuscular disease and can be their most disabling symptom. In combination with other impairments, fatigue often results in low levels of physical activity and decreased social participation, leading to high societal costs. 'Energetic' is a self-management group program aimed at improving social participation, physical endurance and alleviating fatigue in these patients. The primary aim of this study is to evaluate the effectiveness and cost-effectiveness of the Energetic program. METHODS/DESIGN: A multicentered, assessor-blinded, two-armed randomized controlled trial is conducted with evaluations at inclusion and four, seven and fifteen months later. The study includes patients with a neuromuscular disease and chronic fatigue and, when present, their caregivers. The participants are randomized (ratio 1:1) to either an intervention group, receiving the Energetic program, or a control group, receiving usual care (i.e., no specific intervention). The Energetic program covers four months and includes four modules: 1) individually tailored aerobic exercise training; 2) education about aerobic exercise; 3) self-management training in applying energy conservation strategies; and 4) implementation and relapse prevention in daily life. Two months after cessation of the program a booster session is provided. The primary outcome is the perceived performance score of the Canadian Occupational Performance Measure (COPM). Secondary outcomes include the COPM-satisfaction score, and measures of fatigue, physical endurance, activity engagement, mood, and self-efficacy. Caregiver burden is also evaluated as a secondary outcome. Health-related quality of life and medical and societal costs are assessed to estimate cost-effectiveness of the program. DISCUSSION: The Energetic study is the first randomized controlled trial to evaluate the effectiveness and cost-effectiveness of a combined physical and self-management group training program for improving social participation, physical endurance and alleviating fatigue in patients with neuromuscular diseases. It will generate new insights in (cost-)effective rehabilitation strategies for these incurable conditions. TRIAL REGISTRATION: Clinicaltrials.gov NCT02208687 .

Contains fulltext : 155332.pdf (Publisher’s version ) (Open Access) BACKGROUND: In adult patients with developmental hip dysplasia, a surgical procedure (triple innominate osteotomy) of the pelvic bone can be performed to rotate the acetabulum in the frontal plane, establishing better acetabular coverage. Although common clinical hip scores demonstrate significant improvements after surgery, they provide only overall information about function. The purpose of this study was to quantify the long-term outcome of triple innominate osteotomy in more detail using gait analyses and muscle strength measurements. METHODS: We performed gait analyses at self-selected walking speed as well as isometric hip and knee muscle strength tests in twelve women who had undergone a unilateral triple innominate osteotomy (age: 34 +/- 12 y, time post surgery: 80 +/- 18 m). We compared the results to reference values obtained from eight healthy peers (age: 33 +/- 10 y). RESULTS: The patients exhibited slight asymmetries in step length (smaller steps) and stance time (longer stance) as well as lower hip abduction moments in the operated limb in early stance compared to the non-operated limb. However, there were no differences in gait compared to healthy controls, even though the patients showed reduced bilateral hip abduction strength compared to controls. CONCLUSIONS: Our results indicate that the patients' gait pattern had generally recovered very well, despite slight asymmetries in spatiotemporal parameters. Subtle deviations in hip abduction moments were observed during gait, whereas hip abduction strength was substantially reduced. Hence, the patients walked at a higher percentage of their maximal capacity. They may, therefore, be prone to fatigue and adopt compensatory gait strategies more quickly than healthy peers when walking long distances.

Item does not contain fulltext Patients with FSHD suffer from progressive skeletal muscle weakness, which is associated with an elevated fall risk. To obtain insight into fall mechanisms in this patient group, we aimed to assess dynamic stability during level walking and obstacle crossing in patients at different disease stages. Ten patients with at least some lower extremity weakness were included, of whom six were classified as moderately affected and four as mildly affected. Ten healthy controls were also included. Level walking at comfortable speed was assessed, as well as crossing a 10cm high wooden obstacle. We assessed forward and lateral dynamic stability, as well as spatiotemporal and kinematics variables. During level walking, the moderately affected group demonstrated a lower walking speed, which was accompanied by longer step times and smaller step lengths, yet dynamic stability was unaffected. When crossing the obstacle, however, the moderately affected patients demonstrated reduced forward stability margins during the trailing step, which was accompanied by an increased toe clearance and greater trunk and hip flexion. This suggests that during level walking, the patients effectively utilized compensatory strategies for maintaining dynamic stability, but that the moderately affected group lacked the capacity to fully compensate for the greater stability demands imposed by obstacle crossing, rendering them unable to maintain optimal stability levels. The present results highlight the difficulties that FSHD patients experience in performing this common activity of daily living and may help explain their propensity to fall in the forward direction.

Item does not contain fulltext This study explored the feasibility and preliminary effectiveness of a short (one week) intensive intervention combining Constraint Induced Movement Therapy (CIMT) and bimanual training (BiT) to improve upper limb capacity and bimanual performance guided by individual goal setting in children and adolescents with unilateral cerebral palsy aged 8-18 years. Self-management training was added to the intervention to maximize the effect of training and to empower the participants in self-monitoring the effective use of their affected hand. Functional goals (Canadian Occupational Performance Measure), unimanual capacity (Box and Block Test), bimanual performance (ABILHAND-Kids, Children's Hand-use Experience Questionnaire (CHEQ)) and amount of use (Video Observation Aarts and Aarts determine developmental disregard (VOAA-DDD-R)) were measured at baseline, one week and four months post intervention. Twenty children (mean age 9.5 years) participated. Repeated measures ANOVA was used to measure effects over time. Compared to baseline, there were significant improvements on all outcome measures. The largest effect sizes were found for the COPM-performance and COPM-satisfaction (Cohen's d = 2.09 and d = 2.42, respectively). The effect size was large for the ABILHAND-Kids (d = 0.86), moderate for the CHEQ (d = 0.70) and Box and Block Test (d = 0.56), and small for the VOAA-DDD-R (d = 0.33). All effects were retained at the four months post intervention assessment. The results of this study indicate that one-week (36 h) intensive CIMT-BiT combined with self-management training is a feasible and promising intervention for improving the capacity of the upper limb and its use in bimanual activities in older children and adolescents with unilateral CP.