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Background Frail older adults are predisposed to multiple comorbidities and adverse events. Recent interventional studies have shown that frailty can be improved and managed. In this study, effective individualized home-based exercise and nutrition interventions were developed for reducing frailty in older adults. Methods This study was a four-arm, single-blind, randomized controlled trial conducted between October 2015 and June 2017 at Miaoli General Hospital in Taiwan. Overall, 319 pre-frail or frail older adults were randomly assigned into one of the four study groups (control, exercise, nutrition, and exercise plus nutrition [combination]) and followed up during a 3-month intervention period and 3-month self-maintenance period. Improvement in frailty scores was the primary outcome. Secondary outcomes included improvements in physical performance and mental health. The measurements were performed at baseline, 1 month, 3 months, and 6 months. Results At the 6-month measurement, the exercise (difference in frailty score change from baseline: − 0.23; 95% confidence interval [CI]: − 0.41, − 0.05; p = 0.012), nutrition (− 0.28; 95% CI: − 0.46, − 0.11; p = 0.002), and combination (− 0.34; 95% CI: − 0.52, − 0.16; p Conclusions The designated home-based exercise and nutrition interventions can help pre-frail or frail older adults to improve their frailty score and physical performance. Trial registration Retrospectively registered at ClinicalTrials.gov (identifier: NCT03477097); registration date: March 26, 2018.

Background Frail older adults are predisposed to multiple comorbidities and adverse events. Recent interventional studies have shown that frailty can be improved and managed. In this study, effective individualized home-based exercise and nutrition interventions were developed for reducing frailty in older adults. Methods This study was a four-arm, single-blind, randomized controlled trial conducted between October 2015 and June 2017 at Miaoli General Hospital in Taiwan. Overall, 319 pre-frail or frail older adults were randomly assigned into one of the four study groups (control, exercise, nutrition, and exercise plus nutrition [combination]) and followed up during a 3-month intervention period and 3-month self-maintenance period. Improvement in frailty scores was the primary outcome. Secondary outcomes included improvements in physical performance and mental health. The measurements were performed at baseline, 1 month, 3 months, and 6 months. Results At the 6-month measurement, the exercise (difference in frailty score change from baseline: − 0.23; 95% confidence interval [CI]: − 0.41, − 0.05; p = 0.012), nutrition (− 0.28; 95% CI: − 0.46, − 0.11; p = 0.002), and combination (− 0.34; 95% CI: − 0.52, − 0.16; p

Objectives. To investigate the effects of practice variability combined with task-oriented electromyographic biofeedback (EMGBFB) on strength and balance in people with chronic stroke. Methods. Thirty-three participants were randomly assigned into the constant force EMGBFB tibialis anterior (TA) exercise (constant) group, the variable force EMGBFB tibialis anterior exercise (variable) group, or the upper extremity exercise without EMGBFB (control) group. Subjects in each group received 6 weekly sessions of exercise training (18 sessions, 40 minutes each). Motor outcomes were TA strength, balance (anteroposterior sway amplitude defined by limits of stability test in dynamic posturography), walking speed, Timed Up and Go test (TUGT), and six-minute walk test (6MWT). Data were measured at baseline, 1 day, 2 weeks, and 6 weeks posttraining. Results. TA strength increased significantly in both the constant and variable groups after training. Balance significantly improved only in the variable group. All participants showed improvements in walking speed, TUGT, and 6MWT. Conclusions. Task-oriented EMGBFB-assisted TA exercise training improved muscle strength in people with chronic stroke. Practicing to reach varying force levels during EMGBFB-assisted tibialis anterior exercises facilitated improvements in the ability to sway in the anteroposterior direction while standing. Our findings highlight the importance of task-oriented and motor learning principles while using the EMGBFB as an adjunct therapy in stroke rehabilitation. This trial was registered with trial registration number NCT01962662.

A longitudinal study was conducted to investigate the effects of injury type and discharge placement on mortality, falls, hospital admissions, and changes in activities of daily living (ADLs) over a 12-month period among older fallers. Of 762 community-dwelling people aged 65 years or older who visited an emergency department (ED) of a general hospital in Taiwan due to a fall, 273 sustained a hip fracture, 157 had a vertebral fracture, 47 had a distal forearm fracture, 102 had a traumatic brain injury, and 183 had soft-tissue injuries. Results showed that, compared to patients with a soft-tissue injury, those with TBI had significantly higher risks of dying (rate ratio (RR) = 3.59) and hospital admissions (RR = 3.23) and better improvement in ADLs (1.93 points) at 6 months post-injury, and those who sustained a hip fracture (4.26 and 4.41 points), a vertebral fracture (3.81 and 3.83 points), or a distal-forearm fracture (2.80 and 2.80 points) had significantly better improvement in ADLs at 6 and 12 months post-injury. Patients discharged to a nursing home had a significantly increased risk of death (RR = 2.08) and hospital admission (RR = 2.05) than those returning to their usual residence during the first year post-injury. No significant differences in the occurrence of falls during the first post-injury year were found among patients with different injury types or between those with different discharge placements. In conclusion, among the five major fall injury types in older people, TBIs result in the highest risk of death and hospital admissions, while hip and vertebral fractures exhibited the largest improvement during the first year after injury. Additionally, nursing home care may be associated with increased risks of death and hospital admissions than home care. In addition to primary prevention of falls, further research to investigate mechanisms leading to TBIs during a fall is needed to facilitate effective secondary fall-prevention programs for older people.

Objective: To investigate the predictors related to upper extremity functional recovery, with special emphasis on neuromuscular electrical stimulation dose-response in patients after stroke. Subjects: Ninety-five patients with stroke who received a 4-week neuromuscular electrical stimulation intervention. Design: Prospective predictive analysis. Methods: The change score of the Action Research Arm Test (ARAT) was used as the main outcome. Baseline subject characteristics, stroke-related data, and intervention-related data were collected. Multiple linear regression analysis was applied to identify the potential predictors related to main outcome. Results: The regression model revealed that the initial FuglMeyer upper limb score was the most important predictor for ARAT change score post-test, followed by time since stroke onset and location of stroke lesion. At 2-month follow-up, the neuromuscular electrical stimulation dosage became a significant determinant in addition to the above predictors. Conclusion: Initial motor severity and lesion location were the main predictors for upper limb functional improvement in stroke patients. Neuromuscular electrical stimulation dosage became a significant determinant for upper limb functional recovery after stroke at 2-month follow-up. More intensive neuromuscular electrical stimulation therapy during early rehabilitation is associated with better upper limb motor function recovery after stroke.

Background There is a lack of studies related to virtual reality (VR)-augmented balance training on postural control in people with Parkinson disease (PD). Objective The purposes of this study were: (1) to examine the effects of VR-augmented balance training on the sensory integration of postural control under varying attentional demands and (2) to compare the results with those of a conventional balance training (CB) group and an untrained control group. Design A longitudinal, randomized controlled trial was used. Setting The intervention was conducted in the clinic, and the assessment was performed in a research laboratory. Patients Forty-two people with PD (Hoehn and Yahr stages II-III) were recruited. Intervention The VR and CB groups received a 6-week balance training program. Measurements The sensory organization tests (SOTs) of computerized posturography with single- and dual-task conditions were conducted prior to training, after training, and at follow-up. Equilibrium scores, sensory ratios, and verbal reaction times (VRTs) were recorded. Results There were no significant differences in equilibrium scores or VRTs between the VR and CB groups. However, the equilibrium scores in SOT-6 (ie, unreliable vision and somatosensation) of the VR group increased significantly more than that of the control group after training. The equilibrium scores in SOT-5 (ie, unreliable somatosensation with eyes closed) of the CB group also increased significantly more than that of the control group after training. Limitations The functional significance of the improvements in equilibrium scores in the SOTs was not known, and the sample size was small. Conclusions Both VR and CB training improved sensory integration for postural control in people with PD, especially when they were deprived of sensory redundancy. However, the attentional demand for postural control was not changed after either VR or CB training.

This study aimed to, first, investigate the kinematic postural effects of an individualized wheelchair intervention for residents in a long-term care facility and, second, explore factors related to wheelchair postural improvement. Twenty-seven residents participated in this study, with 14 subjects randomly assigned to the intervention group. The tools used to measure static and dynamic posture while seated in a wheelchair were a goniometer and a palpation meter. The individualized wheelchair intervention was performed by a therapist specializing in assistive technology. The results failed to demonstrate a significant effect after individual wheelchair interventions; however, further examination revealed that wheelchair intervention significantly correlated with an improvement in anterior and posterior head tilt while seated in the wheelchair. Other factors such as age, gender, presence of neurological disease, and the transfer score on the Barthel Index were found to be related to wheelchair pos...

Earlier and more intense rehabilitation benefit stroke patients. Yet, studies have caution intensive therapy during acute brain injury. This study examined the rehabilitation commencement time and intensity as predictors of functional outcomes in acute stroke patients admitted to the stroke intensive care unit (ICU).Sociodemographic, medical, rehabilitative and functional data were collected on 154 acute stroke patients. Regression analyses were used to identify predictors for the basic activities of daily living (Barthel Index, BI) and the walking ability at discharge.Rehabilitation commencement time and intensity significantly predicted the BI score at discharge after adjusting for initial severity (National Institute of Health Stroke Scale, NIHSS) and age (p0.05). For the walking function at discharge, only the rehabilitation intensity was a significant predictor after adjusting for initial severity and age (p0.05). Furthermore, with increasing rehabilitation intensity, patients with severe stroke benefited more than those with moderate stroke.Rehabilitation commencement time and intensity, after adjusting for admission functional status and severity of stroke, remained to be important predictors of stroke functional outcomes. This study supported the recommendation to commence rehabilitation early and intensively and provided evidence that this claim can be extended to acute stroke patients admitted to an ICU.

Chien C-W, Hu M-H, Tang P-F, Sheu C-F, Hsieh C-L. A comparison of psychometric properties of the Smart Balance Master system and the Postural Assessment Scale for Stroke in people who have had mild stroke. Objective To compare the psychometric properties (including the test-retest reliability, responsiveness, and predictive validity) of the Smart Balance Master (SBM) system and the Postural Assessment Scale for Stroke patients (PASS) in patients with mild stroke. Design One repeated-measures design (at a 2-wk interval) was used to examine the test-retest reliability of the SBM and PASS, and another similar design was applied to investigate their responsiveness. Patients who participated in the responsiveness study were followed up approximately 1 year later, and the predictive validity of the SBM system and PASS were examined by assessing the patients' comprehensive activities of daily living (ADL) function. Setting Three rehabilitation units in Taiwan. Participants Twenty patients with chronic stroke in the reliability study; 40 and 32 patients who had recently had a stroke in the responsiveness and predictive validity studies, respectively. Interventions Not applicable. Main Outcome Measures Three computerized tests of the SBM (the equilibrium score of the Sensory Organization Test, scores in rhythmic weight-shifting tests, and scores in the limits of stability test) and the PASS were used. The combination of the Barthel Index and Frenchay Activities Index was used to represent the comprehensive ADL function. Results For the SBM, all but the weight-shifting tests of the SBM had moderate to high reliability (intraclass correlation coefficient [ICC] range, .78−.91). The responsiveness of the equilibrium score and the limits of stability test were moderate (effect size [ d ], .63) and small ( d range, .27−.33), respectively, whereas the responsiveness of the weight-shifting tests was limited ( d range, .04−.29). All but the weight-shifting tests of the SBM in the second evaluation had acceptable predictive validity for comprehensive ADL function ( r 2 range, .15−.17). The PASS showed high reliability (ICC=.84) and small responsiveness ( d =.41), and the PASS in the second evaluation had acceptable predictive validity ( r 2 =.24). Conclusions The PASS and the equilibrium score and limits of stability scores of the SBM had acceptable test-retest reliability, responsiveness, and predictive validity in patients with mild stroke, but the psychometric properties of the weight-shifting tests of the SBM should be further examined before consideration of their usage in patients with stroke.

OBJECTIVES: To compare the practicality, reliability, validity, and responsiveness of the timed up and go (TUG), one-leg stand (OLS), functional reach (FR), and Tinetti balance (TB) performance measures in people aged 65 and older. DESIGN: A prospective study. SETTING: Shin-Sher Township of Taichung County, westcentral Taiwan. PARTICIPANTS: Twelve hundred community-dwelling older people. MEASUREMENTS: During an initial assessment at their residences, participants were interviewed for demographics, cognition, fall history, use of a walking aid, and activities of daily living (ADLs), in addition to completing the four balance tests. Falls were ascertained by telephone every 3 months for a 1-year follow-up; the four balance measures and ADLs were also reassessed at the end of the follow-up year. RESULTS: Of the four balance measures, the OLS had the lowest participation rate, and participation of people who were cognitively impaired had fallen in the previous year, used a walking aid, or suffered from an ADL disability was lower than for their counterparts. The time to complete the tests ranged from 58 seconds for OLS, to 160 seconds for the TB. All four balance measures exhibited excellent testretest reliability and discriminant validity but poor responsiveness to fall status. The TB showed better discriminant, convergent, and predictive validities and responsiveness to ADL changes than the other three tests. CONCLUSION: According to psychometric properties, the most suitable performance measure for evaluating balance in community-dwelling older people was the TB, followed by the TUG. J Am Geriatr Soc 52:1343–1348, 2004.

To compare the score of functional independence measure (FIM) between urban and rural residents living in long-term care facilities (LTCF) in Taiwan.A total of 437 subjects in 112 licensed LTCF in Taiwan were randomly selected by stratification strategy. Physical therapists interviewed the subjects in nursing homes (NH) and intermediate care facilities (ICF) to obtain the basic data, and the FIM score.(1) There was no significant difference in basic demographic data between urban and rural LTC subjects. (2) Most of the subjects in urban and rural LTCF were males, less than 80 years old, single/widowed, having multiple diseases, using more than one assistive devices, and having social welfare financial support. (3) Motor abilities (eating, grooming, and transfer) and cognition (comprehension, social interaction and problem solving) in rural LTCF subjects were significantly (p0.05) higher than those in urban areas as revealed by the FIM assessment. (4) The median of FIM total score of rural LTCF subjects was 90.5, which was significantly (p0.05) higher than that of urban LTCF subjects (median = 76).Some of the functional performance of subjects in rural long-term care institutions is better than those in urban areas. Our results may provide guidelines for the manpower and equipment supply estimation.

The Sensory Organization Test (SOT) is a well accepted and commonly used method to quantify stance stability under varying sensory conditions. However, the accuracy of each machine may vary thus hindering the comparison of results from different laboratories. The purpose of this study was to investigate the consistency of postural stability measures of the SOT conducted on two machines made in 1991 and 1997. Three postural stability measures (equilibrium score, sway area, sway velocity) were obtained using standardized static weights (20-80 kg), swaying weights (21-81 kg), and human subjects (n=10, mean age=22.2 years) on the two machines. The testing sequence was balanced between machines. The results showed good consistency between machines while using the swaying weights and while human subjects were tested. However, a significant difference between machines was found while using the static weights (p

Objective: Muscle mass loss, muscle strength decline and poor physical performance, slow gait speed and decreased mobility are characteristics of sarcopenia and the frailty syndrome. Frailty is a dynamic state and it may transit with aging. The purpose of this study was to examine the changes and associations among lower extremity muscle mass and muscle strength observed longitudinally for 3 years in robust and pre-frail outpatient older adults. Methods: This was a 3-year longitudinal cohort study of outpatient older adults recruited from geriatric clinics. Frailty status was characterized according to Fried's Frailty Phenotype. Predicted muscle mass (PMM) of lower extremity was measured by bioelectrical impendence analysis (Tanita BC-418 Pro Segmental Body Composition Analyzer). Cybex Norm dynamometer was used to measure knee extensors and flexors isokinetic muscle strength at 0, 60, and 180 degrees/second. Physical performance was assessed by the 5-times sit-to-stand test (5tSTS), timed up and go test (TUGT) and 5-meter walk test (5MmWT). Data were collected annually and then analyzed by analysis of variance (ANOVA) and Pearson correlation. Results: Overall, 95 subjects (49 males, 46 females) completed all three follow-up examinations. The mean age was 77.48 (±5.79) years. There were 26.3% of subjects in the robust and 73.7% in the pre-frail status. The PMM was significantly decreased in robust older adults (p=0.04), the isokinetic muscle strength of knee extensors at 180 degrees/second decreased significantly both in robust (p=0.005) and pre-frail (p=0.002) group. Regarding physical performance, TUGT was significantly worse in follow up from baseline in both groups (robust p=.05; pre-frail p＜0.001). The change of TUGT from baseline to follow up correlated significantly with the change of isokinetic muscle strength of knee extensors at 0 degrees/second (r=.23, p=0.024). Conclusion: Knee extensor muscle strength was critical for detecting the ageing related changes of muscle strength in robust and pre-frail outpatient older adults. Furthermore, it was significantly related to the ability to stand up, walk, and turn.

The aim of this study was to determine the effect of using a cane on movement time, joint moment, weight symmetry, and muscle activation patterns during sit-to-stand (STS) transfer in healthy subjects and subjects who have had a stroke.Nine subjects with hemiparesis (mean [SD] age, 61.11 [12.83] yrs) and nine healthy adults (mean [SD] age, 63.11 [10.54] yrs) were included. The subjects with hemiparesis performed STS transfer in two randomly assigned conditions: (1) without a cane and (2) with a cane. The healthy subjects performed only STS transfer without a cane. A three-dimensional motion system, force plates, and eletromyography were used to examine STS transfer. The symmetry index between the two limbs was calculated.The movement time of the subjects with hemiparesis in both conditions without a cane and with a cane was longer than that of the healthy subjects without a cane (P0.025). However, STS transfer with a cane in the subjects with hemiparesis resulted in shorter movement time, greater knee extensor moment of the paretic limb, and more symmetry of weight bearing than in those without a cane (P0.05). The sequence of muscle onset tended to improve with a cane in the subjects with hemiparesis.Cane use may promote more symmetrical STS transfers rather than compensation by the unaffected limb.

The aim of this study was to investigate the effects of a task-oriented ambulation training program in regaining walking, balance, and activity of daily living performance for ambulation-challenged residents with walking potential in long-term care facilities.Fifty ambulation-challenged residents with walking potential were randomly assigned to an individualized task-oriented ambulation training group (30-45 mins, three times a week) or a routine nursing care control group for 4 wks. Each subject was evaluated by a blind evaluator before and after training. Walking function was assessed using walking speed, the Timed Up and Go Test, and the 6-Minute Walk Test. Balance and activities of daily living were measured using the Berg Balance Scale and the Barthel Index, respectively.The training group showed significantly more improvement in walking speed, time to complete the Timed Up and Go Test, and the total score of Berg Balance Scale from baseline to posttest than the control group did. No significant difference between groups was observed on the 6-Minute Walk Test or the Barthel Index.Ambulation-challenged residents with walking potential, as defined by slowing of walking speed with concomitant knee muscle weakness and joint range limitation, showed significant improvement in walking function and balance after a 4-wk task-oriented ambulation training in long-term care facilities.

BACKGROUND The purpose of this study was to analyze the electromyographic and kinematic characteristics of postural responses of 24 healthy older adults both prior to and immediately after a multisensory balance training period. It was hypothesized that the muscle and movement characteristics of postural responses would be optimized in the group after training. METHODS Balance was tested by determining muscle and kinematic response characteristics used in compensating for support surface displacements. Twenty-four subjects were randomly assigned to a training group or a control group. The training group received a multisensory balance training program during a 15-day training period (described in the companion article). RESULTS The results showed that the training (a) significantly shortened the onset latency of the neck flexor muscle (p < .05); (b) showed a trend toward decreasing the response frequency of antagonist muscles; (c) showed a trend toward increasing the response frequency of the trunk flexor muscles; and (d) showed a trend toward decreasing the maximal excursion of the first-trial of the ankle joint rotation. CONCLUSIONS From these results and those of the companion article, it was concluded that the multisensory balance training program had an effect in optimizing the muscle and movement characteristics of postural response in the training group older adults.

Background and Purpose— The purpose of our study was to investigate the effects of different doses of neuromuscular electrical stimulation (NMES) on upper-extremity function in acute stroke patients with severe motor deficit. Methods— Sixty-six acute stroke patients were randomized to 3 groups: high NMES, low NMES, or control. The low-NMES group received 30 minutes of stimulation per day, and the high-NMES group received 60 minutes per day, for 4 weeks. The Fugl-Meyer Motor Assessment Scale, Action Research Arm Test, and Motor Activity Log were used to assess the patients at baseline, 4 weeks, and 12 weeks post baseline (follow-up). Results— Both NMES groups showed significant improvement on Fugl-Meyer Motor Assessment and Action Research Arm Test scales compared with the control group at week 4 and follow-up. The high-NMES group showed treatment effects similar to those of the low-NMES group. Conclusions— Higher and lower doses of NMES led to similar improvements in motor function. A minimum of 10 hours of NMES in combination with regular rehabilitation may improve recovery of arm function in stroke patients during the acute stage.

Chen C-H, Lin K-H, Lu T-W, Chai H-M, Chen H-L, Tang P-F, Hu M-H: Immediate effect of lateral-wedged insole on stance and ambulation after stroke. Am J Phys Med Rehabil 2009;88:000‐000. Objective: To perform kinematic and kinetic analyses on the static standing and ambulation in subjects after stroke with and without wearing a 5-degree lateral-wedged insole. Design: Ten hemiparetic individuals with unilateral stroke were recruited. Participants performed quiet stance and ambulation with no insole wedge, paretic side wedged, and nonparetic side wedged in a random order. The vertical ground reaction force and temporal-spatial parameters of gait were measured. Symmetry index was also calculated. Results: During quiet stance, the symmetry index of weight bearing improved significantly with nonparetic side-wedged (P 0.017), but not with paretic side-wedged insoles. During ambulation, the symmetry indices of kinematic and kinetic measurements in the frontal plane were not significantly different among the three conditions. However, the contralateral knee abductor moment was significantly (P 0.05) less than that of the nonparetic limb during nonparetic side-wedged ambulation. The ipsilateral hip and knee abductor moments were significantly (P 0.05) less than the nonparetic limb during paretic side-wedged ambulation. Conclusions: Application of nonparetic side wedge insole can improve stance symmetry and tends to reduce the paretic knee abductor load during ambulation. The effects of paretic side-wedged insole are different. The present results provide guidelines for the placement of wedges in the shoes of individuals after stroke.

The purpose of this study is to examine the predictive validity of seven mobility-related performance tests to identify and predict older adults’ mobility disability status after a 2-year period. Among the 287 community-dwelling older adults who participated in the baseline assessment (physical disability status and seven performance tests), those who reported no mobility disability (n = 192) at baseline assessment were followed up at 2 years. A total of 120 participants returned for the follow-up assessment 2 years later, and those without missing data (n = 109) were used in the final analysis. Mobility disability status and seven performance measures (functional reach, timed chair stands, timed up and go, grip strength, usual and fastest gait speed, and six-minute walk) were re-assessed 2 years later. The timed chair stands (TCSs) were the only test that could significantly predict older adults’ mobility disability status 2 years later, adjusted for age and gender. The TCS is recommended for use in community screening to identify community-dwelling older adults who are at risk of future disability and who might benefit from health promotion programs.

*Research Division, Southern California University of Health Sciences, Whittier, California, USA Musculoskeletal Pain and Injury Research Unit, Department of Physiotherapy, University of Queensland, St. Lucia, Australia zSchool and Graduate Institute of Physical Therapy, National Taiwan University, Taipei, Taiwan, Republic of China Diplomat of American Board of Medical Radiology, Member of Clinical Magnetic Resonance Society

Previous studies have shown that the ability of older adults to balance under conditions of reduced or conflicting sensory inputs is significantly impaired. In order to determine if sensory balance training can improve balance under these conditions two studies were conducted. In the first study healthy older adults (n = 24) were randomly assigned to a training or control group. The training group received 10 one-hour training sessions over two weeks. Training included standing with eyes open, closed, with head normal and extended backward, and on a firm surface vs on foam. Results showed significant reduction in body sway for conditions in which either ankle joint inputs alone were reduced or multiple sensory inputs were reduced (p

Invited Commentary on: ‘Advances in neuromuscular electrical stimulation for the upper limb post stroke’, Hayward et al. Hayward et al.’s review paper summarizes the current applications of neuromuscular electrical stimulation (NMES) and the treatment effects of different types of NMES in the impairment, activity, and participation domains of International Classification of Functioning, Disability and Health model for stroke patients. In addition, they suggested future research directions for NMES research. We would like to remind readers that there is another important question for future research, i.e. the influence of NMES parameters (stimulation time, intensity, treatment duration, and target muscles) on affected upper limb recovery post-stroke. It has been suggested that parameters of electrical stimulation are likely to be crucial factors related to treatment effect. Owing to the heterogeneity of NMES parameters adopted in the articles reviewed in the current study, the readers must be cautious while applying the results from this study to their individual patients. According to motor learning theories, repetition is important for improving movement performance. Hence, it is reasonable to assume that there might be a positive relationship between number of practice trials and motor performance improvement. Previous studies have demonstrated that increasing exercise time led to better functional outcomes. Can we apply this principle for NMES treatment? Will higher doses of NMES lead to better arm function recovery than lower doses of NMES? What is the optimal treatment dose for selected NMES to improve impairment or function of the upper limb after stroke? The answers to these questions remain ambiguous because the stimulation doses of NMES ranged widely from as little as a total of 6 hours to more than 200 hours among studies. The minimal effective dose for improving upper limb function from our own study was 10 hours. Our study revealed that dosage of NMES was a significant predictor for upper limb function improvement and increasing the stimulation dose of NMES led to greater improvement in the action research arm test score at follow-up. Another important issue in NMES application is the influence of selection of target muscles. de Kroon et al.’s study showed that there was no significant difference between alternating stimulation of the hand extensor and flexor muscles or stimulation hand extensors only. Our study found that patients who received stimulation of both hand flexor and extensor muscles showed greater improvement as compared with those receiving stimulation of extensor muscles. Furthermore, de Kroon et al.’s review paper reported an increased likelihood of a positive outcome if elbow and shoulder muscles were stimulated in addition to wrist and/or finger extensors. The relationship between stimulated target muscles and arm function remains unclear based on current available evidences. Hayward et al. suggested that more studies are needed to investigate effects of NMES on patients with severe paresis or paralysis in acute stage. This could provide more information for clinicians regarding which stroke patients will benefit from NMES intervention or is suitable for which types of NMES. Some studies supported the treatment effect of NMES in the acute phase; however, few studies have applied NMES in patients with severe paresis. Our own experience indicated that cyclic NMES can be applied to patients in the acute flaccid stage or to patients with severe arm weakness with satisfactory results on both the impairment and the function levels. NMES is a useful adjunct therapy for stroke rehabilitation during both acute and chronic stages. The current review paper provided an overview of current and emerging NMES applications. It offers a good overview for clinicians to select appropriate NMES techniques for improving either the impairment or function of upper limb after stroke. For future studies, we hope that more information on the influence of NMES parameters on affected upper limb recovery can be provided.

This article briefly reviewed the participation of Taiwan Long Term Care Professional Association in promoting interprofessional care for older adults and disabled people in the field of long term care. The world-wide influence of collaborative practice demonstrated a great impact on the development of Taiwan long term care system and the education of professions involved in long term care. The launching of the 10-year flagship plan for long-term care as well as the mandate of continuing education for long term care professionals accelerated the implementation of collaborative practice. Examples of collaborative practice can be found in practices at home, in the community and in institutions for people needing long term care.