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BACKGROUND: The foot sole represents a sensory dynamometric map and is essential for balance and gait control. Sensory impairments are common, yet often difficult to quantify in neurological conditions, particularly stroke. A functionally oriented and quantifiable assessment, the Foot Roughness Discrimination Test (FoRDT™), was developed to address these shortcomings. OBJECTIVE: To evaluate inter- and intra-rater reliability, convergent and discriminant validity of the Foot Roughness Discrimination Test (FoRDT™). DESIGN: Test-retest design. SETTING: Hospital Outpatient. PARTICIPANTS: Thirty-two people with stroke (mean age 70) at least 3 months after stroke, and 32 healthy, age-matched controls (mean age 70). MAIN OUTCOME MEASURES: Roughness discrimination thresholds were quantified utilising acrylic foot plates, laser-cut to produce graded spatial gratings. Stroke participants were tested on three occasions, and by two different raters. Inter- and intra-rater reliability and agreement were evaluated with Intraclass Correlation Coefficients and Bland-Altman plots. Convergent validity was evaluated through Spearman rank correlation coefficients (rho) between the FoRDT™ and the Erasmus modified Nottingham Sensory Assessment (EmNSA). RESULTS: Intra- and inter rater reliability and agreement were excellent (ICC =.86 (95% CI .72-.92) and .90 (95% CI .76 -.96)). Discriminant validity was demonstrated through significant differences in FoRDT™ between stroke and control participants (p< .001). Stroke fallers had statistically significant higher FoRDT™ scores compared to non-fallers (p=.01). Convergent validity was demonstrated through significant and strong correlations (rho) with the Erasmus MC Nottingham Sensory Assessment (r=.69, p.05). CONCLUSIONS: This simple and functionally oriented test of plantar sensation is reliable, valid and clinically feasible for use in an ambulatory, chronic stroke and elderly population. It offers clinicians and researchers a sensitive and robust sensory measure and may further support the evaluation of rehabilitation targeting foot sensation. This article is protected by copyright. All rights reserved.

PURPOSE: To establish a simple clinical method of predicting addition power achieved with a multifocal intraocular lens (IOL). METHODS: In this prospective cohort study, 41 patients were bilaterally implanted with the Bi-Flex MY multifocal IOL (Medicontur) with +3.50 diopters (D) near addition power. Monocular defocus curves were plotted for each patient and effective addition power was calculated as the dioptric difference between the distance and near inflection points of the defocus curve. Six biometry formulas (Haigis, Holladay, SRK/T, Hill RBF, Barrett Universal II, and Holladay 2) were used to predict the addition power at the spectacle plane. RESULTS: Mean effective addition power was 2.60 ± 0.29 D, with significant ( P < .01) differences between the prediction methods. Significant differences were found between predicted and effective addition when the Holladay, SRK/T, Hill RBF, and Holladay 2 formulas were used. A moderate but significant correlation ( r = 0.342, P = .033) was found with the Barrett formula, and this was also the method to show the least proportional bias with Bland-Altman analysis. CONCLUSIONS: The study demonstrates that the effective addition power can be predicted using the proposed simple clinical method derived using the Barrett Universal II formula. The proposed technique may have significant clinical value in screening for patients where ocular biometry may lead to aberrant addition power. [ J Refract Surg . 2021;37(5):318–323.]

BACKGROUND Telerehabilitation is a feasible and potentially effective alternative to face-to-face rehabilitation. However, specific guidance, training, and support for practitioners who undertake remote assessments in people with physical disabilities and movement impairment are limited. OBJECTIVE The aims of this survey of United Kingdom–based health and social care practitioners were to explore experiences, assess training needs, and collate ideas on best practices in telerehabilitation for physical disabilities and movement impairment. The aim will be to use the findings to inform a practical tool kit and training package for telerehabilitation use. METHODS UK rehabilitation practitioners were invited to complete an online questionnaire from November to December 2020. Opportunity and snowball sampling were used to recruit participants from professional and educational networks, special interest groups, and via social media. Closed questionnaire items were analyzed using descriptive statistics. Qualitative inductive analysis using NVivo was used for open responses. RESULTS There were 247 respondents, of which 177 (72%) were physiotherapists and occupational therapists. Most (n=207, 84%) had used video-based consultations (typically supported by telephone and email), and the use of this method had increased in frequency since the COVID-19 pandemic. Practitioners perceived telerehabilitation positively overall and recognized benefits for patients including a reduced infection risk, convenience and flexibility, and reduced travel and fatigue. Common obstacles were technology related (eg, internet connection), practical (eg, difficulty positioning the camera), patient related (eg, health status), practitioner related (eg, lack of technical skills), and organizational (eg, lack of access to technology). Support from family members or carers was a major facilitator for successful remote consultations. Of the 207 respondents who had used video-based consultations, 103 (50%) had assessed physical impairments using this method, 107 (52%) had assessed physical function, and 121 (59%) had used patient-reported outcome measures. Although practitioners generally felt confident in delivering video-based consultations, they felt less proficient in undertaking remote physical assessments, expressing concerns about validity, reliability, and safety. Only 46 of the 247 (19%) respondents had received any training in telerehabilitation or video consultations, and some felt they were “feeling their way in the dark.” Practitioners desired training and guidance on physical assessment tools suitable for remote use, when to use video-based consultations or alternative methods, governance issues, digital platforms, and signposting to digital skills training for themselves and their patients. CONCLUSIONS In response to the COVID-19 pandemic, practitioners rapidly adopted telerehabilitation for people with physical disabilities and movement impairment. However, there are technical, practical, and organizational obstacles to overcome, and a clear need for improved guidance and training in remote physical assessments. The findings of this survey will inform the development of a tool kit of resources and a training package for the current and future workforce in telerehabilitation.

Background Symptoms arising from vestibular system dysfunction are observed in 49–59% of people with Multiple Sclerosis (MS). Symptoms may include vertigo, dizziness and/or imbalance. These impact on functional ability, contribute to falls and significant health and social care costs. In people with MS, vestibular dysfunction can be due to peripheral pathology that may include Benign Paroxysmal Positional Vertigo (BPPV), as well as central or combined pathology. Vestibular symptoms may be treated with vestibular rehabilitation (VR), and with repositioning manoeuvres in the case of BPPV. However, there is a paucity of evidence about the rate and degree of symptom recovery with VR for people with MS and vestibulopathy. In addition, given the multiplicity of symptoms and underpinning vestibular pathologies often seen in people with MS, a customised VR approach may be more clinically appropriate and cost effective than generic booklet-based approaches. Likewise, BPPV should be identified and treated appropriately. Methods/ design People with MS and symptoms of vertigo, dizziness and/or imbalance will be screened for central and/or peripheral vestibulopathy and/or BPPV. Following consent, people with BPPV will be treated with re-positioning manoeuvres over 1–3 sessions and followed up at 6 and 12 months to assess for any re-occurrence of BPPV. People with central and/or peripheral vestibulopathy will be entered into a randomised controlled trial (RCT). Trial participants will be randomly allocated (1:1) to either a 12-week generic booklet-based home programme with telephone support or a 12-week VR programme consisting of customised treatment including 12 face-to-face sessions and a home exercise programme. Customised or booklet-based interventions will start 2 weeks after randomisation and all trial participants will be followed up 14 and 26 weeks from randomisation. The primary clinical outcome is the Dizziness Handicap Inventory at 26 weeks and the primary economic endpoint is quality-adjusted life-years. A range of secondary outcomes associated with vestibular function will be used. Discussion If customised VR is demonstrated to be clinically and cost-effective compared to generic booklet-based VR this will inform practice guidelines and the development of training packages for therapists in the diagnosis and treatment of vestibulopathy in people with MS. Trial registration ISRCTN Number: 27374299 Date of Registration 24/09/2018 Protocol Version 15 25/09/2019

Background Traumatic brain injury (TBI) is the leading cause of long-term disability in working age adults. Recent studies show that most acute TBI patients demonstrate vestibular features of dizziness and imbalance, often from combined peripheral and central vestibular dysfunction. Effective treatment for vestibular impairments post-TBI is important given its significant adverse impact upon quality of life and employment prospects. The most frequent peripheral vestibular disorder in acute TBI is benign paroxysmal positional vertigo (BPPV), affecting approximately half of acute cases. Although there is effective treatment for idiopathic BPPV, there are no high-quality clinical data for post-TBI BPPV regarding its prevalence, natural history, which treatment is most effective and when is the best time to treat. In particular, observational studies suggest post-TBI BPPV may be recurrent, indicating that hyperacute treatment of BPPV may be futile. Given the potential hurdles and the lack of accurate post-TBI BPPV data, the current study was designed to provide information regarding the feasibility and optimal design of future large-scale prospective treatment studies that would compare different interventions and their timing for post-TBI BPPV. Method A multi-centre randomised mixed methods feasibility study design was employed. We aim to recruit approximately 75 acute TBI patients across a range of clinical severities, from three major trauma centres in London. Patients will be randomised to one of three treatment arms: (1) therapist-led manoeuvres, (2) patient-led exercises and (3) advice. Participants will be re-assessed by blinded outcome assessors at 4 and 12 weeks. Acceptability of the intervention will be obtained by patient interviews at the end of their treatment and therapist interviews at the end of the study. Primary outcomes relate to feasibility parameters including recruitment and retention rates, adverse events and intervention fidelity. We will also aim to provide a more accurate estimate of the prevalence of BPPV in TBI cases on the trauma ward. Discussion The multi-centre nature of our feasibility study will inform the design of a future prospective treatment trial of BPPV in acute TBI. Important parameters we will obtain from this study, key for designing a future prospective treatment study, include estimating the prevalence of BPPV in TBI patients admitted to UK major trauma wards, and elucidating both patient and care-provider barriers in delivering BPPV treatment. Trial registration ISRCTN, ISRCTN91943864. Registered on 10 February 2020.

To examine monocular and binocular visual function and patient-reported outcomes after implantation of multifocal IOLs (mIOLs) or monofocal IOLs, using a rigorous series of clinical assessments.BMI Southend Hospital, United Kingdom.Prospective, randomized, double-masked clinical trial.One hundred patients were randomized for bilateral implantation of either a Bi-Flex 677MY mIOL or a Bi-Flex 677AB IOL and were assessed at 3 to 6 months (V1) and 12 to 18 months (V2). Primary outcomes included distance, intermediate, and near logarithm of the minimum angle of resolution (logMAR) visual acuities (VAs) and defocus curve profile assessment. Secondary outcomes included reading speed, contrast sensitivity (CS), and the subjective perception of quality of vision.Forty-seven subjects with monofocal IOL and 43 mIOL subjects completed the study. Uncorrected (mIOL: 0.10 ± 0.09 logMAR; IOL: 0.09 ± 0.11 logMAR) and corrected (mIOL: 0.04 ± 0.06 logMAR; IOL: 0.01 ± 0.07 logMAR) distance VAs were comparable (P.05). Uncorrected near VA (mIOL: 0.23 ± 0.13 logMAR; IOL: 0.55 ± 0.20 logMAR, P.001) and distance-corrected near VA (mIOL: 0.24 ± 0.13 logMAR; IOL: 0.54 ± 0.17 logMAR, P.001) were significantly improved with mIOLs. There was no significant difference in distance-corrected intermediate VA (mIOL: 0.38 ± 0.13 logMAR; IOL: 0.39 ± 0.13 logMAR, P = .431). Defocus curves demonstrated an increased range-of-focus among mIOLs (mIOL: 4.14 ± 1.10 diopter [D]; IOL: 2.57 ± 0.77 D). Pelli-Robson CS was different at V1 (P.001) but similar by V2 (P = .059). Overall satisfaction was high (90%) in both groups for distance tasks whereas significantly different for near tasks (mIOL, 18.45 ± 16.53 logUnits; IOL, 55.59 ± 22.52 logUnits).Uncorrected near visual acuity was demonstrably better with mIOLs and there was greater subjective satisfaction with quality of near vision. Halos reported by the mIOL group were significant compared with the IOL group but did not show an adverse effect on overall satisfaction.

Background Telerehabilitation is a feasible and potentially effective alternative to face-to-face rehabilitation. However, specific guidance, training, and support for practitioners who undertake remote assessments in people with physical disabilities and movement impairment are limited. Objective The aims of this survey of United Kingdom–based health and social care practitioners were to explore experiences, assess training needs, and collate ideas on best practices in telerehabilitation for physical disabilities and movement impairment. The aim will be to use the findings to inform a practical tool kit and training package for telerehabilitation use. Methods UK rehabilitation practitioners were invited to complete an online questionnaire from November to December 2020. Opportunity and snowball sampling were used to recruit participants from professional and educational networks, special interest groups, and via social media. Closed questionnaire items were analyzed using descriptive statistics. Qualitative inductive analysis using NVivo was used for open responses. Results There were 247 respondents, of which 177 (72%) were physiotherapists and occupational therapists. Most (n=207, 84%) had used video-based consultations (typically supported by telephone and email), and the use of this method had increased in frequency since the COVID-19 pandemic. Practitioners perceived telerehabilitation positively overall and recognized benefits for patients including a reduced infection risk, convenience and flexibility, and reduced travel and fatigue. Common obstacles were technology related (eg, internet connection), practical (eg, difficulty positioning the camera), patient related (eg, health status), practitioner related (eg, lack of technical skills), and organizational (eg, lack of access to technology). Support from family members or carers was a major facilitator for successful remote consultations. Of the 207 respondents who had used video-based consultations, 103 (50%) had assessed physical impairments using this method, 107 (52%) had assessed physical function, and 121 (59%) had used patient-reported outcome measures. Although practitioners generally felt confident in delivering video-based consultations, they felt less proficient in undertaking remote physical assessments, expressing concerns about validity, reliability, and safety. Only 46 of the 247 (19%) respondents had received any training in telerehabilitation or video consultations, and some felt they were “feeling their way in the dark.” Practitioners desired training and guidance on physical assessment tools suitable for remote use, when to use video-based consultations or alternative methods, governance issues, digital platforms, and signposting to digital skills training for themselves and their patients. Conclusions In response to the COVID-19 pandemic, practitioners rapidly adopted telerehabilitation for people with physical disabilities and movement impairment. However, there are technical, practical, and organizational obstacles to overcome, and a clear need for improved guidance and training in remote physical assessments. The findings of this survey will inform the development of a tool kit of resources and a training package for the current and future workforce in telerehabilitation.

A feasibility study of The Fluency Trust Residential Course (FTRC) for adolescents who stutter was conducted. The study aimed to measure key areas of a feasibility trial, for example, recruitment and retention, outcome measure completion, outcome measure reliability, and acceptability of the intervention to inform future research into the FTRC.Quantitative and qualitative methods were used. Participants were 23 adolescents (12-17 years), 23 parents and 2 Speech-Language Pathologists (SLPs) from the FTRC. Data collection included: outcome measure collection via a pre-test post-test quasi-experimental design (including two baseline measures), intervention fidelity checklists, semi-structured interviews with adolescents to explore acceptability of the intervention and semi-structured interviews with SLPs to explore their experiences of research participation and views on a future trial.Recruitment, retention and outcome measure completion levels were all 100%. Intervention fidelity was 95% and there were no adverse events. Outcome measures showed good test- re-test reliability: Progress Questionnaire Child Intraclass Correlation Coefficient (ICC) = 0.87 (95% CI = 0.69-0.94 sig 0.001) and Progress Questionnaire Parent ICC = 0.88 (95% CI = 0.70-0.95 sig 0.001). Descriptive statistics showed that group medians and means of all outcome measures shifted in a positive direction between pre and post-tests (9 weeks follow-up). Twenty-five percent of young people showed changes on the Progress Questionnaire Child that were above the minimal important difference. Seventy-five percent of parents showed changes on the Progress Questionnaire Parent that were above the minimal important difference. Acceptability of the intervention by adolescents was high. SLPs reported participation was manageable and they were pleased to be part of the research.Quantitative and qualitative data suggest that a future definitive trial of the FTRC is indicated after additional development work and feasibility testing. Recommendations for further research are included.

Background: Neurofeedback has been proposed as a treatment for Parkinson’s disease (PD) motor symptoms by changing the neural network activity directly linked with movement. However, the effectiveness of neurofeedback as a treatment for PD motor symptoms is unclear. Aim: To systematically review the literature to identify the effects of neurofeedback in people with idiopathic PD; as defined by measurement of brain activity; motor function; and performance. Design: A systematic review. Included Sources and Articles: PubMed; MEDLINE; Cinhal; PsychoInfo; Prospero; Cochrane; ClinicalTrials.gov; EMBASE; Web of Science; PEDro; OpenGrey; Conference Paper Index; Google Scholar; and eThos; searched using the Population-Intervention-Comparison-Outcome (PICO) framework. Primary studies with the following designs were included: randomized controlled trials (RCTs), non-RCTs; quasi-experimental; pre/post studies; and case studies. Results: This review included 11 studies out of 6197 studies that were identified from the literature search. Neuroimaging methods used were fMRI; scalp EEG; surface brain EEG; and deep brain EEG; where 10–15 Hz and the supplementary motor area were the most commonly targeted signatures for EEG and fMRI, respectively. Success rates for changing one’s brain activity ranged from 47% to 100%; however, both sample sizes and success criteria differed considerably between studies. While six studies included a clinical outcome; a lack of consistent assessments prevented a reliable conclusion on neurofeedback’s effectiveness. Narratively, fMRI neurofeedback has the greatest potential to improve PD motor symptoms. Two main limitations were found in the studies that contributed to the lack of a confident conclusion: (1) insufficient clinical information and perspectives (e.g., no reporting of adverse events), and (2) limitations in numerical data reporting (e.g., lack of explicit statistics) that prevented a meta-analysis. Conclusions: While fMRI neurofeedback was narratively the most effective treatment; the omission of clinical outcome measures in studies using other neurofeedback approaches limits comparison. Therefore, no single neurofeedback type can currently be identified as an optimal treatment for PD motor symptoms. This systematic review highlights the need to improve the inclusion of clinical information and more robust reporting of numerical data in future work. Neurofeedback appears to hold great potential as a treatment for PD motor symptoms. However, this field is still in its infancy and needs high quality RCTs to establish its effectiveness. Review Registration: PROSPERO (ID: CRD42020191097)

People with Charcot Marie Tooth disease (CMT) have impairments of balance and may fall more frequently than those without the condition. This qualitative study aimed to explore the experiences of falling and poor balance through focus group interviews. Participants were recruited through local and national meetings of the CMT United Kingdom support group. Three focus groups took place, including 25 adults with CMT in total. Thematic analysis revealed five main themes: frequent falling; cognitive burden of walking; environmental issues; external support; getting off the floor; perception of others. Participants described the physical issues of poor balance and falling, such as frequency, challenging physical environments and difficulty getting up after a fall. In addition, fear and embarrassment were discussed along with the impact on daily activities and participation. Physical and psychological factors need to be considered when designing falls management interventions for this group.

To determine the differences in the dynamic control ratio of the glenohumeral joint rotators, during internal rotation at 20° and 60° of humeral elevation in the scapular plan. Dynamic control ratio (DCR) is defined as the ratio between eccentric action of the lateral rotators and the concentric action of the medial rotators.A cross-sectional laboratory study.Thirty asymptomatic participants (men n=14, women n=16, mean age=29.4±8.9years, BMI: 24.1±5.4) were tested. Peak torque generated by the concentric action of the MR and the eccentric action of the LR of the shoulder joint and the DCR were evaluated on the dominant arm using an isokinetic dynamometer at 20° and 60° of humeral elevation at a speed of 20°/s.There was a significant decrease in the DCR at 60° humeral elevation when compared to 20° humeral elevation (p0.05). This decrease was due to the significant decrease in eccentric peak torques at 60° humeral elevation when compared to 20° (p0.05). However, there was no significant difference in the concentric peak torques between 20° and 60° (p0.05).The significant decrease in the DCR as a consequence of a decrease in the eccentric peak torque of the LR when the humerus is in a more elevated position suggests that the introduction of humeral elevation can be used as a progression for improving the eccentric action of the shoulder LR and subsequently the dynamic control of the shoulder.

Background: People living with rare neurological conditions (RNCs) often face common physical, cognitive and psychological challenges that lead to reduced physical activity and associated deconditioning. Physical activity interventions are routinely utilised to address disease specific limitations with the intention of promoting participation in people with RNCs. This scoping review aimed to synthesise the body of evidence for such interventions as they are applied across a wide range of RNCs. Methods: We undertook a scoping review of systematic reviews of any type of physical activity and exercise interventions for adults with neuromuscular diseases, motor neurone disease, Huntington’s disease, progressive supranuclear palsy, multiple system atrophy, inherited ataxias and hereditary spastic paraplegia. The reviews were included if they reported at least one outcome that aimed to increase physical activity level at either the body structure/function, activity and/or participation levels. Results: Sixty-two articles were full-text screened of which 27 were included. Most studies involved interventions in people with neuromuscular diseases. No reviews of interventions in hereditary spastic paraparesis were identified. The majority of reviews included studies of structured exercise using outcome measures at the level of body function and functional activity. Interventions were grouped as: i) combined interventions; ii) muscle strength training; iii) respiratory training; iv) aerobic training. Frequency, intensity, time and type of structured exercise utilised varied considerably across studies. Most studies were methodologically limited by small sample sizes, variation in exercise dose and training duration.Conclusions: To date, primary attention has been given to structured exercise interventions, which have demonstrated to have a low to uncertain level of evidence. Novel approaches to implementing common interventions and modalities are needed to increase accessibility and engagement in physical activity irrespective of disease type. Further exploration is warranted to achieve consensus on outcome measures that reflect areas of importance and relevance to people with RNCs.

Objective The objective of this systematic review is to determine the effectiveness of nurse-coordinated, person-centered comprehensive assessment on improving quality of life of community-dwelling, frail older people. Introduction There is a growing need to meet the challenges of the increasingly frail and older population, and to provide proactive, holistic care close to home. A standardized assessment and care planning intervention could be implemented in primary care, which could be delivered by a primary or community healthcare nurse to address these challenges. However, it is not yet clear if an assessment and care planning intervention will improve outcomes for patients, such as quality of life. Inclusion criteria This review will consider studies that evaluate nurse-coordinated, person-centered, comprehensive assessment delivered in partnership with community-dwelling, frail older people, and will compare the intervention to usual care. Studies that include people aged 60 years and older living at home or in supported living accommodation with a recognized level of frailty as assessed by use of frailty screening or assessment tools, will be considered. Studies that include outcomes of health-related quality of life, social functioning, and well-being will also be considered. Methods An initial limited search of PubMed and CINAHL has been undertaken to identify articles on the topic. The following sources will be searched for eligible papers: PubMED, CINAHL, Embase, PsycINFO, BNI, AMED, and OpenGrey. Retrieval of full-text studies, assessment of methodological quality, and data extraction will be performed independently by two reviewers. Meta-analysis will be performed, if possible, and a Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Summary of Findings presented. Systematic review registration number PROSPERO CRD42019137886.

During an initial phase of this research, an e-Delphi survey was conducted to gain consensus among stakeholders on the components of a nurse-led assessment and care planning intervention for older people who live with frailty in primary care. This feasibility randomized controlled trial (fRCT) will test the proposed intervention and its implementation and determine methods for the design of a conclusive randomized controlled trial.The fRCT, with embedded qualitative study, aims to recruit 60 participants. Moderately and severely frail older people will be identified using the electronic frailty index (eFI) and the intervention will be delivered by senior community nurses. The control participants will receive usual primary care for frailty. The study is funded by the National Institute of Health Research (NIHR; funding granted in May 2016, ref: ICA-CDRF-2016-02-018) and received NHS and University Research Ethics Committee approval in 2018.There is evidence that the delivery of complex interventions for community-dwelling older people can reduce care home and hospital admissions and falls, there is less evidence for the benefit of any specific type or intensity of intervention or the additional benefits of targeting the frail population. This trial will determine feasibility of the intervention, define recruitment and retention parameters and trial logistics, and decide outcome measures.This study aims to address the limitations of current research by using a systematic method of frailty diagnosis and participant identification, trialling implementation of a person-centred intervention, and testing of feasibility parameters.ISRCTN: 74345449.目的: 在这项研究的初始阶段,开展线上德尔菲法调查,以便在利益相关者之间就护士主导的评估和护理计划干预措施的组成部分达成共识,这些干预措施针对衰弱老人的初级护理。这项可行性随机对照试验(fRCT)将检验所提出的干预措施及其实施情况,并确定结论性随机对照试验的设计方法。 方法: 可行性随机对照试验采用定性研究的方法,预计招募60名参与者。使用电子衰老指数(eFI)识别中度衰老和重度衰老老年人,并由社区高级护士进行干预。对照组受试者将接受普通衰老的初级护理。该研究由美国国立卫生研究院资助(NIHR;2016年5月批准的资金,编号:ICA-CDRF-2016-02-018),并于2018年获得NHS和伦理委员会的批准。 讨论有证据表明,为社区老年人提供多种干预措施可以减少疗养院和医院的入院率和跌倒率,没有多少证据表明任何特定类型或具有强度的干预措施有益处,或有衰老人口的额外益处。该试验将确定干预的可行性,决定招募人数、保留参数和试验后勤,并明确结果评估标准。: 影响: 本研究旨在通过使用系统的衰弱性诊断、参与者识别方法,以人为本的干预试行措施和可行性参数测试来解决当前研究的局限性。 试验注册号: ISRCTN:74345449。.

Purpose: To evaluate the psychometric properties of two novel tests of lower limb position sense. \ud \ud Methods: Our newly developed tests assess discrimination thresholds of under-foot slope and step height perception using a two alternative forced choice approach. Stroke participants (n=32) and age matched controls (n=32) were tested. Inter- and intra-rater reliability and agreement, sensitivity and specificity, discriminant and convergent validity were evaluated.\ud \ud Results: Intra-rater reliability for both variants of the gradient discrimination test was excellent: intraclass correlation coefficients (ICC) =0.91 and 0.89. The step height discrimination test had excellent intra-rater reliability and agreement: ICC=0.95. Inter-rater reliability was also excellent in both tests (ICC= 0.85-0.93). Discriminant validity was demonstrated with significant differences in test performance between stroke and control participants (p

Background/Aims: Fitness and function can improve with exercise in people with Parkinson's disease. Animal models suggest that exercise may also have a neuroprotective effect, with higher intensity exercise being more beneficial than lower intensity exercise. However, in people with Parkinson's disease the factors limiting exercise capacity are not fully understood and it is unclear whether training at very high intensities would be safe, feasible and acceptable. Methods: Eighteen people with Parkinson's disease were recruited to explore respiratory and neuromuscular factors that may limit exercise capacity. In a purposive subgroup of 6 participants able to achieve >75% of their predicted maximum heart rate the feasibility of undertaking six high intensity interval training sessions over 3 weeks was tested. Their experience was further explored in a focus group. Results: Lower exercise capacity was associated with lower limb flexor muscle strength (r2=0.51) but not with disease severity or respiratory function. There were no adverse events or drop-outs in those taking part in the exercise regimen. Improvements were seen in fitness, health related quality of life, activity levels, walking speed, muscle strength and cycle endurance. Participants reported that they enjoyed high intensity, supervised exercise. High intensity interval training may be feasible and safe. Conclusions: We concluded that high intensity interval training has the potential to be a safe and acceptable mode of exercise in this patient group.

Background The most common physical deficit caused by a stroke is muscle weakness which limits a person’s mobility. Mobility encompasses activities necessary for daily functioning: getting in and out bed, on/off toilet, sitting, standing and walking. These activities are significantly affected in people with severe stroke who typically spend most of their time in bed or a chair and are immobile. Immobility is primarily caused by neurological damage but exacerbated by secondary changes in musculoskeletal and cardiorespiratory systems. These secondary changes can theoretically be prevented or minimised by early mobilisation, in this case standing up early post-stroke. Standing up early post-stroke has been identified as an important priority for people who have suffered a severe stroke. However, trials of prolonged passive standing have not demonstrated any functional improvements. Conversely, task-specific training such as repeated sit-to-stand has demonstrated positive functional benefits. This feasibility trial combines prolonged standing and task-specific strength training with the aim of determining whether this novel combination of physiotherapy interventions is feasible for people with severe stroke as well as the overall feasibility of delivering the trial. Methods/design This is a pragmatic multi-centre parallel single-blinded two-armed feasibility randomised controlled trial. Fifty people with a diagnosis of severe stroke will be randomly allocated to either the functional standing frame programme or usual physiotherapy. All patient participants will be assessed at baseline and followed up at 3 weeks, then 3, 6 and 12 months post-randomisation. Trial objectives are to determine the feasibility according to the following indicators:: (i) Process: recruitment and retention rate, ability to consent, eligibility criteria, willingness/ability of physiotherapists to recruit, willingness of patients to be randomised, and acceptability of the intervention; (ii) Resource: burden and potential costs; (iii) Management: treatment fidelity, participant adherence, acceptability and completeness of outcome measures, impact and management or orthostatic hypotension; and (iv) Safety: number and nature of adverse and serious adverse events. Discussion The functional standing frame programme addresses a key concern for people who have suffered a severe stroke. However, several uncertainties exist which need to be understood prior to progressing to a full-scale trial, including acceptability and tolerance of the functional standing frame programme intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties. Trial registration International Standard Randomised Controlled Trial Number ISRCTN15412695. Registration on 19 December 2016. Electronic supplementary material The online version of this article (10.1186/s40814-018-0254-z) contains supplementary material, which is available to authorized users.

Objectives To evaluate the effectiveness of interventions in reducing falls and/or improving balance as a falls risk in multiple sclerosis (MS). Data Sources Computer-based and manual searches included the following medical subject heading keywords: "Multiple Sclerosis AND accidental falls" OR "Multiple Sclerosis AND postural balance" OR "Multiple Sclerosis AND exercise" OR "Multiple Sclerosis AND physical/physio therapy" NOT animals. All literature published to November 2014 with available full-text details were included. Study Selection Studies were reviewed against the PICO (participants, interventions, comparisons, outcomes) selection criteria: P, adults with MS; I, falls management/balance rehabilitation interventions; C, randomized/quasi-randomized studies comparing intervention with usual care or placebo control; O, falls outcomes and measures of balance. Fifteen articles of the original 529 search results were included. Data Extraction Two reviewers independently extracted data and assessed methodological quality using the Cochrane Risk of Bias tool. Data Synthesis Random-effects meta-analysis indicated a small decrease in falls risk (risk ratio, .74), although the 95% confidence interval (CI) crossed 1 (95% CI, .12–4.38). The pooled standardized mean difference (SMD) for balance outcomes was .55 (95% CI, .35–.74). SMD varied significantly between exercise subgroupings; gait, balance, and functional training interventions yielded the greatest pooled effect size (ES) (SMD=.82; 95% CI, 0.55–1.10). There was a moderate positive correlation between program volume (min/wk) and ES (Cohen's d ) ( r =.70, P =.009), and a moderate negative correlation between program duration in weeks and ES ( r =−.62, P =.03). Variations in interventions and outcomes and methodological limitations mean that results must be viewed with caution. Conclusions This review suggests that balance may improve through exercise interventions, but that the magnitude of the improvements achieved in existing programs may not be sufficient to impact falls outcomes. Supporting participants to achieve an appropriate intensity of practice of highly challenging balance activities appears to be critical to maximizing effectiveness.

Background We investigated whether balance impairments caused by cerebellar disease are associated with specific sensorimotor processing deficits that generalize across all sensory modalities. Experiments focused on the putative cerebellar functions of scaling and coordinate transformation of balance responses evoked by stimulation of single sensory channels. Methods Vestibular, visual, and proprioceptive sensory channels were stimulated in isolation using galvanic vestibular stimulation, moving visual scenery, and muscle vibration, respectively, in 16 subjects with spinocerebellar ataxia type 6 (SCA6) and 16 matched healthy controls. Two polarities of each stimulus type evoked postural responses of similar form in the forward and backward directions. Disease severity was assessed using the Scale for Assessment and Rating of Ataxia. Results Impaired balance of SCA6 subjects during unperturbed stance was reflected in faster than normal body sway (P = 0.009), which correlated with disease severity (r = 0.705, P

Context: Athletic pelvic/groin pain is a common yet often challenging problem to both diagnose and manage. A new tool has been developed based on the clinical effects of applied force on the pelvis. Early findings indicate that this customized compression orthosis may have a positive effect on pelvic/groin pain and performance measures. Objectives: To inform the design and test the practicality of procedures for a future definitively powered randomized controlled trial and to provide an estimate of the effect size of this orthosis on selected clinical and performance measures. Design: Pilot randomized controlled trial with participants randomly allocated to an intervention or waiting-list control group. Setting: The training location of each athlete. Participants: 24 athletes with subacute and chronic pelvic conditions were proposed to be recruited. Intervention: A customized compression orthosis, delivering targeted compression to the pelvic girdle. Outcome Measures: Measures were the active straight leg raise (ASLR) test, squeeze test, broad jump, and the multiple single-leg hop-stabilization test. Results: A total of 16 athletes completed the study. The invention group demonstrated moderate to large estimated effect sizes on the squeeze test and active straight leg raise tests (d = 0.6–1.1) while wearing the orthosis. Small effect sizes (d = 0.2) were seen on jump distance and the dominant leg balance score. Compared with the control group, the intervention group also showed moderate to large estimated effect sizes on the active straight leg raise measures (d = 0.5–0.9) when wearing sports shorts. Conclusions: The protocol was feasible. Effect sizes and recruitment/attrition rates suggest that the intervention holds promise and that a future definitively powered randomized controlled trial appears feasible and is indicated.

To utilise stakeholder input to inform the structure, format and approach of a multiple sclerosis (MS) balance, safe mobility and falls management programme.Using a three-round nominal group technique, participants individually rated their agreement with 20 trigger statements, followed by a facilitated group discussion and re-rating. Three mixed groups included service users (n = 15) and providers (n = 19). Quantitative analysis determined agreement, whilst qualitative responses were analysed thematically.Median scores for each of the 20 trigger statements did not change significantly over sequential rounds, however, deviations around the medians indicated more agreement amongst participants over time. Key recommendations were: Aims and approach: The programme should be tailored to the needs of people with MS. Falls and participation-based outcomes are equally important. Structure and format: The programme should balance expected burden and anticipated benefit, moving away from models requiring weekly attendance and promoting and supporting self-efficacy. Optimising engagement: Support to maintain engagement and intensity of practice over the long term is essential. Sustainability: Adequate funding is necessary. Staff should have MS specific knowledge and experience.Participants collaboratively identified critical components of a MS balance, safe mobility and falls management programme. They also highlighted the importance of a collaborative, user-centred, MS-specific approach. Implications for Rehabilitation People with multiple sclerosis need condition-specific interventions focussed on maximising balance and safe mobility and reducing falls. Programme design should support self-efficacy and flexible engagement. Adequate support and funding are seen as essential by both service users and providers.

This study is funded by the NIHR Health Technology Assessment Programme (14/176/12), United Kingdom. Background: Impaired mobility is a cardinal feature of multiple sclerosis (MS) and is rated by people with MS as their highest priority. By the secondary progressive phase, balance, mobility and physical activity levels are significantly compromised; an estimated 70% of people with secondary progressive MS fall regularly. Our ongoing research has systematically developed ‘Balance Right in MS’ (BRiMS), an innovative, manualised 13-week guided self-management programme tailored to the needs of people with MS, designed to improve safe mobility and minimise falls. Our eventual aim is to assess the clinical and cost effectiveness of BRiMS in people with secondary progressive MS by undertaking an appropriately statistically powered, multi-centre, assessor-blinded definitive, randomised controlled trial. This feasibility study will assess the acceptability of the intervention and test the achievability of running such a definitive trial. Methods/design: This is a pragmatic multi-centre feasibility randomised controlled trial with blinded outcome assessment. Sixty ambulant people with secondary progressive MS who self-report two or more falls in the previous 6 months will be randomly allocated (1:1) to either the BRiMS programme plus usual care or to usual care alone. All participants will be assessed at baseline and followed up at 15 weeks and 27 weeks post-randomisation. The outcomes of this feasibility trial include: • Feasibility outcomes, including trial recruitment, retention and completion • Assessment of the proposed outcome measures for the anticipated definitive trial (including measures of walking, quality of life, falls, balance and activity level) • Measures of adherence to the BRiMS programme • Data to inform the economic evaluation in a future trial • Process evaluation (assessment of treatment fidelity and qualitative evaluation of participant and treating therapist experience) Discussion: The BRiMS intervention aims to address a key concern for MS service users and providers. However, there are several uncertainties which need to be addressed prior to progressing to a full-scale trial, including acceptability of the BRiMS intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties and will enable a protocol to be finalised for use in the definitive trial. Publisher PDF

REVIEW QUESTION/OBJECTIVE The objectives of the review are to determine:Specifically, the review question is:What is the evidence base for non-pharmacological interventions in treating orthostatic hypotension (OH) in elderly people and people with a neurological condition?

Review question/objective The overall aim of this systematic review is to explore the uptake, clinical effectiveness, and personal experience of standing frame use for children with cerebral palsy. The quantitative objectives are to identify: 1.the clinical effectiveness of standing frame use for children with cerebral palsy on impairments, activities, participations, and quality of life. 2.the level of uptake of, and adherence to, regular standing frame programs The qualitative objectives are to identify, for children with cerebral palsy, and their families/caregivers: 1.their experience of using a standing frame program 2.the enablers and barriers of using a standing frame program Quantitative component inclusion criteria Types of participants Quantitative studies that include children and adolescents (aged < 18 years) with cerebral palsy will be considered. Types of intervention(s) Studies that evaluate standing frame interventions in comparison to either usual care or other specific physiotherapy interventions will be considered. Types of outcomes The International Classification of Functioning, Disability and Health will be used as the framework on which to classify the outcomes measured in the reviewed studies. Many physiotherapy approaches or interventions are directed at the “body functions and structures” domain of the The International Classification of Functioning, Disability and Health with the aim of hopefully improving the activities and participation of the child. However, it is often not known whether improvements at the impairment level will transfer into functional gains or gains to a child’s level of participation. This SR will attempt to identify whether this is the case. To ensure categorization to the correct The International Classification of Functioning, Disability and Health domain we will use the http://apps.who.int/classifications/icfbrowser/ tool. Listed below are the outcomes of interest:- Impairments of the child and adolescent with cerebral palsy: • contracture • range of motion • spasticity • spasms • muscle strength • muscle bulk • pain • balance • pressure areas/pressure sores • hip migration index • bone mineral density • bladder symptoms • bowel symptoms/bowel evacuation • sensory • respiration • confidence • self-esteem Activities of the child and adolescent with cerebral palsy • motor function • standing ability • activities of daily living • walking/gait • standing • transfers • mobility • communication • upper limb function • head control Participations of the child and adolescent with cerebral palsy • community mobility • education • leisure pursuits • social life In addition, the following outcomes data will also be extracted: • carer TRUNCATED AT 350 WORDS

Lumbopelvic injuries are often refractory to treatment and can limit return to sport. Research shows that 50 Newtons (N) of force applied transversely to the pelvis improves lumbopelvic stability and pain. This study applies transverse and diagonal forces to the pelvis in athletes with lumbopelvic pain, and investigates effects on pain and function.To investigate the effects of transverse and diagonal compressive forces applied to the pelvis of athletes with lumbopelvic painA randomized, repeated measures design using 20 athletes with lumbopelvic pain.No belt and four pelvic belt configurations (50 N force) were tested. Outcome measures were: resting pain, pain on active straight leg raise (ASLR), resisted hip adduction force and pain on 1-metre broad jump. Force on the adduction test was determined via load cell.Data were analyzed using repeated measures ANOVA. Squeeze test showed significant effect of condition F (4, 76) = 2.7, P0.05. On ASLR ipsilateral to the side of pain, pain decreased across conditions (F (4, 76) = 2.5 P = 0.05).Results suggest application of diagonal forces towards the site of pain may have additional benefits in improving pain and function. Such information may inform the development of an orthosis. Clinical relevance The results may be used clinically to determine the effectiveness of different belt placements (with belts or straps) in managing athletic lumbopelvic pain. The results offer an alternative to the application of transverse belts, and may inform new approaches in the development of orthotics.

Background Falls are a significant issue in people with multiple sclerosis (MS), with research demonstrating fall rates of more than 50%. Purpose The purpose of this study was to evaluate the risk factors associated with falling in people with MS. Data Sources Mixed search methods were used, including computer-based and manual searches. Additionally, hand searches of reference lists and conference abstracts were performed. All literature published from the source's earliest date to January 2012 was included; only full-text English-language sources (or those where a translation was available) were included. Study Selection Eligibility criteria specified articles evaluating any aspect of fall risk in adults with a confirmed MS diagnosis, where the incidence of falling as determined by prospective or retrospective participant report was included. Data Extraction Data were extracted independently by 2 reviewers using a written protocol and standardized extraction documentation. Detailed assessment of each article was independently undertaken by both reviewers, including assessment of study quality using an adaptation of the Newcastle Ottawa Scale plus extraction of key data (participant characteristics, fall incidence, and outcomes). Data Synthesis The final review comprised 8 articles with a total of 1,929 participants; 1,037 (53.75%) were classified as fallers. Eighteen different risk factors were assessed within the included studies. Meta-analysis demonstrated an increase in fall risk associated with impairments of balance and cognition, progressive MS, and use of a mobility aid. Narrative review of the qualitative articles and those factors where meta-analysis was not possible also was undertaken. Limitations Variation in assessment, analysis, and reporting methods allowed meta-analysis for only 4 factors. Conclusion There is limited evidence of the factors associated with fall risk in people with MS. Further methodologically robust studies are needed.

1. The discharges of two motor units were identified in an intrinsic hand muscle (first dorsal interosseous, FDI) or an axial muscle (lumbar paraspinals, PSP) in ten healthy subjects. Each motor unit was situated in the homologous muscle on either side of the body (bilateral condition) or in the same muscle (ipsilateral condition). The relationship between the times of discharge of the two units was determined using coherence analysis. 2. Motor unit pairs in the ipsilateral FDI showed significant coherence over the frequency bands 1-10 Hz and 12-40 Hz. Motor units in the ipsilateral PSP were significantly coherent below 5 Hz. In contrast there was no significant coherence at any frequency up to 100 Hz in the bilateral FDI condition and only a small but significant band of coherence below 2 Hz in the bilateral PSP condition. 3. Common drive to motor units at frequencies of < 4 Hz was assessed by cross-correlation of the instantaneous frequencies of the motor units. A significantly higher coefficient was found in the ipsilateral FDI, ipsi- and bilateral PSP compared with shifted, unrelated data sets. This was not the case for the bilateral FDI condition. 4. The presence of higher frequency coherence ( > 10 Hz) in the ipsilateral FDI condition and its absence in ipsilateral PSP is consistent with a more direct and influential cortical supply to the intrinsic hand muscles compared with the axial musculature. The presence of low frequency drives (< 4 Hz) in the bilateral PSP condition and its absence in the bilateral FDI condition is consistent with a bilateral drive to axial, but not distal, musculature by the motor pathways responsible for this oscillatory input.

OBJECTIVE: To determine the feasibility of conducting a randomised controlled trial of a specialist physiotherapy intervention for functional motor symptoms (FMS). METHODS: A randomised feasibility study was conducted recruiting patients with a clinically established diagnosis of FMS from a tertiary neurology clinic in London, UK. Participants were randomised to the intervention or a treatment as usual control. Measures of feasibility and clinical outcome were collected and assessed at 6 months. RESULTS: 60 individuals were recruited over a 9-month period. Three withdrew, leaving 29 intervention and 28 controls participants in the final analysis. 32% of patients with FMS met the inclusion criteria, of which 90% enrolled. Acceptability of the intervention was high and there were no adverse events. At 6 months, 72% of the intervention group rated their symptoms as improved, compared to 18% in the control group. There was a moderate to large treatment effect across a range of outcomes, including three of eight Short Form 36 (SF36) domains (d=0.46-0.79). The SF36 Physical function was found to be a suitable primary outcome measure for a future trial; adjusted mean difference 19.8 (95% CI 10.2 to 29.5). The additional quality adjusted life years (QALY) with intervention was 0.08 (95% CI 0.03 to 0.13), the mean incremental cost per QALY gained was £12 087. CONCLUSIONS: This feasibility study demonstrated high rates of recruitment, retention and acceptability. Clinical effect size was moderate to large with high probability of being cost-effective. A randomised controlled trial is needed. TRIAL REGISTRATION NUMBER: NCT02275000; Results.

This study is funded by the NIHR Research for Patient Benefit Programme (PB-PG-1013-32047), United Kingdom. BACKGROUND: Multiple sclerosis (MS) is an incurable, unpredictable but typically progressive neurological condition. It is the most common cause of neurological disability in young adults. Within 15 years of diagnosis, approximately 50 % of affected people are unable to walk unaided, and over time an estimated 25 % depend on a wheelchair. Typically, people with such limited mobility are excluded from clinical trials. Severely impaired people with MS spend much of their day sitting, often with limited ability to change position. In response, secondary complications can occur including: muscle wasting, pain, reduced skin integrity, spasms, limb stiffness, constipation, and associated psychosocial problems such as depression and lowered self-esteem. Effective self-management strategies, which can be implemented relatively easily and cheaply within people's homes, are needed to improve or maintain mobility and reduce sedentary behaviour. However this is challenging, particularly in the latter stages of disease. Regular supported standing using standing frames is one potential option. METHODS/DESIGN: SUMS is a pragmatic multi-centre randomised controlled trial evaluating use of Oswestry standing frames with blinded outcome assessment and full economic evaluation. Participants will be randomly allocated (1:1) to either a home-based, self-management standing programme (with advice and support) along with their usual care or to usual care alone. Those in the intervention group will be asked to stand for a minimum of 30 min three times weekly over 20 weeks. Each participant will be followed-up at 20 and 36 weeks post baseline. The primary clinical outcome is motor function, assessed using the Amended Motor Club Assessment. The primary economic endpoint is quality-adjusted life years. The secondary outcomes include measures of explanatory physical impairments, key clinical outcomes, and health–related quality of life. An embedded qualitative component will explore participant’s and carer’s experiences of the standing programme. DISCUSSION: This is the first large scale multi-centre trial to assess the clinical and cost effectiveness of a home based standing frame programme for people who are severely impaired by MS. If demonstrated to be effective and cost-effective, we will use this evidence to develop recommendations for a health service delivery model which could be implemented across the United Kingdom. Publisher PDF

Balance impairment is a principal symptom of cerebellar disease, but is poorly understood partly because subjects with heterogenous cerebellar and extracerebellar lesions have often been studied. Spinocerebellar ataxia type 6 (SCA6) provides an opportunity to understand balance dysfunction associated with a relatively homogenous cerebellar lesion. This study investigated stance instability in SCA6 and how it is affected by varying stance width. Body sway, as well as its directional preponderance and distribution across joints, was measured three-dimensionally in 17 SCA6 and 17 matched healthy control subjects. Subjects stood for 40 seconds on a stable surface with their eyes open and feet positioned at various stance widths (32, 16, 8, 4, and 0 cm). SCA6 subjects swayed faster than controls at every stance width. Decreasing the stance width produced a disproportionate increase in sway speed in SCA6 subjects, compared to controls. Directional preponderance of sway was dependent on stance width, but did not differ between groups. Joint instability was increased by reducing stance width in both groups, but there was greater instability of the ankle joint in the roll plane in the SCA6 group. Measures of global instability correlated strongly with disease severity measured with the Scale for the Assessment and Rating of Ataxia (r = 0.79). The sway characteristics suggest a disruption of sensorimotor processing for balance control in SCA6. The correlation with disease severity implies that balance impairment is a feature of progression of SCA6 clinical syndrome. With stance width standardized, the instability measures employed could provide sensitive, continuous outcome measures of longitudinal or therapeutic change.

Introduction: During walking, people with Charcot-Marie-Tooth (CMT) disease may compensate for distal weakness by using proximal muscles. We investigated the effect of different AFOs on distal leg control and proximal compensatory actions. Methods: Fourteen people with CMT were tested while wearing 3 types of ankle-foot orthosis (AFO) bilaterally compared with shoes alone. Walking was assessed using three-dimensional gait analysis. Stiffness of the splints was measured by applying controlled 5-degree ankle stretches using a motor. Results: The results showed that each AFO significantly stiffened the ankle and increased ankle dorsiflexion at foot clearance compared with shoes alone. At push off, peak ankle power generation was reduced, but only with 1 type of AFO. A significant decrease in hip flexion amplitude during the swing phase was observed with all 3 AFOs. Conclusions: These results indicate that AFOs reduce foot drop and remove the need for some proximal compensatory action.

Background and Purpose. Ankle foot orthoses (AFOs) are commonly prescribed for people with Charcot-Marie-Tooth (CMT) disease. Scant evidence exists to guide the type and timing of orthotic prescription. This study explores the latter issue by investigating the differences in presentation and gait function of people with CMT disease who wore AFOs for daily mobility (n = 11) and a group who did not (n = 21). The aim was to see if there was a difference in the characteristics in people who regularly wear AFOs. Methods. Primary measures of gait function were a 10-m timed walk (comfortable and maximum speed) and a 6-minute walk test. Means of the variables were compared using independent t-tests. Secondary measures included disease severity, lower limb muscle strength, sensory impairment, walking effort, fatigue severity and perceived walking ability. Results. AFO wearers walked slower with higher effort. They also had greater disease severity, weaker leg muscles and perceived greater walking difficulty. Subjects not wearing AFOs showed significant relationships between gait variables and muscle strength, whereas AFO wearers showed significant relationships between gait variables and perceived walking ability, fatigue severity and effort. Conclusions. People who regularly wore AFOs were more severely affected, had a slower maximum walking speed, higher energy cost of walking and worse perceived walking ability. Walking ability in this group was related to fatigue, perceived exertion during walking and perceived walking ability. Gait function of people not using AFOs was determined by lower limb muscle function. People prescribed AFOs, those who do not wear them and those not prescribed AFOs were similar in presentation, suggesting that people choose to wear orthoses when their condition becomes sufficiently severe.

Background. Noninvasive cortical stimulation could represent an add-on treatment to enhance motor recovery after stroke. However, its clinical value, including anticipated size and duration of the treatment effects, remains largely unknown. Objective. The authors designed a small semi-randomized clinical trial to explore whether long-lasting clinically important gains can be achieved by adding theta burst stimulation (TBS), a form of repetitive transcranial magnetic stimulation (TMS), to a rehabilitation program for the hand. Methods. A total of 41 chronic stroke patients received excitatory TBS to the ipsilesional hemisphere or inhibitory TBS to the contralesional hemisphere in 2 centers; each active group was compared with a group receiving sham TBS. TBS was followed by physical therapy for 10 working days. Patients and therapists were blinded to the type of TBS. Primary outcome measures (9-hole Peg Test [9HPT], Jebsen Taylor Test [JTT], and grip and pinch-grip dynamometry) were assessed 4, 30, and 90 days post treatment. The clinically important difference was defined as 10% of the maximum score. Results. There were no differences between the active treatment and sham groups in any of the outcome measures. All patients achieved small sustainable improvements—9HPT, 5% of maximum (confidence interval [CI] = 3%-7%); JTT, 5.7% (CI = 3%-8%); and grip strength, 6% (CI = 2%-10%)—all below the defined clinically important level. Conclusions. Cortical stimulation did not augment the gains from a late rehabilitation program. The effect size anticipated by the authors was overestimated. These results can improve the design of future work on therapeutic uses of TMS.

The left and right vestibular organs always transduce the same signal of head movement, and with natural stimuli can only be activated simultaneously. To investigate how signals from the left and right vestibular organs are integrated to control human balance we electrically modulated the firing of vestibular afferents from each labyrinth independently and measured the resulting balance responses. Stimulation of one side at a time (monaural) showed that individual leg muscles receive equal inputs from the two labyrinths even though a single labyrinth appeared capable of signalling 3-D head motion. To deduce principles of left-right integration, balance responses to simultaneous stimulation of both sides (binaural) were compared with responses to monaural stimuli. The binaural whole-body response direction was compatible with vector summation of the left and right monaural responses. The binaural response magnitude, however, was only 64-74% that predicted by the monaural sum. This probably reflects a central non-linearity between vestibular input and motor output because stimulation of just one labyrinth revealed a power law relationship between stimulus current and response size with exponents 0.56 (force) and 0.51 (displacement). Thus, doubling total signal magnitude either by doubling monaural current or by binaural stimulation produced equivalent responses. We conclude that both labyrinths provide independent estimates of head motion that are summed vectorially and transformed non-linearly into motor output. The former process improves signal-to-noise and reduces artifactual common-mode changes, while the latter enhances responses to small signals, all critical for detecting the small head movements needed to control human balance.

Charcot-Marie-Tooth (CMT) disease results in distal lower limb weakness that affects walking. In this study we assess the role of the hip flexors in compensating for distal weakness while walking and the effects of prolonged walking on these putative compensatory strategies. Eighteen subjects with CMT disease were compared with 14 matched controls while they walked on a treadmill to a predetermined point of perceived effort. A significant reduction was observed in peak hip flexor velocity during walking and hip flexor maximal voluntary contraction. In a second session following selective fatigue of the hip flexors, hip flexor velocity decreased immediately on walking, and walking duration was greatly reduced. This study suggests that hip flexors compensate for distal weakness and that fatigue in the hip flexors can limit walking duration. Treatments directed toward improving proximal muscle strength may therefore help to delay onset of hip flexor fatigue and thus prolong walking duration.

Background People with hereditary and spontaneous spastic paraparesis (HSSP) report that their legs are stiffer and walking is slower when their legs are cold. Objectives This study explored the effects of prolonged superficial cooling and warming of the lower leg on walking speed and local measures of neuromuscular impairments. Methods This was a randomised pre- and post-intervention study of 22 HSSP participants and 19 matched healthy controls. On 2 separate occasions, one lower leg was cooled or warmed. Measurements included walking speed and measures of lower limb impairment: ankle movement, passive muscle stiffness, spasticity (stretch reflex size), amplitude and rate of force generation in dorsi- and plantarflexors and central and peripheral nerve conduction time/velocity. Results For both participants and controls, cooling decreased walking speed, especially for HSSP participants. For both groups, cooling decreased the dorsiflexor rate and amplitude of force generation and peripheral nerve conduction velocity and increased spasticity. Warming increased dorsiflexor rate of force generation and nerve conduction velocity and decreased spasticity. Conclusions Superficial cooling significantly reduced walking speed for people with HSSP. Temperature changes were associated with changes in neuromuscular impairments for both people with spastic paraparesis and controls. This study does not support the use of localised cooling in rehabilitation for people with spastic paraparesis as reported in other neurological conditions. Rehabilitation interventions that help prevent heat loss (insulation) or improve limb temperature via passive or active means, particularly when the legs and/or environment are cool, may benefit people with spastic paraparesis.

Aim To examine intra- and interrater reliability/agreement, and time taken to score, when the Quality Function Measure (QFM) is applied to children with hyperkinetic movement disorders (HMD; e.g. dystonia, chorea, athetosis, tremor, and myoclonus). Method Fifteen ambulant children with HMD participated (eight males, seven females; mean age 13y 7mo, SD 3y 7mo). Three trained raters (two physiotherapists, one occupational therapist) independently scored the QFM using videos of each child performing Gross Motor Function Measure (GMFM) Stand and Walk/Run/Jump dimensions. Reliability was evaluated using intraclass correlation coefficient (ICC) model 2.1, Standard Error of Measurement (SEM), and Bland–Altman methods. Results Rater reliability was excellent for all five QFM attributes: intrarater ICCs ≥0.98 (95% confidence interval [CI] 0.83–1.00), and interrater ICCs ≥0.96 (95% CI 0.91–1.00). SEM varied from 2.07% to 4.72% points for intra- and interrater scores across QFM attributes. Bland–Altman tests demonstrated close agreement between ratings, with absolute mean differences varying from 0.34% to 3.23% (intrarater) to 1.67% to 3.82% (interrater). Median scoring duration time was 83 minutes (range 56–144min, SD 16.02). Interpretation Low measurement error attributable to rater effects suggests the QFM has potential as an evaluative measure in research studies involving children with HMD, though its lengthy scoring requirements are an important consideration for clinical practice. Evaluation of test–retest reliability and responsiveness is required.

Background Stretches are often prescribed to manage increased limb stiffness in people with Multiple Sclerosis . This study determined the ankle plantarflexor torque magnitude that people with Multiple Sclerosis can apply during four commonly prescribed stretches and determined the relationship between the applied torque and functional ability . Methods People with Multiple Sclerosis (N = 27) were compared to healthy control participants (n = 15). Four stretches were investigated; stretching in step standing; using a step; pulling the ankle into dorsiflexion and standing in a frame. Joint position and forces were measured using 3D motion analysis and torque transducers. Baseline ankle strength and stiffness was measured using motor driven ankle perturbations. Findings People with Multiple Sclerosis (N = 27) had higher stretch reflex amplitudes and lower strength compared to the control group (n = 15). People with Multiple Sclerosis achieved less lengthening of the plantarflexor muscle-tendon complex when stretching but similar ankle torques compared to controls. While stretching people with Multiple Sclerosis showed greater muscle activation in the ankle plantarflexors. Stretches in weight bearing positions produced higher plantarflexor torques. People with Multiple Sclerosis with lower functional ability preferred the more supported stretches (ankle pull and standing frame). Interpretation Stretches in weight bearing positions achieve higher ankle torques but this is in part due to increased postural activity in people with Multiple Sclerosis. Functional ability may limit stretch effectiveness

Context:Athletic pelvic and groin injuries are a common yet challenging problem. Pelvic belts have been successfully used to reduce pain and improve function but are not a practical solution for athletes. Therefore, there is scope to explore the use of a more dynamic intervention developed to aid in the management of this type of injury.Objectives:To undertake a preliminary investigation into the effectiveness of a dynamic elastomeric fabric orthosis (DEFO) in supporting the management of athletic pelvic and groin injury.Design:A case series with an AB design. Daily assessments were undertaken over 15 days; the onset of intervention was randomized with a minimum baseline period of 6 d. Follow-up assessment was undertaken after 1 mo.Settings:Community and university.Participants:8 athletes presenting with pelvic or groin injury confirmed through clinical screening.Intervention:A bespoke DEFO.Main Outcome Measures:Force produced on bilateral resisted hip adduction and self-scored pain (using a numerical rating scale of 0–10) at rest and during an active straight-leg raise and a broad jump.Results:In 7 cases a significant improvement was observed on at least 1 measure (2-SD method, celeration line, and/or the point of nonoverlapping data). The remaining case showed minimal symptoms during testing.

Patients with multiple sclerosis (MS) activate a more diffuse cortical network than do healthy subjects when they perform motor tasks. This brain functional reorganisation might contribute to the limiting of disability, but it is unclear whether there is a loss of regional activation in more advanced disease. The aim of this study was to assess whether functional reorganisation diminishes in more disabled patients with primary progressive (PP) MS. The differences in the fMRI response to active and passive movements of the dominant ankle of 13 patients and 16 controls were assessed. The relationships between functional activation and disability and brain lesion load and atrophy were investigated.Patients showed greater fMRI activation than controls with passive movements in the superior temporal gyrus, rolandic operculum, and putamen. The fMRI response to active and passive movements in the ipsilateral inferior frontal gyrus was lower in patients with greater disability and greater brain T2 lesion load, respectively. Furthermore, the fMRI activation with active movements in the contralateral cerebellum was lower in patients with worse mobility. The increased activity with passive movements in regions that participate in sensori-motor integration, such as the putamen, reflects true functional reorganisation, since passive movements induce brain activation through sensory afferents only. The inverse correlation between the fMRI response in regions that are associated with motor control, and clinical or MRI measures of disease progression, suggests that there is a loss of distributed activation in more disabled patients. This may inform future treatment strategies.

The objective of this study was to define cortical and subcortical structures activated during both active and passive movements of the ankle, which have a fundamental role in the physiology of locomotion, to improve our understanding of brain sensorimotor integration. Sixteen healthy subjects, all right-foot dominant, performed a dorsi-plantar flexion task of the foot using a custom-made wooden manipulandum, which enabled measurements of the movement amplitude. All subjects underwent a training session, which included surface electromyography, and were able to relax completely during passive movements. Patterns of activation during active and passive movements and differences between functional MRI (fMRI) responses for the two types of movement were assessed. Regions of common activation during the active and passive movements were identified by conjunction analysis. We found that passive movements activated cortical regions that were usually similar in location to those activated by active movements, although the extent of the activations was more limited with passive movements. Active movements of both feet generated greater activation than passive movements in some regions (such as the ipsilateral primary motor cortex) identified in previous studies as being important for motor planning. Common activations during active and passive movements were found not only in the contralateral primary motor and sensory cortices, but also in the premotor cortical regions (such as the bilateral rolandic operculum and contralateral supplementary motor area), and in the subcortical regions (such as the ipsilateral cerebellum and contralateral putamen), suggesting that these regions participate in sensorimotor integration for ankle movements. In future, similar fMRI studies using passive movements have potential to elucidate abnormalities of sensorimotor integration in central nervous system diseases that affect motor function.

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