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A range of sleep disturbances and disorders are problematic in people after stroke; they interfere with recovery of function during poststroke rehabilitation. However, studies to date have focused primarily on the effects of one sleep disorder-obstructive sleep apnea (OSA)-on stroke recovery.The study protocol for the SLEep Effects on Poststroke Rehabilitation (SLEEPR) Study is presented with aims of characterizing proportion of non-OSA sleep disorders in the first 90 days after stroke, evaluating the effect of non-OSA sleep disorders on poststroke recovery, and exploring the complex relationships between stroke, sleep, and recovery in the community setting.SLEEPR is a prospective cohort observational study across multiple study sites following individuals from inpatient rehabilitation through 90 days poststroke, with three measurement time points (inpatient rehabilitation; i.e., ~15 days poststroke, 60 days poststroke, and 90 days poststroke). Measures of sleep, function, activity, cognition, emotion, disability, and participation will be obtained for 200 people without OSA at the study's start through self-report, capacity assessments, and performance measures. Key measures of sleep include wrist actigraphy, sleep diaries, overnight oximetry, and several sleep disorders screening questionnaires (Insomnia Severity Index, Cambridge-Hopkins Restless Legs Questionnaire, Epworth Sleepiness Scale, and Sleep Disorders Screening Checklist). Key measures of function and capacity include the 10-meter walk test, Stroke Impact Scale, Barthel index, and modified Rankin scale. Key performance measures include leg accelerometry (e.g., steps/day, sedentary time, upright time, and sit-to-stand transitions) and community trips via GPS data and activity logs.The results of this study will contribute to understanding the complex interplay between non-OSA sleep disorders and poststroke rehabilitation; they provide insight regarding barriers to participation in the community and return to normal activities after stroke. Such results could lead to strategies for developing new stroke recovery interventions.

Objective Academic physical therapy has no universal metrics by which educational programs can measure outcomes, limiting their ability to benchmark to their own historical performance, to peer institutions, or to other health care professions. The PT-Graduation Questionnaire (GQ) survey, adapted from the Association of American Medical Colleges’ GQ, addresses this gap by offering both inter-professional insight and fine-scale assessment of physical therapist education. This study reports the first wave of findings from an ongoing multi-site trial of the PT-GQ among diverse academic physical therapy programs, including (1) benchmarks for academic physical therapy, and (2) a comparison of the physical therapist student experience to medical education benchmarks. Methods Thirty-four doctor of physical therapy (DPT) programs (13.2% nationwide sample) administered the online survey to DPT graduates during the 2019 to 2020 academic year. PT-GQ and Association of American Medical Colleges data were contrasted via Welch’s unequal-variance t test and Hedges g (effect size). Results A total of 1025 respondents participated in the study (response rate: 63.9%). The average survey duration was 31.8 minutes. Overall educational satisfaction was comparable with medicine, and respondents identified areas of curricular strength (eg, anatomy) and weakness (eg, pharmacology). DPT respondents provided higher ratings of faculty professionalism than medicine, lower rates of student mistreatment, and a lesser impact of within-program diversity on their training. One-third of respondents were less than “satisfied” with student mental health services. DPT respondents reported significantly higher exhaustion but lower disengagement than medical students, along with lower tolerance for ambiguity. Of DPT respondents who reported educational debt, one-third reported debt exceeding $150,000, the threshold above which the DPT degree loses economic power. Conclusions These academic benchmarks, using the PT-GQ, provided insight into physical therapist education and identified differences between physical therapist and medical student perceptions. Impact This ongoing trial will establish a comprehensive set of benchmarks to better understand academic physical therapy outcomes.

Evidence suggests that there is a significant relationship between cognition and gait. However, studies have primarily focused on overall cognition when elucidating the relationship with gait. This study aimed to delineate specific aspects of cognition that are related to gait and postural control parameters. Participants (N = 11, age = 76.55 ± 7.58 years) performed a series of cognitive tasks categorized as either lower-level (serial subtract 3 and continuous performance task) or higher-level (serial subtract 7 and rapid visual input processing task) tasks. Following the completion of the cognitive tasks, participants performed balance and gait activities. This procedure was performed on two separate days with a minimum 48-h rest period between days. A bivariate Pearson correlation analysis was utilized to identify relationships between cognitive task scores and gait speed, step length, gait imbalance as well as the visual, vestibular, and somatosensory aspect of postural control. Lower-level cognitive tasks, specifically the serial subtract 3 was significantly (P < 0.05) associated with gait speed (r = 0.457), step length (r = 0.481), and the ability to maintain postural control with occluded vision and unreliable somatosensory input (r = -0.504). In contrast, higher-level cognitive tasks, specifically serial subtract 7 were associated (P < 0.05) with gait imbalance (r = -0.540), while rapid visual input processing primary reaction time was associated with the ability to maintain postural control in the absence of visual input (r = -0.751). Our findings align with functional magnetic resonance imaging (fMRI) studies that examine gait, postural control, and cognitive task performance and provide a granular insight. These results may help us to better understand the relationship between cognitive deficits, gait, and postural control with aging.

Background Adequate sleep is vital for health and quality of life. People with stroke and a concomitant sleep disorder may have poorer outcomes than those without a sleep disorder. Objective To systematically evaluate the published literature to determine the impact of sleep disorders on physical, functional recovery at the activity and participation level after stroke. Methods A systematic review was conducted using PubMed, CINAHL, Scopus, and PsycINFO. Studies were selected that reported outcomes on physical, functional recovery at the activity and participation levels in participants with stroke and a diagnosed sleep disorder. A meta-analysis was performed on included studies that reported Barthel Index (BI) and modified Rankin Scale (mRS) scores. Results: A total of 33 studies were included in the systematic review with 9 of them in the meta-analysis. The mean mRS score was 0.51 points higher in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: 0.23-0.78]. The mean BI score was 10.2 points lower in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: −17.9 to −2.6]. Conclusions People with stroke and a sleep disorder have greater functional limitations and disability than those without a sleep disorder. Rehabilitation professionals should screen their patients with stroke for potential sleep disorders and further research is needed to develop sleep and rehabilitation interventions that can be delivered in combination. PROSPERO registration number: CRD42019125562.

Objective: Evaluate the impact of self-reported sleep problems on post-stroke recovery. Design: Cross-sectional secondary analysis of longitudinal data from the Locomotor Experience Applied Post-Stroke (LEAPS) rehabilitation and recovery study (phase-III single-blind randomized controlled clinical trial). Group medians were compared for three sleep problem groups across three time points. Setting: Outpatient and in-home physical therapy. Subjects: Adults during the first year following stroke ( n = 408, 380, 360 at 2, 6, 12 months, respectively). Interventions: The original study compared effects of locomotor training with body weight support in the year post-stroke. This analysis evaluated function in three sleep/functional-impact groups: no sleep problems, sleep problems with no-to-minimal-impact and sleep problems with moderate-to-quite-a-bit of impact. Main measures: Participants’ responses regarding if they had “a sleep problem, such as insomnia” and, if so, what the impact was on their function. Stroke Impact Scale subscales for strength, hand function, mobility, ADLs, memory, communication, emotion, participation, and percent recovery. Results: About 25% of people with stroke reported sleep difficulty, 10% perceived sleep problems negatively impact function. Groups self-reporting worse sleep performed worse in all functional subscales (except self-perceived percent recovery) during the first year post-stroke. Conclusion: Self-reported poor sleep adversely effects post-stroke functional recovery.

Background What contributes to free-living walking after stroke is poorly understood. Studying the characteristics of walking may provide further details that guide interventions. Objective The objectives of this study were to examine how the walking characteristics of bouts per day, median steps per bout, maximum steps per bout, and time spent walking differ in individuals with various walking speeds, walking endurance, and daily steps and to identify cutoffs for differentiating ambulators who were active versus inactive. Design This study involved a cross-sectional analysis of data from the Locomotor Experience Applied Post-Stroke trial. Methods Participants were categorized by walking speed, walking endurance (via the 6-minute walk test), and daily steps (via 2 consecutive days of objective activity monitoring). Differences in walking characteristics were assessed. Linear regression determined which characteristics predicted daily step counts. Receiver operating characteristic curves and areas under the curve were used to determine which variable was most accurate in classifying individuals who were active (≥5500 daily steps). Results This study included 252 participants with chronic stroke. Regardless of categorization by walking speed, walking endurance, or daily steps, household ambulators had significantly fewer bouts per day, steps per bout, and maximum steps per bout and spent less time walking compared with community ambulators. The areas under the curve for maximum steps per bout and bouts per day were 0.91 (95% confidence interval = 0.88 to 0.95) and 0.83 (95% confidence interval = 0.78 to 0.88), respectively, with cutoffs of 648 steps and 53 bouts being used to differentiate active and inactive ambulation. Limitations Activity monitoring occurred for only 2 days. Conclusions Walking characteristics differed based on walking speed, walking endurance, and daily steps. Differences in daily steps between household and community ambulators were largely due to shorter and fewer walking bouts. Assessing and targeting walking bouts may prove useful for increasing stepping after stroke.

Using a crossover-design, we assessed changes in 30-second chair stand test (30 s-CST), Timed Up-and-Go (TUG) and Berg Balance Scale (BBS) and energy and fatigue in older adults (N = 11) after performance of mental tasks. A Wilcoxon Sign Rank Test and a Friedman’s rank test were used to assess changes in 30 s-CST, TUG, BBS and energy and fatigue respectively. A linear mixed model was used to assess joint variance and random forest classifier and support vector machine (SVM) algorithms were used to verify results. Statistically significant declines in feelings of energy (p=.003), specifically mental energy (p=.015), and BBS (p

BACKGROUND AND PURPOSE The 6-minute walk test (6MWT) is commonly used in people with stroke. The purpose of this study was to estimate the minimal clinically important difference (MCID) of the 6MWT 2 months poststroke. METHODS We performed a secondary analysis of data from a rehabilitation trial. Participants underwent physical therapy between 2 and 6 months poststroke and the 6MWT was measured before and after. Two anchors of important change were used: the modified Rankin Scale (mRS) and the Stroke Impact Scale (SIS). The MCID for the 6MWT was estimated using receiver operating characteristic curves for the entire sample and for 2 subgroups: initial gait speed (IGS)

Measuring humans' functional balance is important for clinical estimation of fall risk. Although many clinical assessments, such as Berg Balance Scale and Mini Balance Evaluation System Test, are available to test the functional balance, the results are affected by the skills of different operators. This paper proposes an objective approach to access the functional balance by a wearable sensor system embedded in the shoe and a hip accelerometer. Support Vector Machine regression models are built with numerical features selected by mRMR algorithm to estimate the scores of the clinical assessments. Leave one out cross validation is employed to evaluate the regression models. The approach is validated on a group of 30 seniors ( $76\pm 10.5$ years old), containing fallers and non-fallers. The results show that the wearable sensor system has a capability to estimate the Berg Balance Scale and Mini Balance Evaluation System Test scores with absolute mean errors and standard deviations $6.07\pm 3.76$ and $5.45\pm 3.65$ , respectively, and demonstrates high agreement with falls history based risk assessment.

BACKGROUND AND PURPOSE The purposes of this study were to examine (1) differences in mood and motivation among older adults after the completion of 6 minutes of self-paced walking (6MW) and (2) the relationship between pace and magnitude of mood change. METHODS Eleven participants completed 3 days of testing where energy, fatigue, tension, depression, confusion, mental and physical energy, and motivation to perform mental tasks were measured before and after the 6MW. A repeated-measures analysis of variance was used to examine changes in mood and motivation, and a bivariate Pearson correlation was used to determine relationships between pace and magnitude of changes in mood. RESULTS Faster pace was associated with significant improvements (P < .05) in fatigue, energy, tension, confusion, total mood disturbance, state mental fatigue, and state physical energy. A significant relationship was noted between pace and changes in energy, fatigue, state mental and physical energy, and fatigue in the expected direction. DISCUSSION Results indicate that mood is influenced by pace of the activity. Findings suggest that even 6 minutes of physical activity can improve moods, which may impact how physical therapists approach prescribing exercise to older adults.

Background. The Arm Motor Ability Test (AMAT) is used to assess and quantify upper-extremity (UE) functional limitation in stroke and other conditions. However, the AMAT score change indicative of important and clinically meaningful change has not been determined. Objective. To determine the clinically important difference (CID) for the AMAT for individuals with stroke exhibiting mild to moderate hemiparesis. Methods. A total of 146 chronic stroke survivors exhibiting stable, mild to moderate UE hemiparesis were administered the AMAT before and after interventions targeting their affected UEs. Patients and treating therapists rated perceived amount of UE motor recovery for each participant on a global rating of change (GROC) scale evaluating several facets of UE movement (grasp, release, move the affected UE, perform 5 important functional tasks, overall UE function). Estimated CID of the Functional Ability Scale of the AMAT was calculated using the receiver operating characteristics curve with the GROC scale as the anchor. Distribution-based methods were also used to estimate the CID. Results. Mean baseline, postintervention, and change in AMAT values for all participants were 3.0 (0.68), 3.3 (0.73), and 0.33 (0.43) respectively. The CID was estimated as an improvement of 0.32 to 0.42 when anchored by the therapist’s perception of improvement and 0.29 to 0.40 when anchored by the patient’s perception of improvement. The CID using distribution-based methods ranged from 0.40 to 0.44. Conclusions. A change of 0.44 or greater on the AMAT indicates a clinically meaningful improvement in UE functional movements. Clinicians should use this value to determine goals and interpret change scores.

To determine the degree to which self-selected walking speed (SSWS), maximal walking speed (MWS), and walking speed reserve (WSR) are associated with fall status among community-dwelling older adults.WS and 1-year falls history data were collected on 217 community-dwelling older adults (median age = 82, range 65-93 years) at a local outpatient PT clinic and local retirement communities and senior centers. WSR was calculated as a difference (WSRdiff = MWS - SSWS) and ratio (WSRratio = MWS/SSWS).SSWS (P0.001), MWS (P0.001), and WSRdiff (P0.01) were associated with fall status. The cutpoints identified were 0.76 m/s for SSWS (65.4% sensitivity, 70.9% specificity), 1.13 m/s for MWS (76.6% sensitivity, 60.0% specificity), and 0.24 m/s for WSRdiff (56.1% sensitivity, 70.9% specificity). SSWS and MWS better discriminated between fallers and non-fallers (SSWS: AUC = 0.69, MWS: AUC = 0.71) than WSRdiff (AUC = 0.64).SSWS and MWS seem to be equally informative measures for assessing fall status in community-dwelling older adults. Older adults with SSWSs less than 0.76 m/s and those with MWSs less than 1.13 m/s may benefit from further fall risk assessment. Combining SSWS and MWS to calculate an individual's WSR does not provide additional insight into fall status in this population.Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES:: Upon completion of this article, the reader should be able to: (1) Describe the different methods for calculating walking speed reserve and discuss the potential of the metric as an outcome measure; (2) Explain the degree to which self-selected walking speed, maximal walking speed, and walking speed reserve are associated with fall status among community-dwelling older adults; and (3) Discuss potential limitations to using walking speed reserve to identify fall status in populations without mobility restrictions.Advanced: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity.

Background/Purpose: The increasing popularity of activity tracking devices presents an opportunity to monitor physical activity in patients after stroke. We sought to determine the reliability and accuracy of the Garmin Vivofit and Fitbit Zip for adults after stroke. Methods: Twenty-four participants with stroke-induced hemiparesis wore a Fitbit Zip on the nonparetic hip and Garmin Vivofits on both wrists during a 6-minute walk test to determine the accuracy of the devices against video-determined step counts. Participants also wore the devices during two trials of exactly 50 steps to determine the reliability of the devices. Results: Fitbit Zip showed excellent reliability (ICC2,1 = 0.974) and accuracy (4.2% error) for participants who walked faster than 0.35 m/s. Garmin Vivofit (nonparetic side) had excellent reliability (ICC2,1 = 0.964) but poor accuracy (≤−16.0%) for all participants. Garmin Vivofit (paretic side) had excellent reliability (ICC2,1 = 0.858) and accuracy (−4.0% error) for faster...

Background Advances in sensor technologies and signal processing techniques provide a method to accurately measure walking activity in the home and community. Activity monitors geared toward consumer or patient use may be an alternative to more expensive monitors designed for research to measure stepping activity. Objective The objective of this study was to examine the accuracy of 2 consumer/patient activity monitors, the Fitbit Ultra and the Nike+ Fuelband, in identifying stepping activity in people with stroke and traumatic brain injury (TBI). Secondarily, the study sought to compare the accuracy of these 2 activity monitors with that of the StepWatch Activity Monitor (SAM) and a pedometer, the Yamax Digi-Walker SW-701 pedometer (YDWP). Design A cross-sectional design was used for this study. Method People with chronic stroke and TBI wore the 4 activity monitors while they performed the Two-Minute Walk Test (2MWT), during which they were videotaped. Activity monitor estimated steps taken were compared with actual steps taken counted from videotape. Accuracy and agreement between activity monitor estimated steps and actual steps were examined using intraclass correlation coefficients (ICC [2,1]) and the Bland-Altman method. Results The SAM demonstrated the greatest accuracy (ICC [2,1]=.97, mean difference between actual steps and SAM estimated steps=4.7 steps) followed by the Fitbit Ultra (ICC [2,1]=.73, mean difference between actual steps and Fitbit Ultra estimated steps=−9.7 steps), the YDWP (ICC [2,1]=.42, mean difference between actual steps and YDWP estimated steps=−28.8 steps), and the Nike+ Fuelband (ICC [2,1]=.20, mean difference between actual steps and Nike+ Fuelband estimated steps=−66.2 steps). Limitations Walking activity was measured over a short distance in a closed environment, and participants were high functioning ambulators, with a mean gait speed of 0.93 m/s. Conclusions The Fitbit Ultra may be a low-cost alternative to measure the stepping activity in level, predictable environments of people with stroke and TBI who can walk at speeds ≥0.58 m/s.

This paper presents experimental results of a myoelectric controller designed for reciprocal stair ascent using a transfemoral prosthesis with an actively powered knee joint. The control architecture is derived from able-bodied gait data and estimates knee torque with a linear two-state (stance/swing) impedance control form that includes proportional myoelectric torque control combined with a state-determined knee impedance. The experimentally implemented control interface affords the amputee subject with direct control of knee torque using surface electromyogram (EMG) measurements of muscles in the residual thigh supplemented with a nominal knee impedance whose set-point switches based on the detection of ground contact at the foot. Preliminary clinical evaluations of the EMG-based control system with a single subject with unilateral transfemoral amputation show robust and repeatable performance for alternating stair ascent. The amputee subject effectively modulates power output at the knee using EMG commands during stance, while leveraging the knee's nominal swing-phase impedance and only modest EMG influence to achieve the desired knee trajectories during swing.

The Tinetti Performance-Oriented Mobility Assessment (POMA) is commonly used to measure balance ability in older adults. The purpose of this study was to determine the test-retest reliability and minimal detectable change (MDC) of the POMA and explore its cross-sectional and longitudinal construct validity for use in people early after stroke.Participants were recruited if they had a first documented stroke and were receiving physical therapy during inpatient rehabilitation. The POMA, gait speed, and motor Functional Independence Measure (FIM) scores were collected at admission and at discharge from inpatient rehabilitation. A second trial of the POMA was conducted 1 day after the first trial for reliability analysis. Correlations (Spearman ρ) between raw scores of admission and discharge outcome measures, as well as change in scores between admission and discharge, were used to explore the construct validity of the POMA.Fifty-five people, with average age of 75 ± 11 years, who had experienced first documented stroke participated in the study and began inpatient physical therapy at a mean of 8 ± 5 days poststroke. Test-retest reliability intraclass correlation coefficient (ICC2,1) was 0.84 and MDC was 6 points. The POMA scores were moderately correlated to motor FIM and gait speed scores at admission (rs = 0.55 and 0.70) and discharge (rs = 0.55 and 0.82.) Change scores of all 3 measures had a fair correlation (rs = 0.28-0.51).Test-retest reliability and MDC of the POMA in people with stroke is similar to previous research in older adult long-term care residents. Results support cross-sectional and longitudinal construct validity of the POMA in persons early after stroke and demonstrate validity and reliability to measure balance ability in this population.Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A39) for more insights from the authors.

Background and Purpose— Walking ability poststroke is commonly assessed using gait speed categories developed by Perry et al. The purpose of this study was to reexamine factors that predict home and community ambulators determined from real-world walking activity data using activity monitors. Methods— Secondary analyses of real-world walking activity from 2 stroke trials. Home (100–2499 steps/d), most limited community (2500–4499 steps/d), least limited community (5000–74 999), and full community (≥7500 steps/d) walking categories were developed based on normative data. Independent variables to predict walking categories were comfortable and fast gait speed, 6-minute walk test, Berg Balance Scale, Fugl Meyer, and Stroke Impact Scale. Data were analyzed using multivariate analyses to identify significant variables associated with walking categories, bootstrap method to select the most stable model and receiver-operating characteristic to identify cutoff values. Results— Data from 441 individuals poststroke were analyzed. The 6-minute walk test, Fugl Meyer, and Berg Balance Scale combined were the strongest predictors of home versus community and limited versus unlimited community ambulators. The 6-minute walk test was the strongest individual variable in predicting home versus community (receiver-operating characteristic area under curve=0.82) and limited versus full community ambulators (receiver-operating characteristic area under curve=0.76). A comfortable gait speed of 0.49 m/s discriminated between home and community and a comfortable gait speed of 0.93 m/s discriminated between limited community and full community ambulators. Conclusions— The 6-minute walk test was better able to discriminate among home, limited community, and full community ambulators than comfortable gait speed. Gait speed values commonly used to distinguish between home and community walkers may overestimate walking activity.

Regaining the ability to walk is a major rehabilitation goal after a stroke. Recent research suggests that, in people with stroke, task-oriented and intensive rehabilitation strategies can drive cortical reorganization and increase activity levels. This paper describes development and pilot testing of a novel wearable device for Real-Time Gait and Activity Improving Telerehabilitation (RT-GAIT), designed for use with such rehabilitation strategies. The RT-GAIT provides auditory or tactile feedback to the individual wearing the platform. The feedback is based on the amount of time spent in stance phase on each foot, as measured by the pressure sensors embedded into the insoles. The system was initially bench-validated using sensor signals collected in a previous study. Next, a clinical case study was conducted with one post-stroke individual. The results of the case study suggest that the RT-GAIT device can potentially improve the gait parameters. Mean difference in stance times between the healthy limb and paretic limb was improved by 48% and the standard deviation for the same was improved by 87.5%, between baseline measurements and the measurements taken after the treatment with the RT-GAIT.

The purpose of this study was to determine the ability of a novel shoe-based sensor that uses accelerometers, pressure sensors, and pattern recognition with a support vector machine (SVM) to accurately identify sitting, standing, and walking postures in people with stroke.Subjects with stroke wore the shoe-based sensor while randomly assuming 3 main postures: sitting, standing, and walking. A SVM classifier was used to train and validate the data to develop individual and group models, which were tested for accuracy, recall, and precision.Eight subjects participated. Both individual and group models were able to accurately identify the different postures (99.1% to 100% individual models and 76.9% to 100% group models). Recall and precision were also high for both individual (0.99 to 1.00) and group (0.82 to 0.99) models.The unique combination of accelerometer and pressure sensors built into the shoe was able to accurately identify postures. This shoe sensor could be used to provide accurate information on community performance of activities in people with stroke as well as provide behavioral enhancing feedback as part of a telerehabilitation intervention.

Standardized outcome measures (OMs) are a vital part of evidence-based practice. Despite the recognition of the importance of OMs, recent evidence suggests that the use of OMs in clinical practice is limited. Selecting the most appropriate OM enhances clinical practice by (1) identifying and quantifying body function and structure limitations; (2) formulating the evaluation, diagnosis, and prognosis; (3) informing the plan of care; and (4) helping to evaluate the success of physical therapy interventions. This article (Part I) is the first of a 2-part series on the process of selecting OMs in neurological clinical practice. We introduce a decision-making framework to guide the selection of OMs and discuss 6 main factors-what to measure, the purpose of the measure, the type of measure, patient and clinic factors, psychometric factors, and feasibility-that should be considered when selecting OMs for clinical use. The framework will then be applied to a patient case in Part II of the series (see the article "Outcome Measures in Neurological Physical Therapy Practice: Part II. A Patient-Centered Process" in this issue).

A quiet standing index is developed for tracking the postural sway of healthy and diabetic adults over a range of ages. Several postural sway features are combined into a single composite feature C that increases with age a. Sway features are ranked based on the r(2)-values of their linear regression models, and the composite feature is a weighted sum of selected sway features with optimal weighting coefficients determined using principal component analysis. A performance index based on both reliability and sensitivity is used to determine the optimal number of features. The features used to form C include power and distance metrics. The quiet standing index is a scalar that compares the composite feature C to a linear regression model f(a) using C(')(a) = C/f(a). For a motionless subject, C(') = 0, and when the composite feature exactly matches the healthy control (HC) model, C(') = 1. Values of C(')1 represent excessive postural sway and may indicate impaired postural control. Diabetic neurologically intact subjects, nondiabetic peripheral neuropathy subjects (PN), and diabetic PN subjects (DPN) were evaluated. The quiet standing indexes of the PN and DPN groups showed statistically significant increases over the HC group. Changes in the quiet standing index over time may be useful in identifying people with impaired balance who may be at an increased risk of falling.

Repetitive practice improves function and facilitates cortical plasticity after stroke. Virtual reality (VR) systems have the potential to provide motivating and safe repetitive practice with minimal supervision. The purpose of this case study is to look at the effect of a VR system, activated by surface electromyography of dorsiflexors and plantarflexors, on gait velocity, function, and kinematics.The first person randomized to the treatment group of a larger study was chosen for this case. She was 51 years old and 9 months poststroke. She received treatment 3 times per week for 8 weeks. Each 60-minute session consisted of both structured lower extremity exercise and VR ankle activities.After intervention, the subject demonstrated increased gait speed and decreased time to perform the modified Emory Functional Ambulation Profile. Gait kinematics demonstrated improved ankle motion and plantarflexion moments at push off.The improved gait speed, possibly due to increased ankle plantarflexion motion and moments, resulted in a more normalized trailing limb posture. This case study suggests that ankle to computer VR systems may help stroke patients improve gait function. This VR system has potential as an adjunctive therapy or home program requiring minimal supervision.

The 6-minute walk test (6MWT) is commonly used to measure walking ability. The purpose of this study was to determine the test-retest reliability and concurrent and construct validity of the 6MWT in patients who were actively undergoing inpatient rehabilitation poststroke. Thirty-seven patients undergoing inpatient rehabilitation after a stroke participated; mean age was 66.3 years and mean time since stroke was 33.7 days. Patients underwent two 6MWT trials with 1-3 days between trials. Additional outcome measures taken were gait speed and the Functional Independence Measure (FIM). The 6MWT exhibited high test-retest reliability; ICC(2,1) 0.973 (95% CI=0.925-0.988) and a minimal detectable change (MDC(90)) of 54.1 m. The 6MWT was strongly to moderately correlated with gait speed (r=0.89), locomotion (walk) FIM (r=0.69), and motor FIM (r=0.52). The 6MWT is a clinically useful measure of walking ability poststroke. It is reliable and is related to other measures of walking ability and function that are commonly used during rehabilitation after stroke.

Daily ambulatory activity is associated with health and functional status in older adults; however, assessment requires multiple days of activity monitoring. The objective of this study was to determine the relative capabilities of self-selected walking speed (SSWS), maximal walking speed (MWS), and walking speed reserve (WSR) to provide insight into daily ambulatory activity (steps per day) in community-dwelling older adults. Sixty-seven older adults completed testing and activity monitoring (age 80.39 [6.73] years). SSWS (R2 = .51), MWS (R2 = .35), and WSR calculated as a ratio (R2 = .06) were significant predictors of daily ambulatory activity in unadjusted linear regression. Cutpoints for participants achieving < 8,000 steps/day were identified for SSWS (≤ 0.97 m/s, 44.2% sensitivity, 95.7% specificity, 10.28 +LR, 0.58 −LR) and MWS (≤ 1.39 m/s, 60.5% sensitivity, 78.3% specificity, 2.79 +LR, 0.50 −LR). SSWS may be a feasible proxy for assessing and monitoring daily ambulatory activity in older adults.

The Body Weight Support (BWS) system used in conjunction with a treadmill has become increasingly popular in the clinical arena for the treatment of a variety of patient populations. Currently, commercially available BWS systems are designed with different types of suspension mechanisms and a variety of additional features. The purposes of this article are to: (i) provide an overview of the three main types of BWS suspension systems; (ii) review the uses, advantages, and disadvantages of each type; and (iii) highlight and discuss the many additional features that are available. Rehabilitation research conducted with neurological and non-neurological patient populations using a BWS system as a therapeutic modality is highlighted to assist the clinician to select the most suitable BWS system and features for a particular clinical purpose or patient group. Additionally, research findings for the biomechanical effects of varied BWS suspension devices on gait are discussed.

Usability is an important topic in the field of telerehabilitation research. Older users with disabilities in particular, present age-related and disability-related challenges that should be accommodated for in the design of a user interface for a telerehabilitation system. This paper describes the design, implementation, and assessment of a telerehabilitation system user interface that tries to maximize usability for an elderly user who has experienced a stroke. An Internet-connected Nintendo(®) Wii™ gaming system is selected as a hardware platform, and a server and website are implemented to process and display the feedback information. The usability of the interface is assessed with a trial consisting of 18 subjects: 10 healthy Doctor of Physical Therapy students and 8 people with a stroke. Results show similar levels of usability and high satisfaction with the gaming system interface from both groups of subjects.

Improving community mobility is a common goal for persons with stroke. Measuring daily physical activity is helpful to determine the effectiveness of rehabilitation interventions. In our previous studies, a novel wearable shoe-based sensor system (SmartShoe) was shown to be capable of accurately classify three major postures and activities (sitting, standing, and walking) from individuals with stroke by using Artificial Neural Network (ANN). In this study, we utilized decision tree algorithms to develop individual and group activity classification models for stroke patients. The data was acquired from 12 participants with stroke. For 3-class classification, the average accuracy was 99.1% with individual models and 91.5% with group models. Further, we extended the activities into 8 classes: sitting, standing, walking, cycling, stairs-up, stairs-down, wheel-chair-push, and wheel-chair-propel. The classification accuracy for individual models was 97.9%, and for group model was 80.2%, demonstrating feasibility of multi-class activity recognition by SmartShoe in stroke patients.

This paper presents the development and experimental evaluation of a volitional control architecture for a powered-knee transfemoral prosthesis that affords the amputee user with direct control of knee impedance using measured electromyogram (EMG) potentials of antagonist muscles in the residual limb. The control methodology incorporates a calibration procedure performed with each donning of the prosthesis that characterizes the co-contraction levels as the user performs volitional phantom-knee flexor and extensor contractions. The performance envelope for EMG control of impedance is then automatically shaped based on the flexor and extensor calibration datasets. The result is a control architecture that is optimized to the user's current co-contraction activity, providing performance robustness to variation in sensor placement or physiological changes in the residual-limb musculature. Experimental results with a single unilateral transfemoral amputee user demonstrate consistent and repeatable control performance for level walking at self-selected speed over a multi-week, multi-session period of evaluation.