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Abstract Background Parkinson’s disease (PD) is a neurodegenerative disorder with debilitating motor and non-motor symptoms which affect participation in meaningful occupations. Occupation-based interventions can improve participation in people with PD. Evidence for incorporating structured and intensive occupational therapy by considering the concept of responsibility is lacking for this population. This trial will compare the effects of occupation-based interventions with and without responsibility feedback and conventional interventions on participation in people with idiopathic PD. Methods A total of 45 people with PD, between 35 and 85 years old and Hoehn and Yahr stages between I to III, will be recruited from movement disorder centers for this three-armed study. Participants will be randomized into three groups (occupation-based interventions with responsibility feedback, occupation-based interventions without responsibility feedback, and conventional interventions). All participants will receive intervention for 24 sessions during a period of 12 weeks (2 sessions per week). The primary outcome measure will be participation satisfaction. Participation frequency and restriction, self-perceived performance, performance satisfaction, motivation, volition, sense of agency, responsibility, physical activity, community integration, activities of daily living (ADL), instrumental ADL, upper extremity function, balance, fatigue, and quality of life will be measured as secondary outcome measures. All outcomes will be measured at baseline, session 9, session 17, post-intervention (week 13), and follow-up (week 25). Discussion This home-based high-intensity, structured, client-centered, and occupation-based intervention will be conducted by utilizing the concept of responsibility. This proposed trial may result in enhanced participation that would benefit other motor and non-motor symptoms in people living with PD. Findings from this proposed study are expected to expand the knowledge of clinicians and help them in evidence-based decision-making processes. Trial registration Iranian Registry of Clinical Trials IRCT20140304016830N13. Registered on August 19, 2022

Introduction: Postural instability is a restrictive feature in Parkinson’s disease (PD), usually assessed by clinical or laboratory tests. However, the exact quantification of postural stability, using stability theorems that take into account human dynamics, is still lacking. We investigated the feasibility of control theory and the Nyquist stability criterion—gain margin (GM) and phase margin (PM)—in discriminating postural instability in PD, as well as the effects of a balance-training program.Methods: Center-of-pressure (COP) data of 40 PD patients before and after a 4-week balance-training program, and 20 healthy control subjects (HCs) (Study1) as well as COP data of 20 other PD patients at four time points during a 6-week balance-training program (Study2), collected in two earlier studies, were used. COP was recorded in four tasks, two on a rigid surface and two on foam, both with eyes open and eyes closed. A postural control model (an inverted pendulum with a Proportional-integral-derivative (PID) controller and time delay) was fitted to the COP data to subject-specifically identify the model parameters thereby calculating |GM| and PM for each subject in each task.Results: PD patients had a smaller margin of stability (|GM| and PM) compared with HCs. Particularly, patients, unlike HCs, showed a drastic drop in PM on foam. Clinical outcomes and margins of stability improved in patients after balance training. |GM| improved early in week 4, followed by a plateau during the rest of the training. In contrast, PM improved late (week 6) in a relatively continuous-progression form.Conclusion: Using fundamental stability theorems is a promising technique for the standardized quantification of postural stability in various tasks.

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorders characterized by poor attention and subsequently lower learning abilities than normal children. This study aimed to compare the effectiveness of neurofeedback and perceptual-motor exercises as two common nonpharmacological treatments for visual attention. Methods: A total of 40 combined medicated ADHD children (aged 5-12 years) were randomly allocated into two groups: neurofeedback training and perceptual-motor exercises. Visual attention and motor proficiency were assessed before and after the treatment by continuous performance test (CPT) and Bruininks-Oseretsky Test (BOT), respectively. Results: According to repeated measures analysis of variance (ANOVA), both groups showed significant improvement in three attention-related areas of CPT, including reaction time, omission, and commission errors (P0.05). However, in the perceptual-motor exercises group, motor proficiency improved significantly (P

Objectives: This study aimed to investigate the effect of upper extremity coordination exercises based on fatigue prediction on fine and gross manual dexterity, upper limb motor function, shoulder and elbow proprioception, occupational performance, and activities of daily living in chronic stroke survivors. Methods: In this pilot double-blind randomized clinical trial, 24 chronic strokes were enrolled using the non-probability sampling method. Participants were randomly allocated to the control (received routine occupational therapy) and intervention (received upper extremity coordination exercises based on fatigue prediction using the Kinect) groups. Before and after the interventions (six weeks, three sessions/week, 45 min/session), as well as six weeks after completion of interventions, participants were assessed using the following tools: Box-Block Test, Purdue-Pegboard Test, Wolf-Motor Function Test, Action Research Arm Test, Manual Ability Measure-16, Grip Dynamometer, Shoulder Position Sense Test (SPST), Elbow Position Sense Test (EPST), Canadian Occupational Performance Measure, Shah-Barthel Index (SH-BI), and Multi-dimensional Fatigue Inventory. This project was carried out in the rehabilitation department of Shafa-Yahyaeian Hospital from May 2019 to June 2020. Results: The results showed a significant improvement in all assessments of both control and intervention groups (P≤0.05), except for SH-BI. Further, the improvement of EPST and SPST scores in the intervention group was significantly greater than the control group (P≤0.05). Also, a significant decrease in fatigue severity was observed in both control and intervention groups (P≤0.05). Conclusion: These results suggest that upper extremity coordination exercises based on fatigue prediction in combination with routine occupational therapy could lead to improvement of upper extremity sensory-motor functions and power grip and caused a decrease in fatigue severity in chronic stroke.

Abstract Background Biomechanical risk factors have been identified as the main predisposing factor of chronic low back pain (CLBP), especially in Army personnel. The Job Requirements and Physical Demands (JRPD) questionnaire has been developed to assess the biomechanical exposures related to CLBP. Examining the biomechanical risk factors could prevent CLBP. This study aimed to translate and cross-culturally adapt the JRPD into Persian and assess its psychometric properties among Iranian male Army personnel with CLBP. Methods In this cross-sectional study, the content validation of the JRPD was assessed after translating to Persian. The Persian JRPD was administered to 198 male Army personnel with CLBP, with an interval of 7 days, to assess test-retest reliability, including Cronbach’s α, intraclass correlation coefficients (ICC), standard error of measurement (SEM), and minimal detectable change at 95% confidence interval (MDC95%). Scores of the Persian JRPD were correlated with the scores of visual analog scale (VAS), Borg’s category-ratio (CR10) scale, general health questionnaire-28 (GHQ-28), and physical functioning (PF1 and PF2) subscale of the 12-item short-form health survey (SF-12) to assess convergent validity using Spearman correlation for a priori hypotheses. Results The Persian JRPD had good content validity evidenced by the higher content validity index (> 0.70). The questionnaire had a significant positive negligible to weak correlation with the VAS (rho = 0.27; p

Background and Objectives: An ankle sprain is one of the most common musculoskeletal injuries and has various complications. Various factors can predict post-injury complications, including ankle muscle strength, pain, and activity level. So far, no study has exclusively investigated the predictive role of these factors. Therefore, this study aims to investigate the role of these factors in ankle instability, functional mobility, and gait speed in individuals with ankle sprain. Methods: This study was conducted on 140 individuals with ankle sprains who were referred to medical centers in Shiraz City, Iran. The demographic information of the patients (including the time elapsed since the sprain, etc.) was recorded by a demographic questionnaire. Related tests were also used to evaluate ankle muscle strength, pain, activity level, ankle functional instability, functional mobility, and gait speed, respectively. Results: In the regression models, the predictive value for each outcome of ankle functional instability, functional mobility, and walking speed was 45.5%, 58.8%, and 65.3% of the variance, respectively. In all stepwise models, ankle muscle strength was the strongest predictor for the outcomes of functional ankle instability, functional mobility, and gait speed. Conclusion: Ankle muscle strength, level of education, history of sprain in the last year, and age were the vital predictors of ankle functional instability. Muscle strength, age, and sprain status were the critical predictors of functional mobility respectively. Muscle strength, pain, age, duration of sprain, and activity level were the crucial predictors of gait speed.

Introduction: Balance screening has been identified as a major predictor of falls in the elderly. The current study compares the diagnostic accuracy of various balance instruments in community-dwelling older adults. Materials and Methods: In this cross-sectional study, 145 older adults were recruited. The Berg balance scale (BBS), Fullerton advanced balance (FAB) scale, dynamic gait index (DGI), performance-oriented mobility assessment (POMA), timed up and go (TUG) test, gait speed, step length, step test, and single item question were administered. The receiver operating characteristics curve analysis was used to calculate diagnostic accuracy. Results: All single-item tools had moderate diagnostic accuracy (area under the curve [AUC]=0.76-0.89) and all multi-item tools had high diagnostic accuracy (AUC=0.91-0.95) when using the recommended cut-off point of 45 for BBS. All multi-item tools maintained high to moderate diagnostic accuracy (AUC=0.85-1.00) in all thresholds while using BBS severity cut-off points. The FAB scale showed the highest diagnostic accuracy (AUC=0.95) among all assessment tools. Single-item question scores (Wald=22.61, df=1, P=0.0001, Exp(B)=8.82) were significant as covariates in the regression model. Conclusion: For older adults with or without a history of falling, the FAB scale demonstrated the highest diagnostic accuracy. Along with single-item tools, the FAB scale may be a preferred multi-item tool.

Introduction: Freezing of gait, a common PD motor symptom, could increase the risk of falling. This study aimed to investigate the clinimetric attributes of the Freezing of Gait Questionnaire (FOGQ) for people with Parkinson disease in the “off” state. Methods: A total of 115 patients with Parkinson disease (PD; mean age, 60.25 years) were included. Acceptability, internal consistency (by the Cronbach alpha, and test-retest by Intraclass Correlation [ICC]), and reliability of the Persian-translated version of the FOGQ were examined. Dimensionality was estimated by Exploratory Factor Analysis (EFA). Fall efficacy scale-international, unified Parkinson disease rating scale-II, Berg balance scale, functional reach test, and Parkinson disease questionnaire-39 were applied to determine the convergent validity. Diagnostic accuracy for obtaining optimal cutoff point, separating faller and non-faller groups, was analyzed by Receiver Operating Characteristics (ROC) curve analysis and Area Under the Curve (AUC). All tests were carried out in an “off” state. Results: The Cronbach alpha was high (α=0.92). The test-retest showed high reliability (ICC=0.89). The FOGQ was unidimensional according to the EFA and had acceptable convergent validity with moderate to high correlation with other clinical scales. The optimal cutoff point to discriminate fallers from non-fallers during the “off” state was 9/10, with an AUC of 0.92. Conclusion: Our results suggest that the FOGQ has appropriate reliability, validity, and discriminative ability for measuring FOG in patients with PD during the “off” state.

Background and Objectives: To investigate the correlation between reach and grasp kinematic measures and clinical measures of gross and fine manual dexterity in patients with idiopathic Parkinson Disease (PD). Methods: Sixty patients (44 men, 16 women) with idiopathic PD (Mean±SD of age: 59.85±11.89 years) were recruited in this non-experimental cross-sectional study using a non-probability sampling method. Their gross and fine manual dexterity were assessed using the Box and Block Test (BBT) and Nine Hole Peg Test (NHPT), respectively. Also, reach and grasp kinematic measures (including normalized movement time, peak velocity, Maximum Grip Aperture [MGA], and percentage of movement time in which MGA occurred [PMGA]) were measured in the more affected hand. Results: The results showed a significant and moderate correlation between reach kinematic measures (i.e. normalized movement time and peak velocity) and both gross and fine manual dexterity assessed by BBT (P=0.000) and NHPT (P=0.000), respectively. However, there was not a significant correlation between grasp kinematic measures (i.e. MGA and PMGA) and gross manual dexterity measured by BBT (P>0.05) as well as fine manual dexterity assessed by NHPT (P>0.05). Conclusion: This study showed no to moderate correlation between reach and grasp kinematic measures and clinical measures of gross and fine manual dexterity in patients with PD, supporting the significance of multi-level evaluation using both clinical and kinematic measures in the evaluation of upper limb function in patients with PD.

Background and Objectives: Burn injuries are one of the most common traumas after traffic accidents, falls, and interpersonal violence. This study was done to investigate the correlation between psychological factors, pain, and sleep quality, and disability and occupational performance in subjects with hand and upper extremity burns. Methods: A total of 80 patients with hand and upper extremity burn injuries (16 females and 64 males) with a Mean±SD age of 39.9±10.79 years, mean burn depth (Deep Partial Thickness/ Full Thickness) of 3.42±2.66, and Mean±SD burns extent 1.06±0.24 participated in this non-experimental cross-sectional study using a non-probability sampling method. Their psychological disorders were measured using the Beck Anxiety Disorder Scale and the Self-Rating Depression Scale. The pain was assessed using the Visual Analogue Scale, sleep quality was measured by the Pittsburgh Sleep Quality Index (PSQI), disability was assessed using the Shortened Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, level of independence in daily living activity was measured by the Modified Barthel Index, and occupational performance was measured by the Canadian Occupational Performance Measure (COPM). Results: Psychological factors, pain, and sleep quality were significantly correlated with disability and occupational performance. The regression models explained up to 34.4% of the variance for disability outcome and 12.4% for occupational performance. By assessing the correlation between the psychological disorders, pain, and sleep quality, and disability and occupational performance in these patients, we found that sleep quality was the strongest contributing factor Followed by PSQI. Conclusion: Sleep quality is one of the important factors affecting the occupational performance of patients with hand and upper extremity burns injury that should be considered by therapists.

Abstract Background Balance training improves postural control in Parkinson’s disease (PD). However, a systematic approach for the development of individualized, optimal training programs is still lacking, as the learning dynamics of the postural control in PD, over a training program, are poorly understood. Objectives We investigated the learning dynamics of the postural control in PD, during a balance-training program, in terms of the clinical, posturographic, and novel model-based measures. Methods Twenty patients with PD participated in a balance-training program, 3 days a week, for 6 weeks. Clinical tests assessed functional balance and mobility pre-training, mid-training, and post-training. Center-of-pressure (COP) was recorded at four time-points during the training (pre-, week 2, week 4, and post-training). COP was used to calculate the sway measures and to identify the parameters of a patient-specific postural control model, at each time-point. The posturographic and model-based measures constituted the two sets of stability- and flexibility-related measures. Results Mobility- and flexibility-related measures showed a continuous improvement during the balance-training program. In particular, mobility improved at mid-training and continued to improve to the end of the training, whereas flexibility-related measures reached significance only at the end. The progression in the balance- and stability-related measures was characterized by early improvements over the first 3 to 4 weeks of training, and reached a plateau for the rest of the training. Conclusions The progression in balance and postural stability is achieved earlier and susceptible to plateau out, while mobility and flexibility continue to improve during the balance training.

Objectives: An appropriate and accurate assessment tool is needed to predict the risk of falling in older adults. This study aimed at investigating the construct validity, factor analysis, internal consistency, test-retest and inter-rater reliability, and ceiling/floor effects of the Persian version of Performance-oriented Mobility Assessment (POMA) in community-dwelling elderly. Methods: One hundred and forty-five older adults aged 65 years and older (mean age: 73.68 years) were recruited from daily care centers of Tehran by convenience sampling method. Timed Up and Go (TUG) test and Berg Balance Scale (BBS) were used to investigate the construct validity of the POMA. Test-retest (7-14 days with interval) and inter-rater reliability of the gait and balance subscales and the total score of the POMA were determined by Intraclass Correlation Coefficient (ICC2,1). Results: A moderate to very high correlation (r=0.67-0.9, P≤0.05) was found between the total score of the POMA and BBS, Fullerton Advanced Balance Scale, step test (right and left), TUG, Dynamic Gait index, and walking speed, whereas the correlation between the total score of the POMA and step length was poor (r=0.39, P≤0.05). The results of confirmatory factor analysis showed a poor goodness-of-fit of POMA with the two-factor model (balance and gait) in community-dwelling elderly. Internal consistency (Cronbach's alpha=0.94), test-retest reliability (ICC2,1)=0.97), as well as inter-rater reliability (ICC2,1)=0.92) of the POMA were excellent. The results revealed no floor effect for the total score of the POMA; however, its ceiling effect was 3.44%. Discussion: The Persian version of POMA showed excellent psychometric properties for evaluating different aspects of balance in community-dwelling elderly.

Abstract Background Impaired postural control in Parkinson’s disease (PD) seriously compromises life quality. Although balance training improves mobility and postural stability, lack of quantitative studies on the neurophysiological mechanisms of balance training in PD impedes the development of patient-specific therapies. We evaluated the effects of a balance-training program using functional balance and mobility tests, posturography, and a postural control model. Methods Center-of-pressure (COP) data of 40 PD patients before and after a 12-session balance-training program, and 20 healthy control subjects were recorded in four conditions with two tasks on a rigid surface (R-tasks) and two on foam. A postural control model was fitted to describe the posturography data. The model comprises a neuromuscular controller, a time delay, and a gain scaling the internal disturbance torque. Results Patients’ axial rigidity before training resulted in slower COP velocity in R-tasks; which was reflected as lower internal torque gain. Furthermore, patients exhibited poor stability on foam, remarked by abnormal higher sway amplitude. Lower control parameters as well as higher time delay were responsible for patients’ abnormal high sway amplitude. Balance training improved all clinical scores on functional balance and mobility. Consistently, improved ‘flexibility’ appeared as enhanced sway velocity (increased internal torque gain). Balance training also helped patients to develop the ‘stability degree’ (increase control parameters), and to respond more quickly in unstable condition of stance on foam. Conclusions Projection of the common posturography measures on a postural control model provided a quantitative framework for unraveling the neurophysiological factors and different recovery mechanisms in impaired postural control in PD.

Introduction: In the elderly, functional balance, fear of falling, and independence in daily living activities are interrelated; however, this relationship may change under the influence of drug phase and the severity of disease in individuals with idiopathic Parkinson disease. This study aimed to investigate the association of functional balance, fear of falling, and independence in the Activities of Daily Living (ADL) with the drug on- and drug off-phases. Methods: A total of 140 patients with Parkinson disease (age: Mean±SD; 60.51±12.32 y) were evaluated in terms of their functional balance, fear of falling, and independence in their daily activities by the Berg Balance Scale (BBS), Fall Efficacy Scale-International (FES-I), and Unified Parkinson Disease Rating Scale-ADL (UPDRS-ADL), respectively, in drug on- and drug off-phases. The Hoehn and Yahr scale recorded global disease rating. The Spearman coefficient, Kruskal-Wallis, and Mann-Whitney tests were used to find out whether the distribution of scale scores differs with regard to functional balance or disease severity. Results: A strong correlation was found between the functional balance, fear of falling, and independence in ADL with both drug phases. The results also showed the significant difference in the distribution of the FES-I and UPDRS-ADL scores with regard to functional balance (except independence in ADL in drug off-phase). Also, the distribution of the scores of BBS, FES-I, and UPDRS-ADL showed significant differences with regard to disease severity. Conclusion: The study showed a strong correlation between functional balance, fear of falling, and independence in ADL that can be affected by the drug phase and severity of the disease. However, more studies are needed to understand this relationship precisely.

Background: The majority of hemi-paretic stroke patients showed weight bearing asymmetry effects on postural control during bending and reaching tasks. The purSpose of this study was to investigate the effect improving weight bearing asymmetry using 5˚ and 7.5˚ lateral shoe wedges on dynamic postural control of chronic stroke patients during bending and reaching. Methods: Seventeen hemi-paretic patients (10 female and 7 male, 11 left hemiparesis and 6 right hemiparesis), and weight bearing asymmetry more than 10% during standing participated in this study. Postural sway parameters were computed for six targets (2 distances and three directions) in four conditions of wedges: non- wedge, wedge 5˚, wedge 7.5˚ and last non wedge during bending and reaching tasks. Results: There were no statistical differences between the effects of two types of lateral shoe wedges (5˚ and 7.5˚) on symmetry index and postural sway parameters. The main effects of target were significant for all body sway parameters but the main effects of wedges were only significant for sway path and velocity. Interaction effects of target by wedge were not significant for any of sway parameters. Conclusion: Lateral shoe wedges have a positive effect on dynamic postural control of stroke patients. This method may be used to treat postural control deficits during bending and reaching tasks in stroke rehabilitation.

Background: Freezing of gait (FOG) is a disabling clinical phenomenon in patients with Parkinsonchr('39')s disease (PD), which is characterised by short episodes of inability to step and affect about 38.2 % of these patients. Abrupt FOG may disturb the balance and, thus, it is considered as a common cause of falls in PD. This study was designed to evaluate the fall diagnostic accuracy of the Timed Up and Go Test (TUG), a reliable and valid clinical test to assess mobility and risk of falls, in patients with PD who had FOG. Methods: In this cross-sectional study, 80 subjects with a diagnosis of idiopathic PD who had FOG by mean ± SD age of 63.63±9.76 years and mean ± SD disease duration of 7.82±5.76 years were enrolled by simple non-probability sampling method. They were divided into two faller and non-faller groups based on the history of fall during the past six months. Sensitivity, specificity, negative and positive likelihood ratios, and receiver operator characteristic curve was calculated for TUG. Results: The TUG score indicated significant differences between faller PD patients who had FOG and non-faller PD patients who had FOG (p=0.003). The best cut-off point for discriminating faller and non-faller PD patients who had FOG was 11.85 seconds (sensitivity= 68.97% and specificity= 86%). Conclusion: TUG demonstrated moderate sensitivity and specificity to fall status in patients with PD who had FOG, suggesting its use in conjunction with other tests for screening those who may need intervention for decreasing falls.

BackgroundDespite the high prevalence of anxiety among chronic stroke survivors and evidence of its negative effects on postural control in healthy subjects, it is unclear whether anxiety also affects postural control in these patients. Recent evidence of improved postural control of healthy subjects by distracting the attention using an external focus (EF) or cognitive task, raises the question of whether similar benefits would be observed in stroke survivors. Thus, the current study aimed to investigate the effects of anxiety and distracting the attention on postural control of chronic stroke survivors in terms of both postural sway measures and neuromuscular regulation.MethodsPostural sway measures and ankle muscle activity of chronic stroke survivors with the high and low level of anxiety (HA-stroke (n = 17), and LA-stroke (n = 17), respectively) and age-, sex-, height-, and weight-matched healthy subjects (n = 17) were assessed while standing on rigid and foam surfaces under following conditions: baseline, internal focus (IF), EF, simple and hard cognitive tasks (SC and HC, respectively).ResultsStroke survivors, particularly HA-stroke participants, showed greater postural sway measures (i.e. postural instability) and enhanced co-contraction of ankle muscles (i.e. stiffening of the neuromuscular system) compared with healthy subjects. As opposed to baseline and IF conditions, postural instability and neuromuscular stiffening significantly reduced in EF condition and decreased more in cognitive task conditions, particularly HC condition.ConclusionsThe results suggest that anxiety enhances stroke-induced postural instability promoting improper neuromuscular control of posture with stiffening strategy, which can be alleviated by EF and cognitive tasks.

Objective. Sleep problems are nonmotor symptoms in Parkinson’s disease that should be carefully evaluated for better management and treatment. Parkinson’s Disease Sleep Scale (PDSS-2) is one of the most reliable tools for measuring sleep difficulties in people with Parkinson’s disease. This study investigated the psychometric properties of the Persian version of PDSS-2. Methods. Four hundred and fifty-six people with Parkinson’s disease with a mean age ±standard deviation of 60.7 ± 11.3 years were engaged in this study. Acceptability was assessed by floor and ceiling effects. Dimensionality was measured by exploratory factor analysis. The convergent validity of PDSS-2 with the Hospital Anxiety and Depression Scale (HADS) was assessed. Internal consistency and test-retest reliability were assessed with Cronbach’s alpha and intraclass correlation coefficient (ICC), respectively. Results. No noticeable ceiling and floor effect was detected. The dimensionality analysis showed three factors. A high correlation was obtained between PDSS-2 and HADS (anxiety subscale). Excellent internal consistency with α = 0.94, and good test-retest reliability with ICC = 0.89 were obtained. Conclusion. This study showed that the Persian version of Parkinson’s Disease Sleep Scale has acceptable validity and reliability for measuring sleep disturbances in people with Parkinson’s disease.

Purpose. Pain is one of the nonmotor symptoms of Parkinson’s disease (PD) that, in order to be better managed, requires to be evaluated. Evaluations are done using pain assessment scales such as the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2). The goal of this study was to assess the psychometric properties of SF-MPQ-2 to measure pain in people with PD. Methods. Four hundred and twenty-eight PD patients with a mean (SD) age of 60.11 (11.44) years were included. Accessibility was measured through floor and ceiling effects. Dimensionality was estimated by exploratory factor analysis. The association between SF-MPQ-2 and other scales such as Neuropathic Pain Symptom Inventory, Douleur Neuropathic 4, Brief Pain Inventory, King’s Pain Parkinson’s Disease Scale, and Visual Analog Scale-Pain was considered to calculate convergent validity. Internal consistency and test-retest reliability were assessed by Cronbach’s alpha and intraclass correlation coefficient (ICC), respectively. Results. A noticeable floor effect was found. Dimensionality results indicated four factors for this scale. A strong relationship was found between the SF-MPQ-2 total score and other scales (r = 0.55 to 0.85). In reliability analysis, Cronbach’s alpha and ICC were 0.93 and 0.94 for SF-MPQ-2, respectively. Conclusion. The results of this study showed that SF-MPQ-2 has adequate validity and reliability to measure pain in people with Parkinson’s disease.

Background and Objective: Fear of falling is a major problem among people suffering from stroke. This study aimed to investigate the relationship between functional balance (FB) and fear of falling (FOF) in chronic stroke patients with and without history of falling and to identify the best measurement tool for FB which can assess the FOF in these patients. Methods: Eighty-two participants with chronic stroke with the mean age of 54.90 (±11.30) years participated in this non-experimental cross sectional study. They were divided into faller and non-faller groups based on their history of falling during the last month. The FB was measured by Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Tinetti Balance Test, and Functional Reach Test (FRT). The Persian versions of the self-completed Fall Efficacy Scale-International (FES-I) and Activity-specific Balance-Confidence scale (ABC) were used to evaluate FOF. Results: The results of this study showed that the correlation between FES-I with FRT, BBS, DGI and Tinetti Balance Test were -0.38, -0.67, -0.44 and -0.62, in faller group and -0.11, -0.59, -0.31 and -0.24 in non-faller group. The correlation between ABC and FRT, BBS, DGI and Tinetti Balance Test were 0.58, 0.48, 0.68 and 0.57 in faller group and 0.17, 0.55, 0.45 and 0.44 in non-faller group. The results of multiple regression analysis showed that BBS was the best predictor for FOF (which explained 25% and 31% of total variance of FES-I and ABC in faller group as well as 68% and 42% of total variance of FES-I and ABC in non-faller group). Conclusion: The results of this study showed a low to moderate correlation between FB and FOF in both groups of faller and non-faller chronic stroke patients. Furthermore, BBS seems to be the best functional balance measurement to predict FOF in these patients.

Objectives: One of the most disabling impairments following stroke is upper limb impairment. Despite the important role of somatosensory function in motor control and high prevalence of somatosensory deficits in stroke survivors, little attention has been paid to its effect on UE motor function in chronic stroke survivors. Thus, the aim of this study is to explore the correlation between different somatosensations and manual dexterity as well as UE motor function in these patients. Methods: In this correlational study, 225 chronic stroke survivors (112 female and 113 male) participated, selected by simple non-probability method among the stroke survivors admitted to the rehabilitation centers in Tehran. The lower-order somatosensations, including light touch and wrist Proprioception, were evaluated by Weinstein Enhanced Sensory Test (WEST) and Wrist Position Sense Test (WPST), respectively. The higher-order somatosensations were measured by static and moving 2-Point Discrimination (s2PD and m2PD, respectively), Hand Active Sensation Test (HAST) and Haptic Object Recognition Test (HORT). Gross and fine manual dexterity and UE motor function were assessed using Box-Block Test (BBT), Purdue Pegboard Test (PPT) and Wolf Motor Function Test (WMFT), respectively. Results: The multiple regression models showed that WPST alone accounted for the 38.8%- 56.6% of the variance in manual dexterity and UE motor function. The WEST was the second most significant predictor in all regression models. The HORT, m2PD and HAST explained a small percent of the variance in regression models. Discussion: These results suggest that treatments that target somatosensory impairments, especially wrist Proprioception and light touch, may be particularly important for improving manual dexterity and UE motor function in chronic stroke survivors.

Objectives: The present study aimed to investigate the possible effects of laterality and handedness on higher-order sensory functions and manual dexterity of the elderly. Methods: In this non-experimental cross-sectional study, 58 elderly people aged 60-75 years (35 right-handed) were recruited through a convenience sampling method. Laterality of the selected subjects was examined using the Edinburg test, while the higher-order sensory functions were assessed via haptic performance along with weight and texture discrimination tests. Gross and fine manual dexterity functions were assessed with the help of the box-and-block and Purdue pegboard tests, respectively. Results: Results showed that the main effects of laterality and handedness, as well as the interaction effect of laterality × handedness on the haptic performance of the elderly were not significant. However, the main and interaction effects of laterality and handedness on the texture and weight discrimination of the elderly were significant. On the other hand, the main and interaction effects of laterality and handedness on the gross and fine manual dexterity of the elderly were not found to be significant. Discussion: Laterality has no effect on the higher-order sensory functions of right- and left-handed elderly people. However, effects of laterality on fine motor dexterity in right-handed individuals were detected.

Context: Ellagic acid (EA) is a natural phenol antioxidant with various therapeutic activities. However, the efficacy of EA has not been examined in neuropathologic conditions. Objective: In vivo neuroprotective effects of EA on cuprizone (cup)-induced demyelination were evaluated. Material and methods: C57BL/6 J mice were fed with chow containing 0.2% cup for 4 weeks to induce oligodendrocytes (OLGs) depletion predominantly in the corpus callosum (CC). EA was administered at different doses (40 or 80 mg/kg body weight/day/i.p.) from the first day of cup diet. Oligodendrocytes apoptosis [TUNEL assay and myelin oligodendrocyte glycoprotein (MOG+)/caspase-3+ cells), gliosis (H&E staining, glial fibrillary acidic protein (GFAP+) and macrophage-3 (Mac-3+) cells) and inflammatory markers (interleukin 17 (IL-17), interleukin 11 (IL-11) and stromal cell-derived factor 1 α (SDF-1α) or CXCL12] during cup intoxication were examined. Results: High dose of EA (EA-80) increased mature oligodendrocytes population (MOG+ cells, p

Purpose. Since fear of falling may be one of the main problems in people with Parkinson’s disease (PD), its assessment with valid tools is necessary in both drug phases. This study was carried out to investigate the psychometric attributes of the Fall Efficacy Scale-International (FES-I) in people with PD, both in On and Off phases. Methods. One hundred twenty-four patients with PD (mean age ± standard deviation, 60.33 ± 12.59 years) were assessed with the FES-I, both in On- and Off-drug phases. Dimensionality, internal consistency, and test-retest reliability were, respectively, explored by means of factor analysis, Cronbach’s alpha, and Intraclass Correlation Coefficient. Convergent validity of FES-I was established with Visual Analog Scale-Fear of Falling, Berg Balance Scale, and Functional Reach Test. Parkinson’s Disease Questionnaire-39 and Unified Parkinson Disease Rating Scale-Activities of Daily Living were also applied. Discriminative validity was tested between patients with and without a history of falling. Results. Factor analysis showed two factors for On- and one factor for Off-drug phase. Internal consistency (α = 0.96, On phase; 0.98, Off phase) and test-retest reliability (0.94; 0.91) were satisfactory in both drug phases. There was a moderate/high correlation (rS = |0.50–0.70|) between FES-I and Visual Analog Scale-Fear of Falling, Berg Balance Scale, and Functional Reach Test. Parkinson’s Disease Questionnaire-39 and Unified Parkinson Disease Rating Scale-Activities of Daily Living were achieved in both drug phases too. The sensitivity of FES-I to discriminate Parkinson’s disease with and without falls showed moderate effect size in both phases. Conclusion. This study verified that FES-I is unidimensional, reliable, and valid to measure the Fear of Falling during On- and Off-drug phases in people with PD.

Background and Objectives: One of the most important areas in the rehabilitation of stroke patients is participation in meaningful activities. Participation of individuals with stroke in meaningful activities can increase their satisfaction and quality of life. The present study aimed to investigate the relationship between psychological factors and participation in meaningful activities as well as determining factors predicting participation in meaningful activities in patients with stroke. Methods: In this cross-sectional study, 100 people with chronic stroke participated which were selected from four rehabilitation centers using a convenience non-probability sampling method. Participants were assessed using Meaningful Activity Participation Assessment (MAPA), Satisfaction with Life Scale (SWLS), Center for Epidemiological Studies of Depression Scale (CED-S), 36-Item Short-Form Health Survey (SF-36), Visual Analogue Scale for Fatigue (VAS ‐ F), and Visual Analog Scale for Pain (VAS Pain). Results: The severity of depression had the highest relationship with the level of participation in meaningful activities. Also, the severity of depression, cognitive status, pain intensity, and severity of fatigue were identified as significant factors predicting the rate of participation in meaningful activities of patients with stroke. Conclusion: Participating in meaningful activities in people with stroke is an important issue and a major obstacle in the lives of people with stroke. As a result, identifying problems and making appropriate interventions to remove obstacles, such as fatigue, pain, cognitive problems, and most importantly depression should be a priority for professionals.

Background and Objectives: Cognitive and psychological disorders are among the most debilitating complications of Parkinson’s Disease (PD). Despite the high prevalence of these disorders in patients with PD and the important effect of psychological factors on cognitive factors in other neurological diseases, no study was found on the relationship between psychological factors and cognitive function in patients with PD who have chronic fatigue. The present study was conducted to investigate the relationship between psychological factors and cognitive function in patients with PD and chronic fatigue. Methods: In the present cross-sectional study, a total of 73 patients with PD who had chronic fatigue were selected by non-random convenience sampling method from those visiting Tehran’s rehabilitation centers in 2019. The following questionnaires were used: Fatigue Severity Scale (FSS) for fatigue, Beck’s Depression Inventory for depression, Beck’s Anxiety Inventory for anxiety, and Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) for cognitive function, as well as Unified Parkinson’s Disease Rating Scale (UPDRS-III) and Pain Visual Analog Scale (Pain VAS). Results: The regression models explained the cognitive function variance by a maximum of 1.43% in MMSE and 8.79% in MoCA. In all stepwise models of cognitive function, anxiety was the strongest predictor of cognitive function followed by age and UPDRS-III score. Conclusion: The results of this study indicated that anxiety as the strongest predictor can affect cognitive function in patients with PD who have chronic fatigue. Hence, therapeutic interventions focusing on psychological factors may be particularly important for improving cognitive function in these patients.

Background and Objectives: “Meaningful Activity Participation Assessment” (MAPA) questionnaire is a suitable tool for examining the frequency and meaningfulness of 28 activities. The aim of this study was to assess the face and content validity of the Persian version of MAPA for older adults. Methods: The face validity was assessed qualitatively using interviews and quantitively using the item impact method (IIM) with 15 elderly aged 65-90 years old and MMSE≥21. They measured the suitability simplicity and comprehensibility of the items. To assess the content validity using CVR and CVI, 15 occupational therapists (eight PhD. Candidates, seven masters) who had more than five years of experience in geriatric rehabilitation and aged>30 years old took part. Results: All items of MAPA using IIM were more than 1.5. The CVR scores for each item were 0.6-1 (the cut-off base on Lawshe table 0.49). The average CVR value of MAPA was 0.84. The I-CVI of the Persian version of MAPA ranged from 0.86-1. All items scored higher than 0.79. The S-CVI/UA was 0.58 and the S-CVI/Ave was 0.96. Conclusion: The Persian version of MAPA has acceptable content and face validity in the elderly. Investigation of test-retest and internal consistency reliability and construct validity (convergent, divergent, and factor analysis) is suggested.

Objectives: This study was performed to evaluate convergent validity, test-retest reliability and internal consistency of the Persian translation of the Fullerton advanced balance (FAB) for use in Iranian community- dwelling older adults and improve the quality of their functional balance assessment. Methods & Materials: The original scale was translated with forward-backward protocol. In the next step, using convenience sampling and inclusion criteria, 88 functionally independent older adults were selected to participate in the study. Their mean (SD) age was 67.15(5.79) years. The Persian version of the scale was administered to each participant twice with an interval of 2-4 days by the same examiner (occupational therapist). Convergent validity was assessed by correlating the scale with Berg balance scale, timed up and go test, and functional reach test. Results: The test-retest reliability of individual items indicated good to excellent reliability (Cohen’s Kappa=0.63–1). Intraclass correlation coefficient was excellent (ICC=0.98), standard error of measurement was good (SEM=0.17), and minimal detectable change was 0.46. Construct validity showed moderate to good correlation between the Persian version of FAB and Berg balance scale (r=0.65), functional reach (r=0.62), and timed up and go test (r=-0.77). Internal consistency was acceptable (Cronbach α=0.83-0.84) for both phases. Conclusion: The Persian version of the FAB Scale is an acceptable and excellent psychometric instrument in assessing the multiple dimensions of balance in Iranian community-dwelling older adults.

Although anxiety is a common non-motor outcome of Parkinson's disease (PD) affecting 40% of patients, little attention has been paid so far to its effects on balance impairment and postural control. Improvement of postural control through focusing on the environment (i.e. external focus) has been reported, but the role of anxiety, as a confounding variable, remains unclear.This study aimed to investigate the influence of anxiety and attentional focus instruction on the standing postural control of PD patients.Thirty-four patients with PD (17 with high anxiety (HA-PD) and 17 with low anxiety (LA-PD)), as well as 17 gender- and age-matched healthy control subjects (HC) participated in the study. Postural control was evaluated using a combination of two levels of postural difficulty (standing on a rigid force plate surface with open eyes (RO) and standing on a foam surface with open eyes (FO)), as well as three attentional focus instructions (internal, external and no focus).Only the HA-PD group demonstrated significant postural control impairment as compared to the control, as indicated by significantly greater postural sway measures. Moreover, external focus significantly reduced postural sway in all participants especially during the FO condition.The results of the current study provide evidence that anxiety influences balance control and postural stability in patients with PD, particularly those with high levels of anxiety. The results also confirmed that external focus is a potential strategy that significantly improves the postural control of these patients. Further investigation of clinical applicability is warranted towards developing effective therapeutic and rehabilitative treatment plans.

Introduction: Because of the effect of person, task and environment on the postural control of children with Hemiparetic Cerebral Palsy (HCP), different clinical and laboratory methods have been designed for postural control evaluation. The purpose of this study was to investigate the correlation between clinical and laboratory tests of mobility and balance in children with HCP. Methods: In this correlational study, twenty eight children with HCP by average age of 10.09 (±2.34) years were selected by simple non-probability sampling method. Timed Up and Go (TUG), Functional Reach (FR) and Bruininks Oseretsky Test of Motor Proficiency (BOTMP) and mean velocity, path length, total phase plane, area parameters of center of pressure fluctuations in 3 levels of postural difficulty (quiet standing on rigid surface with open and closed eyes and foam with closed eyes) and two levels of cognitive difficulty (with and without cognitive task) recorded by force plate were used as clinical and laboratory assessments respectively. Results: Among three postural tasks, the only in standing on foam with closed eyes was seen the significantly moderate to very high correlation between the all center of pressure sway measures and TUG, FR and BOTMP tests. The cognitive task in standing on foam surface condition cause to increase correlation between clinical and laboratory measures. Conclusion: The proper correlation was obtained between functional balance and mobility tests and center of pressure sway parameters in standing on foam surface with closed eyes condition. Key words: Postural control, Functional balance and mobility tests, Force plate parameters, Children, hemiparesia, cerebral palsy

Introduction: Falling is a common problem after stroke that occurs following the physical and psychological problems. Psychological factors such as reduce of self-efficacy in maintain balance could have an equal or even greater contribution than physical problems in falling. Therefore, having a suitable tool with acceptable repeatability seems to be necessary for evaluation of individual confidence in balance in prevention and rehabilitation programs. The aim of this study is Persian translation and investigation of the test-retest reliability of the Persian version of Activities-specific Balance Confidence (ABC) scale in chronic stroke. Material and Methods: The translation was done according to International Quality of Life Assessment procedure. Then, the Persian version of the ABC scale evaluated twice with 1 week interval by an expert occupational therapist on 62 patients with chronic stroke in Tehran city. The reliability if the scale was determined by internal consistency (Cronbach’s alpha coefficients); and test-retest reliability (Intraclass correlation coefficient, Pearson coefficient, standard errors of measurement; and minimum detectable change). Results: Content face validity of the Persian version for all questions of this scale showed good to excellent. Cronbach’s alpha coefficient was 0.97 in the first and second evaluation which indicates the excellent the internal consistency of this scale. The relative reliability total score of the scale was very excellent (0.97) in test-retest. Standard errors of measurement with 68% confidence were obtained 0.96 which is excellent. Furthermore, Pearson coefficient was in range of 0.86-0.97 in the investigation of the test-retest agreement for each item. Minimum detectable change was calculated 2.66. Conclusion: The result of this study indicated that the Persian version of the ABC scale has excellent test-retest reliability in Iranian chronic stroke and its minimum detectable change is acceptable.

Introduction: The following study was carried out in order to translate, cultural adaptation, and determine the content and face validity of the “Patient-Rated Wrist Evaluation” questionnaire with the aim of evaluating the two components of pain and disability in patients with wrist injuries. Material and Methods: The methodology of this survey was non-experimental study. After translation and cultural adaptation according to the Beaton method (approved by the American Surgeon Association), the pilot test was performed on patients with wrist injuries (fractures of the distal radius, scaphoid fractures and carpal tunnel syndrome). To assess content and face validity, the questionnaire was given to 10 specialists (6 of whom were occupational therapists, 2 were physiotherapists, and 2 were orthopaedic surgeons), and 20 patients with wrist injuries. Results: The qualitative content and face validity of the questionnaire for wrist injuries was appropriately reported good. Each item of the content validity ratio was slightly higher than 0.75 and this justified the necessity to include all items. Each item of the content validity index was slightly higher than 0.79. Therefore, all the items were approved in terms of their simplicity, clarity, and relevance. The impact score in order to evaluate the importance of each item was calculated and all were higher than 1.5. Therefore, in terms of face validity all the items were approved. Conclusion: The results showed that the Persian version of the “Patient-Rated Wrist Evaluation” questionnaire for evaluating the pain and disability of wrist injuries was indeed satisfactory, in terms of it’s content and face validity, thus it can be used in patients by specialists and therapists.

Objective: In some reviewed studies on children with dyslexia it is observed that there is a significant relationship between the ability of postural control and dyslexia. In this study, by controlling the interfering factors, we have reviewed this relation by comparing postural control and balance ability in normal and dyslexic children. Materials & Methods: This case-control study is done on 19 boys with dyslexia (112.90±13.78) and 19 Normal boys (118.42±15.62). Normal children and children with dyslexia were matched in age, height and weight. Positioning duties included standing with adjacent feet on firm surface with open and closed eyes, and with close eyes on the foam and with internal perturbation on firm surface. Duration of each assignment was 35 seconds and the force plate device was used to evaluate the condition performance. Balances component of Bruininks Oseretsky test were take from all of the samples and correlation between functional and laboratory test were examined. Results: The results showed that the area on firm surface with open eyes, internal perturbation dependency rate in the standard deviations of the lateral body sways (SDX) and of the antero-posterior body sways (SDY) and the surface area, there were significant differences between normal and dyslexic children, but there was not any significant difference between the two groups in path length and mean velocity in different postural control modes (foam, firm surface, open and close eyes) and visual dependence in all parameters (path length, velocity and surface area). We did not find significant correlation between Center of Pressure (COP) and the balance part of Bruininks Oseretsky test in children with dyslexia. Conclusion: In spite of differences in some postural control parameters between normal group and children with dyslexia, it was not found significant relationship between postural control and dyslexia.

Introduction: Independence in bending and picking up an object from the floor has great importance in activities of daily living. Asymmetrical distribution of weight is effective factor in imbalance and postural instability in people with hemiparesis. This study aimed to investigate the correlation between symmetry index and postural sway in selected dynamic task and functional balance tests in people with right and left chronic hemiparesis. Materials and Methods: Seventeen hemiparetic patients (6 right, 11 left) were selected by simple non-probability sampling. Weight bearing symmetry was measured by two weight scales. Postural sway parameters of the dynamic tasks were examined by force platform and Functional Reach and Timed Up and Go tests were used to measure functional balance. Results: Average for a value (standard deviation) for the months after stroke in right and left hemiparesis were 49.33 (43.06) and 75.36 (91.13) respectively. Symmetry index showed high to very high correlation (r = 0.865-0.925) with average COP velocity in right-far target and with total path excursion of COP in all near targets and right-far target in right hemiparesis and high correlation (r = -0.716) with maximum COP displacement in anterior-posterior direction in left-near target in left hemiparesis. Similarly, high correlation (r = -0.716) was found with maximum COP displacement in anterior-posterior direction in left-near target in left hemiparesis. Also it had no significant correlation with maximum COP displacement in anterior-posterior direction in right hemiparesis and with maximum COP displacement in medial-lateral direction in left hemiparesis. Symmetry index had a moderate correlation (r = -0.623) with Functional Reach test in left-sided hemiparesis but had no correlation with balance tests in right-sided hemiparesis. Conclusion: Because of difference in symmetry index correlation with postural sway parameters in dynamic task and functional balance tests in right and left hemiparesis, it can be noted that these two groups use different strategies while doing this task. Keywords: Weight bearing symmetry, Dynamic task, Functional balance, Hemiparesis

Objectives: The main goal of this study was to investigate the impact of difficulty level of postural task on dual task performance in young and older adults. Methods & Materials: 20 young (20-30 years) and 20 elderly (65-70 years) participants were selected by non-probable sampling method. Postural tasks (standing with parallel feet on the hard and foam surface) and cognitive task retrieved via auditory reaction times were applied. Cognitive and postural task assigned once individually and once simultaneously. Results: In the older group comparison Consequence analysis of easy balance task performance in a single and dual mode, showed no significant differences (P>0.05), but difficult balance task performance in dual-mode revealed more significant differences in compare than to single mode in elderly group. In the youth group performance of single and dual tasks were not significantly different (P>0.05). Comparing the performance of dual tasks in young and elderly groups revealed, with performing difficult balance tasks, different between aforementioned groups were significantly different (P

Objectives: It has been found that older adults fall or sway significantly more than younger ones under sensory conflict conditions. Considering the prospects of future increases in the elderly population size of Iran and the lack of proper postural control and the high costs of its probable consequences, this study investigated the effects of multi balance training on postural control. Methods & Materials: In this semi-experimental study, 34 elderly women participated in two training and control groups with the mean ages of 72.4 and 72.9 respectively. Before and after training, to investigate the functional balance and postural control, the Berg Balance Scale and a force plate were used. The training group participated in multisensory balance training sessions of 1 hour classes held three days per week for five weeks. Data was analyzed using an independent sample and a paired t-test. Results: The analysis showed significant differences between the training group and the control after balance training in the measured parameters of postural control consisting of path length and mean velocity in the eyes open (P=0.001) and eyes closed (P=0.0001) conditions and the Berg Balance Scale (P=0.002). Conclusion: Results indicate that multisensory balance training can improve the parameters of postural control even in short term.

Objectives: The Parkinson's disease is a progressive phenomenon that effort for maintain of independence in functional and self-care skills is considered as one of the most important aspects of their life. PASS (Performance Assessment of Self Care Skills) evaluates the activities of daily living (ADL), instrumental activities of daily living (IADL), and functional mobility (MOB) of the patients. Validity and reliability of this test has been evaluated in few disabilities and it has never been performed on patients with Parkinson's disease. The purpose of the present study was to assess the validity and reliability of PASS in evaluating the self-care skills of patients with Parkinson's disease. Methods & Materials: PASS was first translated into Persian and' after minor modifications, was given to 5 specialists (all were occupational therapists) along with a questionnaire especially designed for this purpose. For the purpose of testing the reliability 50 patients with Parkinson's disease aging 45-85 years were no randomly selected from 5 geographic regions of Tehran. The test and retest was performed on 2 consecutive days using the PASS manual for evaluating the self-care skills of the patients for 3 aspects of independence, safety, and outcome. Pearson correlation coefficient was measured between the results using SPSS 11package. Results: There was a significant agreement (P=95%) between the scores of 5 specialists in all 3 aspects of independence (X2=5.83, DF=4), safety (X2=5.44, DF=4), and outcome (X2=2.45, DF=4). Pearson correlation coefficient for test-retest results was 93%, 91%, and 91% for independence, safety, and outcome respectively (P=0.01) which is indicative of very high reliability of PASS for evaluating self-care skills of patients with Parkinson's disease. Conclusion: The results of the present study indicate that PASS is highly valid and reliable in evaluating the self-care skills of patients with Parkinson's disease. These results were not unexpected in the sense that' as long as the standards of test performance are observed, there should be no difference between the test-retest results of the same patient performed in 2 sessions. One other important aspect is patient education and familiarization with the test procedure. This aspect was tried to be effectively observed during the tests. It can be concluded from the results of this study that PASS is an appropriate tool for assessment of the self-care skills of patients with Parkinson's disease by rehabilitation specialists including occupational therapists.