Journal of Neurologic Physical Therapy最新文献

Background and purpose: Poor adherence to vestibular rehabilitation protocols is a known barrier to optimal care. Vestibular clinicians' comprehensive understanding of the barriers and facilitators to vestibular home exercise programs (VHEP) is a key element to achieving optimal care in the context of vestibular rehabilitation. The aims of this study are as follows: (1) to identify primary barriers and facilitators to VHEP from the perspective of patients with vestibular dysfunction and vestibular physical therapists (PTs); and (2) to provide strategies for clinicians to improve adherence and outcomes of VHEP.

Methods: A qualitative research with single-session focus groups conducted separately for: (1) patients with vestibular disorders and (2) vestibular PTs. Six focus groups were conducted, 3 for each population, with a total of 39 participants. An online survey was conducted to evaluate the estimates of adherence rates, followed by a structured discussion over barriers and facilitators to VHEP as perceived by patients and PTs. Thematic data analyses were performed using a mixed deductive-inductive approach.

Results: Eighteen patients with vestibular disorders and 21 experienced vestibular PTs participated in this study. Six barrier categories and 5 facilitator categories were identified. Barriers included motivation aspects, provocation of symptoms, time management, associated impairments, missing guidance and feedback, and psychosocial factors. Facilitators included motivation aspects, time management, patient education and exercise instructions, exercise setting, and associated symptom management.

Discussion and conclusions: Clinicians who prescribe home exercise to patients with vestibular disorders can use this information about common barriers and facilitators for patient education and to provide optimal care and improve rehabilitation outcomes.

Video abstract available: for more insights from the authors (see the video, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A467 ).

Background and purpose: Poststroke fatigue (PSF) is prevalent and often manifests as high perceived effort during activities. Little is known about how PSF influences goal-directed reaching after stroke. The purpose of this study was 2-fold (1) to evaluate how perceived effort changed when individuals with stroke performed a reaching task with various demands and (2) to determine whether PSF was associated with perceived effort during reaching and reach performance.

Methods: Thirty-six individuals with chronic stroke performed 2-dimensional reach actions under varied conditions with the more and less affected arms. Perceived effort during reaching was assessed using rating of perceived exertion (RPE) and Paas Mental Effort Rating Scale (MERS). Derived reach kinematics were used to quantify reach performance. The Fatigue Severity Scale (FSS) was administered to assess fatigue severity.

Results: Perceived effort was higher when participants reached with the more affected arm, reached toward far and small targets, and performed memory-guided reaching. Both RPE and MERS significantly correlated with the FSS score (r = 0.50 and 0.35, respectively, P < 0.05). Further, FSS correlated with movement time during the more affected arm reaching (ρ = 0.40, p < 0.05) and reach performance discrepancy between the fast and self-selected speed conditions when participants performed with the less affected arm (ρ = 0.36, P < 0.05). Exploratory analysis revealed that the relationship between fatigue and reach control appeared to be modulated by task demand.

Discussion and conclusions: PSF is associated with perceived effort during reaching and reach performance after stroke. These relationships might offer insights into arm performance in the real world after stroke.

Video abstract: for more insights from the authors Supplemental Digital Content available at http://links.lww.com/JNPT/A476.

Background and purpose: Functional recovery after stroke is often limited, despite various treatment methods such as robot-assisted therapy. Repetitive sensory stimulation (RSS) might be a promising add-on therapy that is thought to directly drive plasticity processes. First positive effects on sensorimotor function have been shown. However, clinical studies are scarce, and the effect of RSS combined with robot-assisted training has not been evaluated yet. Therefore, our objective was to investigate the feasibility and sensorimotor effects of RSS (compared to a control group receiving sham stimulation) followed by robot-assisted arm therapy.

Methods: Forty participants in the subacute phase (4.4-23.9 weeks) after stroke with a moderate to severe arm paresis were randomized to RSS or control group. Participants received 12 sessions of (sham-) stimulation within 3 weeks. Stimulation of the fingertips and the robot-assisted therapy were each applied in 45-min sessions. Motor and sensory outcome assessments (e.g. Fugl-Meyer-Assessment, grip strength) were measured at baseline, post intervention and at a 3-week follow-up.

Results: Participants in both groups improved their sensorimotor function from baseline to post and follow-up measurements, as illustrated by most motor and sensory outcome assessments. However, no significant group effects were found for any measures at any time (P > 0.058). Stimulations were well accepted, no safety issues arose.

Discussion and conclusions: Feasibility of robot-assisted therapy with preceding RSS in persons with moderate to severe paresis was demonstrated. However, RSS preceding robot-assisted training failed to show a preliminary effect compared to the control intervention. Participants might have been too severely affected to identify changes driven by the RSS, or these might have been diluted or more difficult to identify because of the additional robotic training and neurorehabilitation.

Video abstract available: for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A478).

Background and purpose: Visual biofeedback can be used to help people post-stroke reduce biomechanical gait impairments. Using visual biofeedback engages an explicit, cognitively demanding motor learning process. Participants with better overall cognitive function are better able to use visual biofeedback to promote locomotor learning; however, which specific cognitive domains are responsible for this effect are unknown. We aimed to understand which cognitive domains were associated with performance during acquisition and immediate retention when using visual biofeedback to increase paretic propulsion in individuals post-stroke.

Methods: Participants post-stroke completed cognitive testing, which provided scores for different cognitive domains, including executive function, immediate memory, visuospatial/constructional skills, language, attention, and delayed memory. Next, participants completed a single session of paretic propulsion biofeedback training, where we collected treadmill-walking data for 20 min with biofeedback and 2 min without biofeedback. We fit separate regression models to determine if cognitive domain scores, motor impairment (measured with the lower-extremity Fugl-Meyer), and gait speed could explain propulsion error and variability during biofeedback use and recall error during immediate retention.

Results: Visuospatial/constructional skills and motor impairment best-explained propulsion error during biofeedback use (adjusted R 2  = 0.56, P = 0.0008), and attention best-explained performance variability (adjusted R 2  = 0.17, P = 0.048). Language skills best-explained recall error during immediate retention (adjusted R 2  = 0.37, P = 0.02).

Discussion and conclusions: These results demonstrate that specific cognitive domain impairments explain variability in locomotor learning outcomes in individuals with chronic stroke. This suggests that with further investigation, specific cognitive impairment information may be useful to predict responsiveness to interventions and personalize training parameters to facilitate locomotor learning.

Background and purpose: Studies investigating high-intensity interval exercise (HIIE) in stroke typically emphasize treadmill training. However, a literature review suggested that seated devices such as a recumbent stepper or cycle offer a promising alternative for HIIE since exercise can be prescribed using peak power output (PPO). Therefore, this would give health care professionals the ability to monitor and adapt power output for the target heart rate range. The purpose of this secondary analysis was to examine the feasibility of prescribing short-interval, low-volume HIIE using PPO in chronic stroke.

Methods: We used several methods to test feasibility: (1)Acceptability: Measured by the percentage of participants who completed the entire HIIE protocol; (2) Implementation was assessed by the number of reported cardiac or serious adverse events during submaximal exercise testing and HIIE and the average percentage of participants reaching vigorous intensity, defined by the American College of Sports Medicine as at least 77% of age-predicted maximal heart rate (HR max ).

Results: Data were available for 28 participants who were 32.2 (17.2) months post-stroke and 61.4 (11.9) years of age. Twenty-eight participants completed HIIE per protocol. No cardiac or serious adverse events occurred during the submaximal exercise test or during HIIE. The rapid switching between HIIE and recovery showed no evidence of blood pressure reaching unsafe thresholds. Average intensity during HIIE reached 76.8% HR max , which is slightly below the target of 77.0%.

Discussion and conclusions: A single bout of short-interval, low-volume HIIE, prescribed using PPO, was feasible in chronic stroke.

Video Abstract : Available for more insights from the authors (Supplemental Digital Content, Video, available at: http://links.lww.com/JNPT/A474 ).

Background and purpose: Individuals with downbeat nystagmus (DBN) syndrome present with DBN, dizziness, blurred vision, and unsteady gait. Pharmacological intervention with 4-aminopyridine (4-AP) may be effective in improving oculomotor function, but there is minimal evidence to date that it improves gait. This suggests the possible benefit of combining pharmacotherapy with physical therapy to maximize outcomes. This case report documents improvements in gait and balance after physical therapy and aminopyridine (AP) in an individual with DBN syndrome.

Case description: The patient was a 70-year-old man with a 4-year history of worsening dizziness and imbalance, diagnosed with DBN syndrome. He demonstrated impaired oculomotor function, dizziness, and imbalance, which resulted in falls and limited community ambulation.

Intervention: The patient completed a customized, tapered course of physical therapy over 6 months. Outcome measures included the 10-meter walk test, the Timed Up and Go (TUG), the Dynamic Gait Index (DGI), and the modified clinical test of sensory integration and balance.

Outcomes: Improvements exceeding minimal detectable change were demonstrated on the TUG and the DGI. Gait speed on the 10-meter walk test did not change significantly, but the patient was able to use a cane to ambulate in the community and reported no further falls.

Discussion: Controlled studies are needed to explore the potential for AP to augment physical therapy in people with DBN syndrome. Physical therapists are encouraged to communicate with referring medical providers about the use of AP as pharmacotherapy along with physical therapy for individuals with DBN syndrome.

Background and purpose: Cerebral palsy (CP) is a congenital neurological disorder that causes musculoskeletal weakness and biomechanical dysfunctions. Strength training guidelines recommend at least 70% of 1-repetition maximum to increase muscle strength and mass. However, individuals with CP may not tolerate such high exercise intensity. Blood flow restriction (BFR) can induce similar gains in strength and muscle mass using loads as low as 20% to 30% 1-repetition maximum. This case series described the safety, feasibility, and acceptability of BFR in adults with CP and examined changes in muscle mass and strength.

Case description: Three male participants with gross motor function classification system level 3 CP underwent strength training using a periodized 8-week BFR protocol. Outcomes included: Safety via blood pressure during and post-BFR exercises in addition to adverse event tracking; Feasibility via number of support people and time-duration of BFR exercises; Acceptability via rate of perceived discomfort (0-10) and qualitative interviews; Muscle Mass via ultrasonographic cross-sectional area of the quadriceps and hamstring; and Strength via (1) 3-repetition maximum in the leg press and knee extension, (2) isometric knee flexor and extensor muscle force measured with a hand-held dynamometer, and (3) 30-second sit-to-stand test.

Intervention: Participants replaced 2 exercises from their current regimen with seated knee extension and leg press exercises using progressively higher limb occlusion pressure and exercise intensity. Limb occlusion pressure started at 60%, by week 4 progressed to 80%, and then remained constant. The exercise repetition scheme progressed from fixed nonfailure repetition sets to failure-based repetition sets.

Outcomes: Blood pressure never exceeded safety threshold, and no adverse events were reported. The BFR training was time-consuming and resource-intensive, but well-tolerated by participants (rate of perceived discomfort with a mean value of 5.8, 100% protocol adherence). Strength, as measured by 3-repetition maximum testing and 30-second sit-to-stand test, increased, but isometric muscle force and muscle mass changes were inconsistent.

Discussion: Blood flow restriction may be an effective means to increase strength in adults with CP who cannot tolerate high-intensity resistance training. Future research should compare BFR to traditional strength training and investigate mediators of strength changes in this population.

Video abstract available: for more insights from the authors (see the Video, Supplemental Digital Content available at: http://links.lww.com/JNPT/A473).

Background and purpose: The test-retest reliability and minimal detectable changes (MDCs) for respiratory muscle strength measures have not been determined in individuals with multiple sclerosis (MS). This study determined the test-retest reliability and MDCs for specific respiratory muscle strength measures, as well as their associations with health-related quality of life (HRQoL), disability, dyspnea, and physical activity level measures in this population. In addition, the study examined differences in respiratory muscle strength between different degrees of disability.

Methods: Sixty-one individuals with MS attended 2 appointments separated by 7 to 10 days. Respiratory muscle strength was evaluated by maximal inspiratory and expiratory pressures (MIP/MEP), HRQoL by EuroQol-5D-5L (index and visual analog scale [EQ-VAS]), disability by the Expanded Disability Status Scale, dyspnea by the Medical Research Council scale, and physical activity levels by the International Physical Activity Questionnaire.

Results: Respiratory muscle strength measures had excellent test-retest reliability (ICC ≥ 0.92). The MDC for MIP is 15.42 cmH 2 O and for MEP is 17.84 cmH 2 O. Participants with higher respiratory muscle strength (MIP/MEP cmH 2 O and percentage of predicted values) had higher HRQoL ( r = 0.54-0.62, P < 0.01, EQ-5D-5L index; r = 0.30-0.42, P < 0.05, EQ-VAS); those with higher expiratory muscle strength (cmH 2 O and percentage of predicted values) had lower levels of disability ( r ≤ -0.66) and dyspnea ( r ≤ -0.61). There were differences in respiratory muscle strength between different degrees of disability ( P < 0.01; d ≥ 0.73).

Discussion and conclusion: Respiratory muscle strength measures provide excellent test-retest reliability in individuals with MS. MDCs can be interpreted and applied in the clinical setting. Low respiratory muscle strength can contribute to a poor HRQoL; specifically, expiratory muscle strength appears to have the strongest influence on disability status and dyspnea.

Background and purpose: Aerobic exercise can elicit positive effects on neuroplasticity and cognitive executive function but is poorly understood after stroke. We tested the effect of 4 weeks of aerobic exercise training on inhibitory and facilitatory elements of cognitive executive function and electroencephalography markers of cortical inhibition and facilitation. We investigated relationships between stimulus-evoked cortical responses, blood lactate levels during training, and aerobic fitness postintervention.

Methods: Twelve individuals with chronic (>6 months) stroke completed an aerobic exercise intervention (40 minutes, 3×/wk). Electroencephalography and motor response times were assessed during congruent (response facilitation) and incongruent (response inhibition) stimuli of a Flanker task. Aerobic fitness capacity was assessed as o2peak during a treadmill test pre- and postintervention. Blood lactate was assessed acutely (<1 minute) after exercise each week. Cortical inhibition (N2) and facilitation (frontal P3) were quantified as peak amplitudes and latencies of stimulus-evoked electroencephalographic activity over the frontal cortical region.

Results: Following exercise training, the response inhibition speed increased while response facilitation remained unchanged. A relationship between earlier cortical N2 response and faster response inhibition emerged postintervention. Individuals who produced higher lactate during exercise training achieved faster response inhibition and tended to show earlier cortical N2 responses postintervention. There were no associations between o2peak and metrics of behavioral or neurophysiologic function.

Discussion and conclusions: These preliminary findings provide novel evidence for selective benefits of aerobic exercise on inhibitory control during the initial 4-week period after initiation of exercise training and implicate a potential therapeutic effect of lactate on poststroke inhibitory control.

Background and purpose: Surgical removal of a vestibular schwannoma (vestibular schwannoma resection; VSR) results in a unilateral vestibular hypofunction with complaints of dizziness and imbalance. Although the anatomic lesion is permanent, recovery of balance and diminution of dizziness occurs through central neurophysiologic compensation. Compensation of the system is maintained through daily activity. Unfortunately, interruption of stimulus, such as decreased activities due to illness, can cause decompensation. Decompensation is described as the return of symptoms consistent with that experienced during the initial insult/injury (eg, dizziness, oscillopsia, balance difficulty). This case study describes a reoccurrence of vestibular dysfunction in a person with a history of VSR following hospitalization and protracted recovery from a COVID-19 infection. It further documents her recovery that may be a result of vestibular rehabilitation.

Case description: A 49-year-old woman (M.W.) with a surgical history of VSR (10 years prior) and a medical history of significant COVID-19 infection, resulting in an intensive care unit stay and prolonged use of supplemental oxygen, presented to physical therapy with persistent dizziness and imbalance. The video head impulse test confirmed unilateral vestibular hypofunction.

Intervention: M.W. attended biweekly vestibular rehabilitation for 6 weeks and completed daily home exercises.

Outcomes: At discharge, M.W. demonstrated improvements in patient-reported outcomes (Dizziness Handicap Inventory), functional testing (MiniBEST, 2-Minute Walk Test), and gaze stability measures (video head impulse testing, dynamic visual acuity).

Discussion: Vestibular decompensation preluded by a COVID-19 infection caused a significant decrease in functional mobility. Vestibular rehabilitation targeted at gaze and postural stability effectively reduced symptoms and facilitated recovery to M.W.'s pre-COVID-19 level of function. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A458 ).