Archives of physical medicine and rehabilitation最新文献

Objective: To compare the efficacy of forearm- and wrist-prioritized robotic training on upper extremity motor recovery in individuals with stroke.

Design: Randomized controlled trial.

Setting: Four outpatient rehabilitation clinics.

Participants: Thirty individuals with stroke were randomized to either a forearm-prioritized robotic training group (N = 15) or a wrist-prioritized robotic training group (N = 15).

Interventions: Participants in both groups received 45 minutes of robotic training and 45 minutes of impairment-oriented training per session, three times per week for six weeks. The forearm-prioritized group initiated robotic training with the forearm practice module of the Bi-Manu-Track robotic device followed by the wrist module. In contrast, the wrist-prioritized group began with the wrist module and then proceeded to the forearm module.

Main outcome measures: The Fugl-Meyer Assessment for Upper Extremity and Medical Research Council scale before, immediately after, and 3 months after treatment as well as Wolf Motor Function Test and Stroke Impact Scale before and immediately after treatment.

Results: The wrist-prioritized group demonstrated significantly greater improvements in distal motor function (P < .01, η² = 0.19) and muscle strength (P = .04, η² = 0.14), while the forearm-prioritized group showed superior gains in proximal motor recovery (P = .03, η² = 0.17). A trend toward retention of distal gains was observed in the wrist-prioritized group at 3-month follow-up (P = .05, η² = 0.13).

Conclusions: Our findings suggest that forearm- and wrist-prioritized regimens provide different benefits. The focus of robotic training may affect specific aspects of upper extremity motor recovery in stroke, highlighting the need for individually tailored strategies based on patient-specific deficits. However, further research is needed to validate the findings.

Objective: This study aimed to (1) investigate changes in the quality of life among people with Parkinson's disease (PwPD) over a 1-year group-based telerehabilitation (TR) program and (2) explore the TR program's perceived impacts from the perspectives of the PwPD and their caregivers.

Design: Observational and longitudinal study.

Setting: Group-based TR program.

Participants: PwPD who voluntarily enrolled in a 1-year group-based TR program.

Interventions: Group-based TR program that included physical, rhythmic, cognitive, and swallowing exercises plus education about disease management.

Main outcome measures: The primary outcome was Parkinson's Disease Questionnaire-39 (PDQ-39) total score at baseline, 6 months, and 1 year. Secondary outcomes were PDQ-39 domain scores, responses by the PwPD and their caregivers to the self-reported questionnaire to evaluate perceived emotional, physical, and lifestyle effects, and Client Satisfaction Questionnaire-8 (CSQ-8).

Results: A total of 49 PwPD and 43 caregivers participated; 24 (49%) PwPD and 22 (51%) caregivers met the regular participation criterion (≥80% of scheduled sessions). Baseline characteristics were similar between regular and nonregular participants. Mixed models for repeated measures (MMRM) adjusted for baseline PDQ-39, Hoehn & Yahr stage, and disease duration showed better adjusted PDQ-39 total scores in the regular group than in the nonregular group (group effect P=.046). The emotional well-being domain showed a significant time effect (P=.007), and better adjusted scores in the regular than in the nonregular group at 1 year. The social support domain also favored the regular group (P=.017), and the communication domain showed a significant group × time interaction, indicating more favorable trajectories in the regular group. Both the PwPD and caregivers reported greater emotional benefits than physical benefits, and Client Satisfaction Questionnaire-8 scores indicated high satisfaction in both groups.

Conclusions: Although causal relationships cannot be inferred, these findings suggest that higher and sustained participation in long-term, group-based TR is associated with maintenance of overall quality of life and improvements in emotional well-being among PwPD.

Objective: To estimate anchor-based minimal important change (MIC) values for the Fugl-Meyer assessment-lower extremity (LE) in patients with acute stroke from the perspectives of patients and physiotherapists using the ROC method (MIC_ROC) and adjusted MIC (MIC_adjusted).

Design: Prospective cohort study.

Setting: Stroke care unit at a single acute care hospital.

Participants: Adults with acute stroke analyzed (n=100); baseline assessment within 5 days of onset and follow-up at 2 weeks.

Interventions: Not applicable.

Main outcome measures: The Fugl-Meyer assessment-LE, Short Physical Performance Battery, and Functional Ambulation Category were assessed within 5 days and at 2 weeks after stroke onset. The anchors were the 7-point Global Rating of Change (GRC) Scale for LE motor function and walking among the patients and physiotherapists. Patient- and physiotherapist-rated GRC scores were assessed at 2 weeks. Patients' and physiotherapists' perspectives on GRC were divided into 2 groups based on meaningful improvement (GRC≥6). Then, the MIC_ROC and MIC_adjusted values of the Fugl-Meyer assessment-LE were calculated.

Results: The MIC_ROC values were 3.5 points (95% confidence interval [CI], 0.5-7.5) for patient-rated GRC (LE motor function) and 3.5 (1.5-7.5) for patient-rated GRC (walking). The MIC_ROC values were 1.5 points (0.5-6.5) for therapist-rated GRC (LE motor function) and 3.5 (0.5-7.5) for therapist-rated GRC (walking). The MIC_adjusted values for patient-rated LE motor function and walking were both 4.3 points (3.7-4.9). The MIC_adjusted values for physiotherapist-rated LE motor function and walking were 3.3 (2.4-4.1) to 3.8 points (3.0-4.4), respectively.

Conclusions: The MIC_adjusted values were more robust than the MIC_ROC values. The MIC_adjusted value from the physiotherapist's perspective was lower than that from the patient's perspective. These MIC values may be helpful for setting rehabilitation goals and evaluating interventions objectively, thereby providing important benchmarks for clinical decision-making in acute stroke rehabilitation.

Objective: To investigate the components of trunk function using multiple existing assessments and construct a new evaluation model.

Design: A prospective observational cohort study with a 1-week follow-up.

Setting: A single-center tertiary care hospital.

Participants: In total, 200 patients with early-onset stroke (mean age, 75.9±12y; 57% male) were consecutively recruited. Key inclusion criteria were a diagnosis of acute cerebral infarction or hemorrhage and the ability to mobilize within 48 hours of onset.

Interventions: Not applicable.

Main outcome measures: The prespecified primary outcome measure was trunk function, assessed 1.2±2.5 days poststroke using the Verheyden and Fujiwara Trunk Impairment Scales, Functional Assessment for Control of Trunk, and Trunk Control Test. Exploratory factor analysis was used to classify functional factors, followed by Rasch analysis to confirm unidimensionality and item difficulty within each factor. Assessors were not blinded to participants' clinical information.

Results: Exploratory factor analysis identified 4 functional factors: static sitting, basic movements, and dynamic sitting tasks (more challenging and less challenging). Rasch analysis confirmed unidimensionality for all factors after excluding 4 items from the less challenging dynamic sitting factor. The resulting factors and item difficulties revealed a hierarchical pattern, suggesting that trunk function recovery progresses from static controlled movements to complex dynamic movements.

Conclusions: To our knowledge, this is the first study to clarify the factor structure and hierarchical organization of trunk function after stroke, providing a framework to reorganize evaluation tools and improve personalized physical therapy. Further research is needed to develop a short-form version to enhance clinical utility.

Objectives: The primary aim of this study was to explore factors that may influence the rate of mobility function decline. A secondary aim was to identify the impact of neck weakness on mobility decline in people living with motor neuron disease (MND).

Design: Retrospective, longitudinal observational study design.

Setting: This study was conducted at a Statewide Progressive Neurological Disease Service (SPNDS) in inpatients, outpatients, and community-based services. The SPNDS clinic treats adults with MND from both metropolitan and rural settings.

Participants: Adults with MND attending the SPNDS were recruited to participate in the study.

Interventions: Not applicable.

Main outcome measures: Categorical data relating to mobility function (walking endurance, gait aid used, and level of assistance required) were recorded. Neck weakness was measured as present or absent based on the participant's subjective report and/or objective observation of head position when upright.

Results: Results from the 358 participants recruited showed that the median time to loss of independent gait was 30.5 months (range, 4-239; interquartile range [IQR], 26), full-time wheelchair use was 34 months (IQR, 35; range, 5-238), and median time to becoming housebound was 28 months from MND symptom onset (IQR, 24.5; range, 5-219 mo). A total of 141 (39.4%) participants had neck weakness. The presence of neck weakness resulted in earlier loss of independent gait and quicker to become housebound. There was no significant difference in time to full-time wheelchair use between participants with or without neck weakness.

Conclusions: There was an effect of both phenotype and neck weakness on the trajectory of mobility function decline in people with MND. Overall, people with amyotrophic lateral sclerosis phenotype (bulbar, cervical, or lumbar onset) experienced a more rapid rate of decline in mobility function than those with flail limb and primary lateral sclerosis phenotypes. In addition, those demonstrating neck weakness were quicker to decline in mobility than those without neck weakness.

Objective: To evaluate the effects of intermittent theta burst stimulation (iTBS) on motor function, gait, pain level, sensory function, independence, and spasticity in individuals with spinal cord injury (SCI).

Data sources: Five databases (PubMed, Cochrane Library, EMBASE, Web of Science, and ClinicalTrials.gov) were searched from inception to February 2025.

Study selection: Two reviewers independently identified the relevant articles. The included studies were randomized controlled trials evaluating iTBS in individuals with SCI.

Data extraction: Two reviewers independently extracted data, including author, publication year, sample size, mean age, interventions, follow-up period, and statistical measures. The risk-of-bias was assessed by Risk-of-Bias Tool 2.0. Any disagreement was resolved with a senior reviewer.

Data synthesis: A total of 6 randomized Controlled Trials involving 116 patients were included. Compared with sham iTBS, iTBS showed significant improvements in Lower Extremity Motor Score (mean difference [MD], 7.13; 95% CI, 0.71-13.56; P=.03), step length (MD, 7.99; 95% CI, 5.45-10.53; P<.001); pain measures (standardized MD [SMD], 2.77; 95% CI, 0.05-5.5; P=.05), Spinal Cord Independence Measure (MD, 15.42; 95% CI, 6.72-24.13; P<.001), and Modified Ashworth Scale (MD, -2.89; 95% CI, -5.76 to -0.02; P=.05). However, no significant differences were observed in upper extremity motor score (MD, -5.83; 95% CI, -12.44 to 0.78; P=.08), walking speed (MD, 0.03; 95% CI, -0.0 to 0.07; P=.08), or Extremity Sensory Score (SMD, 0.13; 95% CI, -0.43 to 0.7; P=.64).

Conclusions: iTBS may offer beneficial effects on lower-limb motor function, step length, pain, functional independence, and spasticity in patients with SCI. However, no improvements were observed in walking speed or sensory function. Further trials are needed to validate the efficacy of iTBS.

Objective: To examine the postinjury utilization and cost of Veterans Affairs (VA) outpatient care in a cohort of service members and veterans (SMVs) treated in VA Polytrauma Rehabilitation Centers (PRCs) for traumatic brain injury (TBI).

Design: Analysis of merged datasets from the VA TBI Model Systems (VA-TBIMS) national database and Veterans Health Administration outpatient utilization and cost data.

Setting: Five VA PRCs.

Participants: VA-TBIMS participants (N = 1,030) who received inpatient rehabilitation at any of the 5 PRCs between 2010 and 2020.

Interventions: Not applicable.

Main outcome measures: Utilization and costs of VA outpatient clinics.

Results: Polytrauma/TBI clinics had the highest SMVs (87.9%), with 54.4% also using telephone. Laboratories (78.6%) had the second highest, and primary care (77.1%) had the third. The 1030 SMVs treated in PRCs had a median annual VA outpatient facility cost of $15,027. The costliest clinic type was mental health ($6834), followed by TBI/Polytrauma ($4747) + phone ($1229), and physical therapy ($4441). SMVs had a median of 4.1 years since injury. Time to care increased costs by $42 per day for inpatient rehabilitation and $29,426 5 years after injury for outpatient care. Each additional point on the Disability Rating Scale increased total costs by $593, whereas sexual dysfunction increased total costs by $8214.

Conclusions: VA PRCs are a gateway for SMVs to use VA Polytrauma/TBI clinic outpatient services, highlighting the VA Polytrauma System of Care as a framework for continuing critical clinical health services after inpatient rehabilitation. Indeed, time to access inpatient rehabilitation as well as outpatient care was associated with increasingly higher costs. Disability Rating Scale was a cost driver for SMVs treated in PRCs, consistent with previous studies of VA and Department of Defense costs. Sexual dysfunction emerged as an important condition impacting VA outpatient costs, confirming evidence of its link to TBI and its importance to Veterans.

The growing volume of stroke rehabilitation trials underscores the need to ensure that outcome measures are aligned with patient priorities to maximize clinical relevance and minimize research waste. The objective of this review was to examine the extent to which primary outcomes used in randomized and quasi-randomized trials of poststroke walking rehabilitation capture community mobility and participation-level constructs. This review evaluated the selection of primary outcomes in randomized and quasi-randomized trials of walking rehabilitation after stroke. A search of PubMed, CENTRAL, and PEDro identified 593 eligible studies (2013-2023), from which a random sample of 100 trials was analyzed. Primary outcomes were classified a priori into 4 construct-level categories: impairment-based, performance-based walking capacity, functional walking and mobility, and community and participation-level outcomes. Performance-based walking capacity outcomes were most frequently selected as primary outcomes (39%), followed by functional walking and mobility outcomes (36%) and impairment-based outcomes (22%). Community and participation-level walking outcomes were rarely prioritized (3%). With respect to participant characteristics, most trials enrolled ambulatory participants (68%), whereas trials exclusively enrolling nonambulatory participants were underrepresented (10%). These findings highlight a persistent emphasis on performance-based and impairment-level primary outcomes in stroke walking rehabilitation trials. Based on an evaluation of primary outcome selection in a randomly sampled subset of trials, this review underscores the need for systematic incorporation of participation-level outcomes that capture real-world functioning after stroke, as well as greater inclusion of nonambulatory participants to ensure that intervention research addresses the full spectrum of walking recovery.

Objectives: To examine daily within-person associations between symptoms reported by people with multiple sclerosis (MS) and psychoactive substance use using ecological momentary assessment (EMA).

Design: This secondary analysis used EMA data collected 4 times daily for 14 days at baseline and 1-year and 2-year follow-ups.

Setting: Community.

Participants: Ambulatory adults with MS (N=258).

Main outcome measures: Participants completed daily EMAs via smartphone, reporting use of psychoactive substances and symptoms. Psychoactive substance use (alcohol, caffeine, nicotine, cannabis, and opioids) was assessed dichotomously (yes/no). Momentary symptoms, including fatigue, pain, stress, and depressive symptoms, were assessed using brief self-report measures. Mixed-effects logistic regression models assessed lagged associations between symptoms and subsequent substance use; multilevel models examined the reverse direction.

Results: Momentary increases in stress predicted lower odds of alcohol use. Higher average pain was linked to reduced alcohol use and increased opioid use. Substance use also predicted symptoms: alcohol, nicotine, and cannabis were associated with greater fatigue, whereas caffeine predicted reduced fatigue. Cannabis was linked to higher momentary pain, and opioids to higher average pain. Alcohol was associated with reduced stress, whereas caffeine predicted increased stress.

Conclusions: MS symptoms and psychoactive substance use are dynamically and bidirectionally related. These findings improve understanding of how individuals with MS use substances for symptom regulation, which may lead to both beneficial and adverse outcomes.