Clinical Rehabilitation

Objective: To examine the test—retest reliability of the StepWatch Activity Monitor outputs over two periods, a week apart, in participants with stroke.

Design: Test—retest reliability study over monitoring periods of one, two and three days.

Setting: Participant's usual environment.

Participants: Forty participants more than six months post stroke.

Main measures: StepWatch outputs: total step count, number of steps at high medium and low stepping rates, sustained activity indices, peak activity index.

Results: The intraclass correlation coefficients were high for all StepWatch outputs and all monitoring periods but were highest for the three-day monitoring period (0.930—0.989) and lowest for the one-day monitoring period (0.830—0.950). The coefficient of variation ranged from 6.7% to 48.7% over the monitoring periods, with higher variation shown for shorter monitoring periods. The most reliable four outputs had 95% limits of agreement between three-day periods that were less than 40%. These were total step count (±37.8%), highest step rate in 1 minute (±23.0%), highest step rate in 5 minutes (±38.6%) and peak activity index (±29.8%).

The highest step rate in 1 minute was the only StepWatch output that had 95% limits of agreement less than 40% for the two-day (±31.2%) and one-day (±36.7%) monitoring periods.

Conclusions: Total step count, highest step rate in 1 minute, highest step rate in 5 minutes and peak activity index have good test—retest reliability over a three-day monitoring period, with lower reliability shown by the other StepWatch outputs. In general, monitoring over one or two days is less reliable.

Objective: The use of wearable motion-sensing technology offers important advantages over conventional methods for obtaining measures of physical activity and/or physical functioning in aged individuals. This review aims to identify the actual state of applying wearable systems for monitoring mobility-related activity in older populations. In this review we focus on technologies and applications, research designs, feasibility and adherence aspects, and clinical relevance of wearable motion-sensing technology.

Data sources: PubMed (MEDLINE since 1990), Ovid (BIOSIS, CINAHL), and Cochrane (Central) and reference lists of all relevant articles were searched.

Review methods: Two authors independently reviewed randomized and non-randomized trials on people above 65 years systematically. Quality of selected articles was scored and study results were summarised and discussed.

Results: Two hundred and twenty-seven abstracts were considered. After application of inclusion criteria and full text reading, 42 articles were taken into account in a full text review. Twenty of these papers evaluated walking with step counters, other papers used varying accelerometry approaches for obtaining overall activity measures (n = 16), or for monitoring changes in body postures and activity patterns (n = 17). Seven studies explicitly mentioned feasibility and/or adherence aspects. Eight studies presented outcome evaluations of interventions. Eight articles were representing descriptive research designs, three articles were using mixed descriptive and exploratory research designs, 23 articles used exploratory research-type designs, and eight articles used experimental research designs.

Conclusion: Although feasible methods for monitoring human mobility are available, evidence-based clinical applications of these methods in older populations are in need of further development.

Objective: To compare oxygen consumption for traumatic high-functioning transfemoral amputees wearing initially a conventional prosthetic foot (Multiflex) and then an energy-storing prosthetic foot (Vari-Flex).

Setting: A regional prosthetic and amputee rehabilitation tertiary referral centre in a teaching hospital.

Study design: Experimental crossover trial.

Subjects: Six established unilateral transfemoral prosthetic users.

Interventions: Oxygen consumption breath-by-breath analysis at multiple speeds on a treadmill for each amputee wearing initially the Multiflex foot and then repeated wearing the Vari-Flex foot.

Results: Mean oxygen consumption across all subjects was lower for the Vari-Flex foot than for the Multiflex foot at all speeds, although the differences were only significant at speeds of 0.83 and 1.1 m/s (P<0.05). ANCOVA analysis across all speeds showed that oxygen consumption with the Vari-Flex foot was significantly lower (P<0.001). The estimated difference across all speeds was 3.54 mL/kg.min.

Conclusion: A high functioning transfemoral amputee who wears an energy-storing prosthetic foot may have significantly reduced oxygen consumption at normal walking speeds.

Objective: To determine the thresholds of lower extremity muscle strength below which performing activities of daily living (ADL) is impaired in older adults.

Design: Cross-sectional.

Setting: Community.

Subjects: Forty-nine older adults (81—89 years) were divided into an independent group (n = 25) who needed no assistance and a dependent group (n = 24) who needed assistance to perform ADL.

Interventions: Not applicable.

Main measures: Functional independence measures to determine level of disability and muscular strength of hip flexors, hip extensors, knee flexors, knee extensors and ankle dorsiflexors assessed by a hand-held dynamometer (HHD). Muscle groups were tested separately for each leg and values were averaged for the two legs. A ratio of maximal muscular strength to body weight was calculated by dividing the muscular strength (N) by body weight (kg).

Results: Muscular strength thresholds to perform ADL independently were 2.3 N/kg for hip flexors, 1.7 N/kg for hip extensors, 0.7 N/kg for knee flexors, 2.8 N/kg for knee extensors and 2.8 N/kg for ankle dorsiflexors.

Conclusion: The thresholds of lower extremity muscle strength below which assistance is required to perform ADL in community-dwelling older adults were identified. Furthermore, results indicate that the muscular strength of hip extensors is more important in performing ADL than other muscles of the lower extremities.

Objective: To examine the effect of functional strength training in subacute stroke.

Design: A single-blinded randomized controlled trial.

Setting: Two rehabilitation units.

Subjects: Eighteen patients in the subacute phase post stroke, randomly allocated to a functional strength training (intervention) group (n = 8) and a training-as-usual (comparison) group (n = 10).

Intervention: The functional strength training group participated in functional progressive strength training of the affected lower extremity. The training-as-usual group had traditional training, excessive muscle power being avoided to prevent associated reactions. All trained 50 minutes five days a week for four weeks.

Main measures: Maximum weight-bearing in standing (primary outcome), isometric muscle strength, gait speed and items of Motor Assessment Scale.

Results: Maximum weight-bearing on the affected leg improved more in the functional strength training group (mean 17.4% of body weight) than in the training-as-usual group (mean 5.6% of body weight), but taking test data at inclusion into consideration, the difference in change was not statistically significant (P = 0.056). More patients in the functional strength training group (57%) could weight-bear on the affected leg while stepping forward, than in the training-as-usual group (17%). Improvement was clinically significant in 7 of 9 outcome measures in the functional strength training group (effect size ≥0.80, large), but in only 3 of 9 in the training-as-usual group. All patients in the functional strength training group and 70% of the patients in the training-as-usual group rated their overall status as `much' or `very much' improved.

Conclusions: This pilot study indicates that functional strength training of lower extremities improves physical performance more than traditional training.

Objective: To investigate whether the addition of a kinaesthetic ability training device could enhance the effect of a conventional rehabilitation programme on balance and mobility in hemiparetic patients late after stroke.

Design: Randomized, controlled, assessor-blinded trial.

Setting: The rehabilitation ward of a university hospital. Thirty hemiparetic patients (mean age (SD) of 57.4 (8.1) years) late after stroke (mean time since stroke (SD) 545.2 (99.9) days) were assigned randomly to an experimental or a control group.

Interventions: The control group (n = 15) participated in a conventional rehabilitation programme. The experimental group (n = 15) participated in balance training with a kinaesthetic ability training device in addition to a conventional rehabilitation programme for four weeks, five days a week.

Outcome measures: Kinaesthetic ability training static and dynamic balance indices, balance and lower extremity subscores of the Fugl-Meyer Stroke Assessment Instrument (FMA), total motor and locomotor subitem scores of the Functional Independence Measure (FIM) were evaluated at baseline and after treatment.

Results: The experimental group had greater improvement in measures of balance including static (P = 0.045) and dynamic balance index (P = 0.001) and FMA balance score (P = 0.001) than the control group. No between-group differences were detected in subscore of FMA, total motor and locomotor subscores of FIM. There were significant improvements in balance subscores of FMA, static and dynamic balance indexes in the experimental group and in sub-item scores of FIM and lower extremity scores of FMA in both groups.

Conclusion: Kinaesthetic ability training in addition to a conventional rehabilitation programme is effective in improving balance late after stroke. However, this improvement is not reflected in individual functional status.

Objective: To determine whether 10 minutes of treadmill walking had a different effect on overground walking pattern compared with 10 minutes of overground walking in newly ambulatory stroke patients. Are any changes influenced by walking ability?

Design: A within-participant, repeated measures experimental study was conducted. Each participant carried out 10 minutes of overground walking practice followed by 10 minutes of treadmill walking practice at matched heart rate on separate days. Setting: An inpatient rehabilitation facility.

Subjects: Twenty-one participants receiving inpatient rehabilitation following stroke.

Measures: Overground walking pattern was measured as linear and angular kinematics using GAITRite and a two-dimensional webcam application respectively.

Results: Following treadmill walking practice, there was 6 degrees (95% confidence interval (CI) 2 to 10) more knee extension at heel strike during overground walking than following overground walking practice. Poorer walkers increased non-paretic limb step length following treadmill walking practice more than those with better walking ability (mean difference 2.2 cm, 95% CI 0 to 5).

Conclusions: Ten minutes of treadmill walking practice resulted in a similar overground walking pattern compared with overground walking practice in newly ambulatory stroke patients undergoing rehabilitation, regardless of walking ability.

Objective: To assess the effectiveness of domiciliary physical fitness programmes in obese individuals.

Design: Nine-month randomized controlled trial.

Setting: Home-based intervention with outpatient visits.

Subjects: Morbidly obese subjects (body mass index (BMI) ≥30) aged 25—65 years suitable for physical activities at home.

Intervention: At the end of a preliminary one-month in-hospital rehabilitation programme (baseline), 52 patients were randomly assigned either to a structured educational programme (intervention group) of daily incremental physical activity at home (walking and skeletal muscle resistance training, with booklets and written instructions) or to a programme of general advice (control group) regarding exercise and long-term fitness.

Main measures: Both groups were evaluated at baseline and every three months for: (1) time, metabolic equivalents (METs), and heart rate reserve (HRR) during a standardized 2-km walking test (2kmWT); (2) anthropometric measures (body weight, BMI, abdominal and neck circumference); (3) the Polar Fitness Test index (PFTI), and (4) time to exhaustion while sustaining consecutive isoload extensions in the dominant leg (isoload LE). Time during 2kmWT was the study primary outcome.

Results: Body weight, BMI and abdominal circumference improved significantly (P<0.05) over time in the intervention group. The cardiopulmonary fitness variables changed significantly (P<0.05) over time in both study groups. However, all variables improved in the intervention patients, while some worsened or remained stable in the controls. Thus, the mean group difference in changes was significant (P<0.05) for 2kmWT time (—77.4 seconds), HRR (11.7%), and PFTI (5.4 points).

Conclusion: This structured domiciliary fitness programme is feasible and provides sustained anthropometric and physiological benefits in some morbidly obese individuals.

Objectives: To describe clinical changes with two protocols of physiotherapy following arthroscopic subacromial decompression (ASD) over two years. Reliability of Functional Index of the Shoulder was performed.

Design: A prospective, randomized pilot study, within-subject design.

Subjects: Thirty-four shoulders (13 women), mean age 46 (SD 7) years with primary shoulder impingement, listed for arthroscopic subacromial decompression.

Interventions: The traditional group (n = 20) started with active assisted range of motion exercises on the day of surgery, dynamic exercises for the rotator cuff after six weeks and strengthening exercises after eight weeks. The progressive group (n = 14) started active assisted range of motion and dynamic exercises for the rotator cuff on the day of surgery. Strengthening exercises started after six weeks.

Main measures: A clinical evaluation was made preoperatively, six weeks, three, six, 12 and 24 months after surgery. Pain, patient satisfaction, active range of motion and muscular strength were evaluated. Shoulder function was evaluated using Constant score, Hand in neck, Pour out of a pot and Functional Index of the Shoulder.

Results: Both groups showed significant improvements in pain during activity and at rest, in range of motion in extension and abduction, in strength of external rotation and in function. There were no clinical differences in changes between groups. Most patients were pain-free from six months. After two years, the majority of patients achieved ≥160^° in flexion, ≥175^° in abduction and 80^° in external rotation, the traditional achieved 67 and the progressive group 87 with Constant score.

Conclusions: Early activation using a comprehensive, well-defined and controlled physiotherapy protocol can be used safely after arthroscopic subacromial decompression.

Objective: To evaluate the effect of an aquatic therapy programme designed to increase balance in stroke survivors.

Design: A randomized, controlled pilot trial.

Setting: Rehabilitation department of a university hospital.

Subjects: Ambulatory chronic stroke patients (n = 25):13 in an aquatic therapy group and 12 in a conventional therapy group.

Interventions: The aquatic therapy group participated in a programme consisting of Ai Chi and Halliwick methods, which focused on balance and weight-bearing exercises. The conventional therapy group performed gym exercises. In both groups, the interventions occurred for 1 hour, three times per week, for eight weeks.

Main measures: The primary outcome measures were Berg Balance Scale score and weight-bearing ability, as measured by vertical ground reaction force during four standing tasks (rising from a chair and weight-shifting forward, backward and laterally). Secondary measures were muscle strength and gait.

Results: Compared with the conventional therapy group, the aquatic therapy group attained significant improvements in Berg Balance Scale scores, forward and backward weight-bearing abilities of the affected limbs, and knee flexor strength (P<0.05), with effect sizes of 1.03, 1.14, 0.72 and 1.13 standard deviation units and powers of 75, 81, 70 and 26%, respectively. There were no significant changes in the other measures between the two groups.

Conclusions: Postural balance and knee flexor strength were improved after aquatic therapy based on the Halliwick and Ai Chi methods in stroke survivors. Because of limited power and a small population base, further studies with larger sample sizes are required.

Objective: To examine the effect of pre-operative physiotherapy before hip arthroplasty in patients with end-stage hip osteoarthritis.

Design: A prospective randomized controlled study.

Setting: Physical medicine and rehabilitation and orthopaedic departments of Policlinico Gemelli of Rome.

Subjects: Twenty-three patients randomized in study and control groups.

Intervention: The study group took part in an educational and physiotherapy programme one month before surgery. Both groups took part in the same inpatient rehabilitation programme after surgery.

Main outcome measures: Both groups were evaluated one month (T0) and the day before arthroplasty (T1), after 15 days (T2), four weeks (T3) and three months (T4) post surgery, using the Barthel Index, the Short Form-36 (SF-36), the Western Ontario and McMaster Osteoarthritis Index (WOMAC), the Hip Harris Score (HHS), visual analogue scale (VAS), the British Medical Research Council (BMRC) measures of hip abductor and quadriceps strength and range of hip abduction and external rotation.

Results: There were no significant differences between groups with regard to the Barthel Index, SF-36, WOMAC and HHS at T4. The study group presented significant improvements of the SF-36 physical composite score at T1. The hip external rotation was significantly higher in the study group at each evaluation and the visual analogue scale values were lower at T1, T3 and T4.

Conclusion: Pre-operative physiotherapy in patients undergoing hip arthroplasty does not improve impairment and health-related quality of life after intervention. Physiotherapy and educational therapy may be useful for end-stage osteoarthritis.

Objective: To evaluate cost, adherence and effects on cardiovascular function and quality of life of a home-based cardiac rehabilitation programme for patients with coronary disease.

Design: A randomized, prospective controlled trial.

Setting: Department of Rehabilitation, University Hospital, Brazil.

Subjects: Thirty-nine low-risk patients were assigned to a home exercise training group (n = 19) or a control group (n = 20).

Interventions: The home group performed home-based training for three months with biweekly telephone monitoring.

Main outcome measures: The aerobic capacity and the quality of life (Medical Outcomes Study 36-Item Short Form Survey (SF-36)) of all patients were evaluated before and after the three-month period. Adherence was evaluated weekly. Programme cost was estimated using the Brazilian Classification of Medical Procedures.

Results: After training, the home group had higher peak Vo₂ from 28.8 (6.4) to 31.7 (8.1) mL/kg per minute, peak heart rate from 135 (22) to 143 (20) bpm, work rate from 4780 (2021) to 7103 (3057) kpm/min and exercise time from 11.5 (1.9) to 13.6 (2.3) minutes (P ≤ 0.05). The control group showed reduction in peak Vo₂ from 28.6 (6.6) to 26.8 (7.2) mL/kg per minute, peak Vo₂ pulse from 15.5 (3.9) to 14.3 (3.8) mL/bpm and exercise time from 11.5 (2.3) to 11.4 (2.7) minutes (P ≤ 0.05). The home group reported improvements in all domains of SF-36. The control group showed improvement in only three domains of SF-36. In the home group the average cost per patient was US$502.71 and the adherence achieved 100%.

Conclusion: The programme seems to provide an efficient low-cost approach to cardiac rehabilitation in low-risk patients.

Objective: To explore the secondary benefits of treadmill training for people in the chronic stage of recovery from stroke.

Design: Modified random assignment, matched-pair control group design with repeated measures.

Setting: Outpatient stroke centre.

Participants: Twenty individuals post first stroke who acknowledged walking slower than pre stroke. Participants matched by side of hemiparesis and motor impairment.

Interventions: Twelve 20-minute sessions of walking on a treadmill or weekly phone call.

Main outcome measures: Depression (Beck Depression Index), mobility and social participation (Stroke Impact Scale 3.0 subscales) were assessed initially, at the end of 12 treatments (four weeks) and six weeks later.

Results: No significant difference was found between groups for any dependent measure. The ANOVA to investigate main effects in each group found no significant findings in the control group; however in the treatment group significant improvements over time for depression (P=0.005, P<0.001), mobility (P=0.008) and social participation (P= 0.004) were demonstrated.

Conclusions: A task-specific intervention designed to improve gait speed may potentially provide secondary benefits by positively impacting depression, mobility and social participation for people post stroke.

Objective: We performed a systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adolescents and adults living with cystic fibrosis.

Data sources: MEDLINE, EMBASE and CINAHL electronic databases were searched up to January 2008.

Review methods: We performed a systematic review using the methodology outlined in the Cochrane Collaboration protocol. Articles were included if: (1) participants were adolescents or adults with cystic fibrosis (>13 years of age); (2) an IMT group was compared to a sham IMT, no intervention or other intervention group; (3) the study used a randomized controlled trial or cross-over design; and (4) it was published in English. Data were abstracted and methodological quality was assessed independently by two reviewers.

Results: The search strategy yielded 36 articles, of which two met the inclusion criteria. Both studies used a targeted or threshold device for IMT. Meta-analyses were limited to forced expiratory volume in 1 second (FEV₁) and forced vital capacity (FVC), which showed no difference in effect between the IMT group and the sham and/or control group. Individual study results were inconclusive for improvement in inspiratory muscle strength. One study demonstrated improvement in inspiratory muscle endurance.

Conclusion: The benefit of IMT in adolescents and adults with cystic fibrosis for outcomes of inspiratory muscle function is supported by weak evidence. Its impact on exercise capacity, dyspnoea and quality of life is not clear. Future research should investigate the characteristics of the subgroup of people with cystic fibrosis that might benefit most from IMT.