Timing, Intensity, and Duration of Rehabilitation for Hip Fracture and Stroke: Report of a Workshop at the National Center for Medical Rehabilitation Research

This article summarizes the proceedings of an NIH workshop on timing, intensity, and duration of rehabilitation for acute stroke and hip fracture. Participants concentrated on methodological issues facing investigators and suggested priorities for future research in this area.

Rehabilitation Medicine Summit: Building Research Capacity Executive Summary

The general objective of the “Rehabilitation Medicine Summit: Building Research Capacity” was to advance and promote research in medical rehabilitation by making recommendations to expand research capacity. The five elements of research capacity that guided the discussions were: (1) researchers; (2) research culture, environment, and infrastructure; (3) funding; (4) partnerships; and (5) metrics. The 100 participants included representatives of professional organizations, consumer groups, academic departments, researchers, governmental funding agencies, and the private sector. The small group discussions and plenary sessions generated an array of problems, possible solutions, and recommended actions. A post-Summit, multi-organizational initiative is called to pursue the agendas outlined in this report.

Abstract TP156: Robot-Guided Ankle and Knee Therapeutic Training Improves Motor Functions in Stroke

Introduction: Stroke survivors develop substantial disability such as weakness, spasticity, increased stiffness, and reduced range of motion in lower limbs, contributing to reduced quality of life. It is important to stretch impaired ankle and knee to increase range of motion and reduce spasticity, and to conduct active movement training to improve balance and locomotion.

Hypothesis: We addressed the hypotheses that robot-aided ankle and knee training will reduce motor impairments and improve balance and gait functions, and the improvements will maintain to the 6-weeks follow-up.

Methods: Seven male stroke survivors participated in the robot-guided ankle and knee rehabilitation training using a pair of ankle and knee rehabilitation robots over 18 training sessions (3 sessions/week for 6 weeks). Three evaluations were done before and after training, and 6 weeks follow-up. Each session involved passive stretching under intelligent control and active movement training under real-time, audiovisual and haptic feedback. About equal time was spent on the ankle and knee training.

Results: We found significant improvement in 6-Minute Walk Test (6MWT: 294.8 m pre-training to 386.4 m post training; p<0.01), Berg Balance Scale (BBS, 45 pre to 52 post; p<0.05), ankle active range of motion (AROM) (-11.7° pre to 1.7° post; p<0.05, a negative value means not being able to reach 0° dorsiflexion), passive ROM in dorsiflexion (12.7° pre to 23.3° post; p<0.01), and dorsiflexion muscle strength (-0.3 Nm pre to 5.7 Nm post; p<0.05, negative means lower than the passive torque at 0° ankle dorsiflexion). The knee had significant improvement in AROM in extension against the load of the robot (34.8° pre to 15.9° knee flexion post; p<0.05) and maximal flexion strength at 90° knee flexion (19.3 Nm pre to 31.7 Nm post; p<0.01). At the follow-up, the outcomes were found as similar results of post evaluation, e.g., 379m (p<0.05) in 6MWT, 51 (p<0.05) in BBS, and 5.2 Nm (p=0.05) in dorsiflexion strength.

Conclusions: In conclusions, robot-guided stretching and active movement training reduced impairments at the knee and ankle of stroke survivors resulting in improved mobility. Furthermore, the effect of training was maintained at the 6-weeks follow-up after the treatment.

A body machine interface based on inertial sensors

Spinal cord injury (SCI) survivors generally retain residual motor and sensory functions, which provide them with the means to control assistive devices. A body-machine interface (BoMI) establishes a mapping from these residual body movements to control commands for an external device. In this study, we designed a BoMI to smooth the way for operating computers, powered wheelchairs and other assistive technologies after cervical spinal cord injuries. The interface design included a comprehensive training paradigm with a range of diverse functional activities to enhance motor learning and retention. Two groups of SCI survivors and healthy control subjects participated in the study. The results indicate the effectiveness of the developed system as an alternative pathway for individuals with motor disabilities to control assistive devices while engaging in functional motor activity.

Energy Cost of Lower Body Dressing, Pop-Over Transfers, and Manual Wheelchair Propulsion in People with Paraplegia Due to Motor-Complete Spinal Cord Injury

BACKGROUND

Energy required for able-bodied individuals to perform common activities is well documented, whereas energy associated with daily activities among people with spinal cord injury (SCI) is less understood.

OBJECTIVE

To determine energy expended during several basic physical tasks specific to individuals with paraplegia due to motor-complete SCI.

METHODS

Sixteen adults with motor-complete SCI below T2 level and duration of paraplegia greater than 3 months were included. Oxygen consumption (VO2), caloric expenditure, and heart rate were measured at rest and while participants performed lower body dressing (LBD), pop-over transfers (POTs), and manual wheelchair propulsion (MWP) at a self-selected pace. These data were used to calculate energy expenditure in standard metabolic equivalents (METs), as defined by 1 MET = 3.5 mL O2/kg/min, and in SCI METs using the conversion 1 SCI MET = 2.7 mL O2/kg/min.

RESULTS

VO2 at rest was 3.0 ± 0.9 mL O2/kg/min, which equated to 0.9 ± 0.3 standard METs and 1.1 ± 0.4 SCI METs in energy expenditure. LBD required 3.2 ± 0.7 METs and 4.1 ± 0.9 SCI METs; POTs required 3.4 ± 1.0 METs and 4.5 ± 1.3 SCI METs; and MWP required 2.4 ± 0.6 METs and 3.1 ± 0.7 SCI METs.

CONCLUSIONS

Resting VO2 for adults with motor-complete paraplegia is 3.0 mL O2/kg/min, which is lower than standard resting VO2 in able-bodied individuals. Progressively more energy is required to perform MWP, LBD, and POTs, respectively. Use of the standard METs formula may underestimate the level of intensity an individual with SCI uses to perform physical activities.

Variable Intensive Early Walking Poststroke (VIEWS): A Randomized Controlled Trial

BACKGROUND

Converging evidence suggests that the amount of stepping practice is an important training parameter that influences locomotor recovery poststroke. More recent data suggest that stepping intensity and variability are also important, although such strategies are often discouraged early poststroke.

OBJECTIVE

The present study examined the efficacy of high-intensity, variable stepping training on walking and nonwalking outcomes in individuals 1 to 6 months poststroke as compared with conventional interventions. Methods Individuals with unilateral stroke (mean duration = 101 days) were randomized to receive ≤40, 1-hour experimental or control training sessions over 10 weeks. Experimental interventions consisted only of stepping practice at high cardiovascular intensity (70%-80% heart rate reserve) in variable contexts (tasks or environments). Control interventions were determined by clinical physical therapists and supplemented using standardized conventional strategies. Blinded assessments were obtained at baseline, midtraining, and posttraining with a 2-month follow-up. Results A total of 32 individuals (15 experimental) received different training paradigms that varied in the amount, intensity, and types of tasks performed. Primary outcomes of walking speed (experimental, 0.27 ± 0.22 m/s vs control, 0.09 ± 0.09 m/s) and distances (119 ± 113 m vs 30 ± 32 m) were different between groups, with stepping amount and intensity related to these differences. Gains in temporal gait symmetry and self-reported participation scores were greater following experimental training, without differences in balance or sit-to-stand performance. Conclusion Variable intensive stepping training resulted in greater improvements in walking ability than conventional interventions early poststroke. Future studies should evaluate the relative contributions of these training parameters.

Upper Body-Based Power Wheelchair Control Interface for Individuals With Tetraplegia

Many power wheelchair control interfaces are not sufficient for individuals with severely limited upper limb mobility. The majority of controllers that do not rely on coordinated arm and hand movements provide users a limited vocabulary of commands and often do not take advantage of the user's residual motion. We developed a body-machine interface (BMI) that leverages the flexibility and customizability of redundant control by using high dimensional changes in shoulder kinematics to generate proportional control commands for a power wheelchair. In this study, three individuals with cervical spinal cord injuries were able to control a power wheelchair safely and accurately using only small shoulder movements. With the BMI, participants were able to achieve their desired trajectories and, after five sessions driving, were able to achieve smoothness that was similar to the smoothness with their current joystick. All participants were twice as slow using the BMI however improved with practice. Importantly, users were able to generalize training controlling a computer to driving a power wheelchair, and employed similar strategies when controlling both devices. Overall, this work suggests that the BMI can be an effective wheelchair control interface for individuals with high-level spinal cord injuries who have limited arm and hand control.

Safety and efficacy of medically performed tongue piercing in people with tetraplegia for use with tongue-operated assistive technology

BACKGROUND

Individuals with high-level spinal cord injuries need effective ways to perform activities.

OBJECTIVES

To develop and test a medically supervised tongue-piercing protocol and the wearing of a magnet-containing tongue barbell for use with the Tongue Drive System (TDS) in persons with tetraplegia.

METHODS

Volunteers with tetraplegia underwent initial screening sessions using a magnet glued on the tongue to activate and use the TDS. This was followed by tongue piercing, insertion of a standard barbell, a 4-week healing period, and an exchange of the standard barbell for a magnet-containing barbell. This was then used twice weekly for 6 to 8 weeks to perform computer tasks, drive a powered wheelchair, accomplish in-chair weight shifts, and dial a phone. Symptoms of intraoral dysfunction, change in tongue size following piercing, and subjective assessment of receiving and wearing a magnet-containing tongue barbell and its usability with the TDS were evaluated.

RESULTS

Twenty-one volunteers underwent initial trial sessions. Thirteen had their tongues pierced. One individual's barbell dislodged during healing resulting in tongue-tract closure. Twelve had the barbell exchanged for a magnet-containing barbell. One subject withdrew for unrelated issues. Eleven completed the TDS testing sessions and were able to complete the assigned tasks. No serious adverse events occurred related to wearing or using a tongue barbell to operate the TDS.

CONCLUSIONS

Using careful selection criteria and a medically supervised piercing protocol, no excess risk was associated with tongue piercing and wearing a tongue barbell in people with tetraplegia. Participants were able to operate the TDS.

Assessment of the Tongue-Drive System Using a Computer, a Smartphone, and a Powered-Wheelchair by People With Tetraplegia

Tongue-Drive System (TDS) is a wireless and wearable assistive technology that enables people with severe disabilities to control their computers, wheelchairs, and smartphones using voluntary tongue motion. To evaluate the efficacy of the TDS, several experiments were conducted, in which the performance of nine able-bodied (AB) participants using a mouse, a keypad, and the TDS, as well as a cohort of 11 participants with tetraplegia (TP) using the TDS, were observed and compared. Experiments included the Fitts' law tapping, wheelchair driving, phone-dialing, and weight-shifting tasks over five to six consecutive sessions. All participants received a tongue piercing, wore a magnetic tongue stud, and completed the trials as evaluable participants. Although AB participants were already familiar with the keypad, throughputs of their tapping tasks using the keypad were only 1.4 times better than those using the TDS. The completion times of wheelchair driving task using the TDS for AB and TP participants were between 157 s and 180 s with three different control strategies. Participants with TP completed phone-dialing and weight-shifting tasks in 81.9 s and 71.5 s, respectively, using tongue motions. Results showed statistically significant improvement or trending to improvement in performance status over the sessions. Most of the learning occurred between the first and second sessions, but trends did suggest that more practice would lead to increased improvement in performance using the TDS.

Seven-Year Trends in Stroke Rehabilitation: Patient Characteristics, Medical Complications, and Functional Outcomes

Studies of stroke trends have focused primarily on incidence, mortality, and hospitalization rates. There has been little evaluation of changes over time in the common patient characteristics, medical comorbidities, and functional outcomes of patients. The present study evaluated changes during a 7-year period. We found that while demographic variables, stroke severity, and most stroke characteristics remained relatively stable, disability levels at admission and discharge decreased and frequencies of both medical tube usage and many secondary medical complications increased over time. These changes have important implications for the clinical management of stroke patients in rehabilitation and for the organization and financing of stroke rehabilitation programs.

Concurrent deficits of soleus and gastrocnemius muscle fascicles and Achilles tendon post stroke

Calf muscles and Achilles tendon play important roles in functional activities. However, it is not clear how biomechanical properties of the uniarticular soleus (SOL) and biarticular gastrocnemius muscle and Achilles tendon, including the fascicle length, pennation angle, and stiffness, change concurrently post stroke. Biomechanical properties of the medial gastrocnemius (GM) and soleus muscles were evaluated bilaterally in 10 hemiparetic stroke survivors using combined ultrasonography-biomechanical measurements. Biomechanical properties of the Achilles tendon including the length, cross-sectional area (CSA), stiffness, and Young's modulus were evaluated, together with calf muscle biomechanical properties. Gastrocnemius and SOL contributions were separated using flexed and extended knee positions. The impaired side showed decreased fascicle length (GM: 6%, P = 0.002 and SOL: 9%, P = 0.03, at full knee extension and 0° ankle dorsiflexion) and increased fascicular stiffness (GM: 64%, P = 0.005 and SOL: 19%, P = 0.012, at a common 50 N force level). In contrast, Achilles tendon on the impaired side showed changes in the opposite direction as the muscle fascicles with increased tendon length (5%, P < 0.001), decreased tendon CSA (5%, P = 0.04), decreased tendon stiffness (42%, P < 0.001) and Young's modulus (30%, P < 0.001) compared with the unimpaired side. The fascicle and tendon stiffness changes were correlated negatively to the corresponding fascicle and tendon length changes, and decrease in Achilles tendon stiffness was correlated to the increases of SOL and GM fascicular stiffness (P < 0.05). Characterizations of calf muscle fascicles and Achilles tendon biomechanical properties help us better understand concurrent changes of fascicles and tendon as part of the calf muscle-tendon unit and facilitate development of more effective treatments.

Rehabilitation Medicine Summit: Building Research Capacity

The general objective of the "Rehabilitation Medicine Summit: Building Research Capacity" was to advance and promote research in medical rehabilitation by making recommendations to expand research capacity. The five elements of research capacity that guided the discussions were 1) researchers; 2) research culture, environment, and infrastructure; 3) funding; 4) partnerships; and 5) metrics. The 100 participants included representatives of professional organizations, consumer groups, academic departments, researchers, governmental funding agencies, and the private sector. The small group discussions and plenary sessions generated an array of problems, possible solutions, and recommended actions. A post-Summit, multi-organizational initiative is called to pursue the agendas outlined in this report.

Abstract W MP57: Effects of Wearable Robotic Training of Ankle and Mobility Rehabilitation in Acute Stroke

Background and Purpose: Stroke is the fourth leading cause of death in the US and is a leading cause of adult disability. It was reported that the first few months post stroke is critical in neural plasticity and motor recovery. Presently, effective treatment options for ankle impairment and mobility are limited, especially for in-bed acute stroke rehabilitation. In this study, wearable robotic training involving passive stretching and active movement training was investigated to determine its efficacy in improving stroke outcome.

Methods: Eleven patients with acute stroke participated. This was completed in a clinical in-patient setting (45 min/session, 3~5х/week, total 18 session). Participants were aged 53.7±17.4 (mean±SD); robotic treatment was given averaged 40.5 days of stroke onset. They continued receiving standard inpatient physical therapy during the study. One way repeated measures ANOVA was used to compare clinical and biomechanical outcome measures across the repeated measures.

Results: Preliminary results showed an improvement after the multiple sessions of training with F-M in LE increased from 14.8 ± 8.8 and 19.4 ± 8.2 (p<.01), STREAM score in LE from 32.1±21.4 to 47.9±30.1 (p=.02), the BBS increased from 35.2±17.8 to 38.0±18.2. Ankle active range of motion (AROM) in dorsiflexion increased from -5.7 ± 7.2° to 2.3 ± 8.1°(p=.004), ankle passive ROM in dorsiflexion from 14.0 ± 7.1° to 19.9 ± 5.3° (p=.002). Dorsiflexor strength increased from 0 ± 2.2 N m before training to 2.4 ±3.5 N m after training (p=.003). Plantarflexor strength increased from 6.7±9.9 Nm, to 12.6 ± 11.4 Nm (p=.004). Other measures showed no significant improvements, such as 6MWT increased from 302.0 ± 416.4 and 540.6 ± 563.4 feet, the MAS of ankle was 2.2 ± 1.1 to 1.6 ± 1.2.

Conclusions: The use of robotic device demonstrated improvements in selected outcome measures in hospital settings, and it was efficiently administer in the clinic. The results suggest that impaired lower limbs of acute stroke can respond to controlled stretching and movement training in terms of muscle biomechanical properties and improve lower extremity functional activities in acute rehabilitation.The limitation of this study was its small sample size and lack of a control group.