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Fatigue and impaired upright postural control (balance) are the 2 most common findings in people with multiple sclerosis (MS), with treatment approaches varying greatly in effectiveness. The aim of this study was to investigate the benefits of implementing a vestibular rehabilitation program for the purpose of decreasing fatigue and improving balance in patients with MS. The study was a 14-week, single-blinded, stratified blocked randomized controlled trial. Measurements were conducted in an outpatient clinical setting, and interventions were performed in a human performance laboratory. Thirty-eight patients with MS were randomly assigned to an experimental group, an exercise control group, or a wait-listed control group. The experimental group underwent vestibular rehabilitation, the exercise control group underwent bicycle endurance and stretching exercises, and the wait-listed control group received usual medical care. Primary measures were a measure of fatigue (Modified Fatigue Impact Scale), a measure of balance (posturography), and a measure of walking (Six-Minute Walk Test). Secondary measures were a measure of disability due to dizziness or disequilibrium (Dizziness Handicap Inventory) and a measure of depression (Beck Depression Inventory-II). Following intervention, the experimental group had greater improvements in fatigue, balance, and disability due to dizziness or disequilibrium compared with the exercise control group and the wait-listed control group. These results changed minimally at the 4-week follow-up. Limitations The study was limited by the small sample size. Further investigations are needed to determine the underlying mechanisms associated with the changes in the outcome measures due to the vestibular rehabilitation program. A 6-week vestibular rehabilitation program demonstrated both statistically significant and clinically relevant change in fatigue, impaired balance, and disability due to dizziness or disequilibrium in patients with MS.

Exercise confers short-term benefits for individuals with Parkinson disease (PD). The purpose of the study was to compare short- and long-term responses among 2 supervised exercise programs and a home-based control exercise program. The 16-month randomized controlled exercise intervention investigated 3 exercise approaches: flexibility/balance/function exercise (FBF), supervised aerobic exercise (AE), and home-based exercise (control). This study was conducted in outpatient clinics. The participants were 121 individuals with PD (Hoehn & Yahr stages 1-3). The FBF program (individualized spinal and extremity flexibility exercises followed by group balance/functional training) was supervised by a physical therapist. The AE program (using a treadmill, bike, or elliptical trainer) was supervised by an exercise trainer. Supervision was provided 3 days per week for 4 months, and then monthly (16 months total). The control group participants exercised at home using the National Parkinson Foundation Fitness Counts program, with 1 supervised, clinic-based group session per month. Outcomes, obtained by blinded assessors, were determined at 4, 10, and 16 months. The primary outcome measures were overall physical function (Continuous Scale-Physical Functional Performance [CS-PFP]), balance (Functional Reach Test [FRT]), and walking economy (oxygen uptake [mL/kg/min]). Secondary outcome measures were symptom severity (Unified Parkinson's Disease Rating Scale [UPDRS] activities of daily living [ADL] and motor subscales) and quality of life (39-item Parkinson's Disease Quality of Life Scale [PDQ-39]). Of the 121 participants, 86.8%, 82.6%, and 79.3% completed 4, 10, and 16 months, respectively, of the intervention. At 4 months, improvement in CS-PFP scores was greater in the FBF group than in the control group (mean difference=4.3, 95% confidence interval [CI]=1.2 to 7.3) and the AE group (mean difference=3.1, 95% CI=0.0 to 6.2). Balance was not different among groups at any time point. Walking economy improved in the AE group compared with the FBF group at 4 months (mean difference=-1.2, 95% CI=-1.9 to -0.5), 10 months (mean difference=-1.2, 95% CI=-1.9 to -0.5), and 16 months (mean difference=-1.7, 95% CI=-2.5 to -1.0). The only secondary outcome that showed significant differences was UPDRS ADL subscale scores: the FBF group performed better than the control group at 4 months (mean difference=-1.47, 95% CI=-2.79 to -0.15) and 16 months (mean difference=-1.95, 95% CI=-3.84 to -0.08). Absence of a non-exercise control group was a limitation of the study. Findings demonstrated overall functional benefits at 4 months in the FBF group and improved walking economy (up to 16 months) in the AE group.

Neuromuscular electrical stimulation (NMES) can facilitate the recovery of quadriceps muscle strength after total knee arthroplasty (TKA), yet the optimal intensity (dosage) of NMES and its effect on strength after TKA have yet to be determined. The primary objective of this study was to determine whether the intensity of NMES application was related to the recovery of quadriceps muscle strength early after TKA. A secondary objective was to quantify quadriceps muscle fatigue and activation immediately after NMES to guide decisions about the timing of NMES during rehabilitation sessions. This study was an observational experimental investigation. Data were collected from 30 people who were 50 to 85 years of age and who received NMES after TKA. These people participated in a randomized controlled trial in which they received either standard rehabilitation or standard rehabilitation plus NMES to the quadriceps muscle to mitigate strength loss. For the NMES intervention group, NMES was applied 2 times per day at the maximal tolerable intensity for 15 contractions beginning 48 hours after surgery over the first 6 weeks after TKA. Neuromuscular electrical stimulation training intensity and quadriceps muscle strength and activation were assessed before surgery and 3.5 and 6.5 weeks after TKA. At 3.5 weeks, there was a significant association between NMES training intensity and a change in quadriceps muscle strength (R(2)=.68) and activation (R(2)=.22). At 6.5 weeks, NMES training intensity was related to a change in strength (R(2)=.25) but not to a change in activation (R(2)=.00). Furthermore, quadriceps muscle fatigue occurred during NMES sessions at 3.5 and 6.5 weeks, whereas quadriceps muscle activation did not change. Some participants reached the maximal stimulator output during at least 1 treatment session and might have tolerated more stimulation. Higher NMES training intensities were associated with greater quadriceps muscle strength and activation after TKA.

Introduction Recruitment of sufficient patients with Parkinson disease into clinical trials is a barrier to successful, timely study completion. Non-pharmacologic studies have shown to be even more challenging for recruitment, despite some studies focusing on de novo Parkinson disease populations. This paper describes successful recruitment techniques from a randomized exercise clinical trial in Parkinson disease. Methods Several recruitment strategies were used to enroll de novo patients with Parkinson disease into a year-long clinical trial. Strategies focused on infrastructure included fast-track clinic scheduling, weekly research meetings, an established clinical repository, real-time clinic recruitment, and outreach to the community. The nature of the study facilitated recruitment by offering a wait-listed control group, exercise at a local fitness center with a paid membership, and collection of data by shipping equipment foregoing some visits. An experienced nurse study coordinator involved in recruitment and training of the principal investigator in recruitment of minorities enhanced overall recruitment. Finally, the patient population chosen for this study, patients with de novo Parkinson disease, may be more likely to enroll in an exercise study than patients with later stage disease. Results Seventy-six patients with de novo Parkinson disease were successfully enrolled into the exercise clinical trial from a single site. Conclusion Targeted recruitment strategies were successful in this study. Additional modifications to the study protocol, such as eliminating treadmill stress tests before randomization, travel to an urban downtown location for study visits, and a relatively healthy Parkinson disease population, may also have impacted this study. These strategies could all be adopted for other studies in Parkinson disease, neurodegenerative diseases, or other chronic disorders. Trial registration Clinicaltrials.gov, NCT01506479 . Registered on 10 January 2012.

Background and Purpose. Evidence suggests that individuals with early and mid-stage Parkinson disease (PD) have diminished range of motion (ROM). Spinal ROM influences the ability to function. In this investigation, the authors examined available spinal ROM, segmental excursions (the ROM used) during reaching, and their relationships in community-dwelling adults with and without PD. Subjects. The subjects were 16 volunteers with PD (modified Hoehn and Yahr stages 1.5–3) and 32 participants without PD who were matched for age, body mass index, and sex. Methods. Range of motion of the extremities was measured using a goniometer, and ROM of the spine was measured using the functional axial rotation (FAR) test, a measure of unrestricted cervico-thoracic-lumbar rotation in the seated position. Motion during reaching was determined using 3-dimensional motion analysis. Group differences were determined using multivariable analysis of variance followed by analysis of variance. Contributions to total reaching distance of segmental excursions (eg, thoracic rotation, thoracic lateral flexion) were determined using forward stepwise regression. Results. Subjects with PD as compared with subjects without PD had less ROM (FAR of 98.2° versus 110.3°, shoulder flexion of 151.9° versus 160.1°) and less forward reaching (29.5 cm versus 34.0 cm). Lateral trunk flexion and total rotation relative to the ground contributed to reaching, with the regression model explaining 36% of the variance. Discussion and Conclusion. These results contribute to the growing body of evidence demonstrating that spinal ROM is impaired early in PD.

Abstract Rationale Early physical therapy (PT) interventions may benefit patients with acute respiratory failure by preventing or attenuating neuromuscular weakness. However, the optimal dosage of these interventions is currently unknown. Objectives To determine whether an intensive PT program significantly improves long-term physical functional performance compared with a standard-of-care PT program. Methods Patients who required mechanical ventilation for at least 4 days were eligible. Enrolled patients were randomized to receive PT for up to 4 weeks delivered in an intensive or standard-of-care manner. Physical functional performance was assessed at 1, 3, and 6 months in survivors who were not currently in an acute or long-term care facility. The primary outcome was the Continuous Scale Physical Functional Performance Test short form (CS-PFP-10) score at 1 month. Measurements and Main Results A total of 120 patients were enrolled from five hospitals. Patients in the intensive PT group received 12.4 ± 6.5 sessions for a total of 408 ± 261 minutes compared with only 6.1 ± 3.8 sessions for 86 ± 63 minutes in the standard-of-care group (P < 0.001 for both analyses). Physical function assessments were available for 86% of patients at 1 month, for 76% at 3 months, and for 60% at 6 months. In both groups, physical function was reduced yet significantly improved over time between 1, 3, and 6 months. When we compared the two interventions, we found no differences in the total CS-PFP-10 scores at all three time points (P = 0.73, 0.29, and 0.43, respectively) or in the total CS-PFP-10 score trajectory (P = 0.71). Conclusions An intensive PT program did not improve long-term physical functional performance compared with a standard-of-care program. Clinical trial registered with www.clinicaltrials.gov (NCT01058421).

Although Parkinson disease (PD) is common throughout the world, the evidence for physical therapy interventions that enable long-term improvement in walking is still emerging. This article critiques the major physical therapy approaches related to gait rehabilitation in people with PD: compensatory strategies, motor skill learning, management of secondary sequelae, and education to optimize physical activity and reduce falls. The emphasis of this review is on gait specifically, although balance and falls are of direct importance to gait and are addressed in that context. Although the researchers who have provided the evidence for these approaches grounded their studies on different theoretical paradigms, each approach is argued to have a valid place in the comprehensive management of PD generally and of gait in particular. The optimal mix of interventions for each individual varies according to the stage of disease progression and the patient's preferred form of exercise, capacity for learning, and age.

Background and Purpose. The Continuous-Scale Physical Functional Performance Test (CS-PFP) can be used to obtain valid, reliable, and sensitive measurements of physical functional capacity. This test requires a fixed laboratory space and approximately 1 hour to administer. This study was carried out in 4 steps, or substudies, to develop and validate a short, community-based version (PFP-10) that requires less space and equipment than the CS-PFP. Subjects and Methods. Retrospective data (n=228) and prospective data (n=91) on men and women performing the CS-PFP or the PFP-10 are reported. A 12-week exercise program was used to examine sensitivity to change. Data analyses were done using paired t-test, Pearson correlation, intraclass correlation coefficient (ICC), and delta index (DI) procedures. Results. The PFP-10 total score and 4 of the 5 domain scores were statistically similar (within 3%) to those of the CS-PFP. The PFP-10 upper-body strength domain score was 17% lower, but was highly correlated (ICC=.97). Community and established laboratory PFP-10 scores were similar (ICC=.85–.97). The PFP-10 also is sensitive to change (DI=.21–.54). Discussion and Conclusion. The PFP-10 yields valid, reliable, and sensitive measurements and can be confidently substituted for the CS-PFP.

Background and Purpose. Initiation of gait requires transitions from relatively stationary positions to stability with movement and from double- to single-limb stances. These are deliberately destabilizing activities that may be difficult for people with early Parkinson disease (PD), even when they have no problems with level walking. We studied differences in postural stability during gait initiation between participants with early and middle stages of PD (characterized by Hoehn and Yahr as stages 1–3) and 2 other groups of participants without PD—older and younger adults. Subjects. The mean ages of the 3 groups of participants were as follows: subjects with PD, 69.3 years (SD=5.7, range=59–78); older subjects without PD, 69.0 years (SD=3.9, range=65–79); and younger subjects without PD, 27.5 (SD=3.9, range=22–35). Methods. A 3-dimensional motion analysis system was used with 2 force platforms to obtain data for center of mass (COM) and center of pressure (COP). The distance between the vertical projections of the COM and the COP (COM–COP distance) was used to reflect postural control during 5 events in gait initiation. Results. By use of multivariate analysis of variance, differences in COM–COP distance were found among the 3 groups. An analysis of variance indicated differences for 4 of the 5 events in gait initiation. A Scheffe post hoc analysis demonstrated differences in gait initiation between the subjects with PD and both groups of subjects without PD (2 events) and between the subjects with PD and the younger subjects without PD (2 events). Discussion and Conclusion. The COM–COP distance relationship was used to measure postural control during the transition from quiet standing to steady-state gait. Differences between groups indicated that individuals with impaired postural control allow less COM–COP distance than do individuals with no known neurologic problems. The method used could prove useful in the development and assessment of interventions to improve ambulation safety and enhance the independence of people with impaired postural control.

Patients admitted to the intensive care unit (ICU) can develop a condition referred to as “ICU-acquired weakness.” This condition is characterized by profound weakness that is greater than might be expected to result from prolonged bed rest. Intensive care unit–acquired weakness often is accompanied by dysfunction of multiple organ systems. Individuals with ICU-acquired weakness typically have significant activity limitations, often requiring physical assistance for even the most basic activities associated with bed mobility. Many of these individuals have activity limitations months to years after hospitalization. The purpose of this article is to review evidence that guides physical rehabilitation of people with ICU-acquired weakness. Included are diagnostic criteria, medical management, and prognostic indicators, as well as criteria for beginning physical rehabilitation, with an emphasis on patient safety. Data are presented indicating that rehabilitation can be implemented with very few adverse effects. Evidence is provided for appropriate measurement approaches and for physical intervention strategies. Finally, some of the key issues are summarized that should be investigated to determine the best intervention guidelines for individuals with ICU-acquired weakness.