Movement System Diagnoses for Balance Dysfunction: Recommendations From the Academy of Neurologic Physical Therapy's Movement System Task Force.

The movement system was identified as the focus of our expertise as physical therapists in the revised vision statement for the profession adopted by the American Physical Therapy Association in 2013. Attaining success with the profession's vision requires the development of movement system diagnoses that will be useful in clinical practice, research, and education. To date, only a few movement system diagnoses have been identified and described, and none of these specifically address balance dysfunction. Over the past 2 years, a Balance Diagnosis Task Force, a subgroup of the Movement System Task Force of the Academy of Neurologic Physical Therapy, focused on developing diagnostic labels (or diagnoses) for individuals with balance problems. This paper presents the work of the task force that followed a systematic process to review available diagnostic frameworks related to balance, identify 10 distinct movement system diagnoses that reflect balance dysfunction, and develop complete descriptions of examination findings associated with each balance diagnosis. A standardized approach to movement analysis of core tasks, the Framework for Movement Analysis developed by the Academy of Neurologic Physical Therapy Movement Analysis Task Force, was integrated into the examination and diagnostic processes. The aims of this perspective paper are to (1) summarize the process followed by the Balance Diagnosis Task Force to develop an initial set of movement system (balance) diagnoses; (2) report the recommended diagnostic labels and associated descriptions; (3) demonstrate the clinical decision-making process used to determine a balance diagnosis and develop a plan of care; and (4) identify next steps to validate and implement the diagnoses into physical therapist practice, education, and research. IMPACT: The development and use of diagnostic labels to classify distinct movement system problems is needed in physical therapy. The 10 balance diagnosis proposed can aid in clinical decision making regarding intervention.

A Framework for Movement Analysis of Tasks: Recommendations From the Academy of Neurologic Physical Therapy's Movement System Task Force.

The American Physical Therapy Association's Vision Statement of 2013 asserts that physical therapists optimize movement in order to improve the human experience. In accordance with this vision, physical therapists strive to be recognized as experts in movement analysis. However, there continues to be no accepted method to conduct movement analysis, nor an agreement of key terminology to describe movement observations. As a result, the Academy of Neurologic Physical Therapy organized a task force that was charged with advancing the state of practice with respect to these issues, including the development of a proposed method for movement analysis of tasks. This paper presents the work of the Task Force, which includes (1) development of a method for conducting movement analysis within the context of the movement continuum during 6 core tasks (sitting, sit to stand, standing, walking, step up/down, and reach/grasp/manipulate); (2) glossary of movement constructs that can provide a common language for movement analysis across a range of tasks: symmetry, speed, amplitude, alignment, verticality, stability, smoothness, sequencing, timing, accuracy, and symptom provocation; and (3) recommendations for task and environmental variations that can be systematically applied. The expectation is that this systematic framework and accompanying terminology will be easily adapted to additional patient or client-specific tasks, contribute to development of movement system diagnostic labels, and ultimately improve consistency across patient/client examination, evaluation, and intervention for the physical therapy profession. Next steps should include validation of this framework across patient/client groups and settings.

Checklist-Style Rubric Development for Practical Examination of Clinical Skills in Entry-Level Physical Therapist Education.

BACKGROUND: Grading rubrics used in the assessment of physical therapy students' clinical skills should be developed in a method that promotes validity. This study applied a systematic approach to the development of rubrics to assess student performance within a Doctor of Physical Therapy curriculum. PARTICIPANTS: Ten faculty participated. METHODS: Checklist-style rubrics covering four clinical skills were developed using a five-step process: 1) evidence-based rubric item development; 2) multiple Delphi review rounds to achieve consensus on item content; 3) pilot testing and formatting of rubrics; 4) final Delphi review; 5) weighting of rubric sections. Consensus in the Delphi review was defined as: ≥75% of participants rate each item Agree/Strongly Agree in two consecutive rounds, no statistically significant difference between Likert ratings on the final two rounds for each item using the Wilcoxon signed-rank test (p>0.05), and a reduction in participant comments between the first and last rounds. RESULTS: All rubric items achieved consensus with: 100% agreement, no statistically significant difference between the two final sets of ratings (p=0.102 to 1.000), and a decrease in the number of comments from 81 in Round 1 to 21 in Round 5. CONCLUSION: This method of rubric development resulted in rubrics with validity, acceptability, and time efficiencies.

White Paper: Movement System Diagnoses in Neurologic Physical Therapy.

BACKGROUND AND PURPOSE: The APTA recently established a vision for physical therapists to transform society by optimizing movement to promote health and wellness, mitigate impairments, and prevent disability. An important element of this vision entails the integration of the movement system into the profession, and necessitates the development of movement system diagnoses by physical therapists. At this point in time, the profession as a whole has not agreed upon diagnostic classifications or guidelines to assist in developing movement system diagnoses that will consistently capture an individual's movement problems. We propose that, going forward, diagnostic classifications of movement system problems need to be developed, tested, and validated. The Academy of Neurologic Physical Therapy's Movement System Task Force was convened to address these issues with respect to management of movement system problems in patients with neurologic conditions. The purpose of this article is to report on the work and recommendations of the Task Force. SUMMARY OF KEY FINDINGS: The Task Force identified 4 essential elements necessary to develop and implement movement system diagnoses for patients with primarily neurologic involvement from existing movement system classifications. The Task Force considered the potential impact of using movement system diagnoses on clinical practice, education and, research. Recommendations were developed and provided recommendations for potential next steps to broaden this discussion and foster the development of movement system diagnostic classifications. RECOMMENDATIONS FOR CLINICAL PRACTICE: The Task Force proposes that diagnostic classifications of movement system problems need to be developed, tested, and validated with the long-range goal to reach consensus on and adoption of a movement system diagnostic framework for clients with neurologic injury or disease states.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A198).

Afferent stimulation provided by glove electrode during task-specific arm exercise following stroke.

BACKGROUND: Sensory amplitude electrical stimulation (SES) and repetitive task practice reduce impairments and arm dysfunction when delivered separately following stroke. OBJECTIVE: To determine if home-based, task-specific arm exercise was more effective when administered concurrent with SES. METHODS: Thirty-eight subjects with chronic stroke and mean Fugl-Meyer Assessment (FMA) score 28/66 (15-45) participated. Subjects were randomly assigned to an SES (n = 20) or sham stimulation (n = 18) group. Subjects engaged in task-based home exercise for 30 minutes, twice daily, for four weeks while wearing a glove electrode on the impaired hand. Experimental subjects received SES while control subjects received sham stimulation during exercise. PRIMARY OUTCOME MEASURES: FMA and Arm Motor Ability Test (AMAT). RESULTS: There were no significant between-group differences for outcome measures. There was a significant difference between the pre- and post-test scores in the SES group AMAT median time (P = 0.003 95% confidence interval (CI): -14.304, -6.365; effect size: 0.84). Practice time was not associated with changes in outcomes. Subjects with more sensorimotor dysfunction had significantly greater improvements on AMAT median time (P = 0.037). There was a significant relationship between baseline FMA score and FMA change score (r = 0.402; P = 0.006). CONCLUSIONS: This study describes a unique SES delivery system via glove electrode that enabled delivery of SES during home-based arm task practice in stroke survivors. Task practice with concurrent SES did not demonstrate significantly better effects than task practice with sham stimulation, however there was a trend for greater improvement in one activity measure.

An initial exploration of the perceptual threshold test using electrical stimulation to measure arm sensation following stroke.

OBJECTIVE: To explore the viability of the perceptual threshold test using electrical stimulation to measure light touch sensation in the hands of stroke survivors. DESIGN: Descriptive study. SETTING: University research laboratory. SUBJECTS: Twenty-nine adult community-dwelling chronic stroke survivors. MAIN MEASURE(S): Perceptual threshold test using electrical stimulation, stroke rehabilitation assessment of movement, Nottingham sensory assessment for stereognosis, action research arm test, Fugl-Meyer assessment of sensation and motor activity log 14. RESULTS: Perceptual threshold test using electrical stimulation mean threshold values were 1.23 (0.6) milliamperes (range 0.5-3.5) for the uninvolved side and 1.68 (0.91) milliamperes (range 0.5-4.5) for the involved side. The perceptual threshold test using electrical stimulation demonstrated excellent intra-rater reliability (intraclass correlation coefficient = 0.896 - uninvolved; 0.829 - involved). There was a statistically significant difference between the perceptual threshold test using electrical stimulation mean threshold values for the uninvolved and involved arms (P = 0.003), but this significance did not hold for subjects who had normal sensation as measured by the Fugl-Meyer assessment of sensation (P = 0.083). Low to nonexistent correlations were found between the perceptual threshold test using electrical stimulation and other measures of sensation, arm movement, activity and participation. CONCLUSIONS: The perceptual threshold test using electrical stimulation is a reliable and clinically feasible test with the potential to identify sensory capacity in stroke survivors with substantial sensory loss. Electrical sensory thresholds do not reflect overall sensory function or motor capabilities in stroke survivors.

Sensory dysfunction following stroke: incidence, significance, examination, and intervention.

Recent studies have provided evidence of the widespread incidence of sensory dysfunction following stroke. The importance of these findings lies in the association between sensory loss poststroke and poorer outcomes in motor capacity, functional abilities, length of inpatient stay, and quality of life. Since literature suggests that clinicians can use information about clients' sensory status to predict rehabilitation outcomes and select appropriate interventions, the accuracy of somatosensory assessment is extremely clinically relevant. However, many of the clinical tests that are commonly used to examine sensation have not been found to be valid or reliable. Emerging evidence supports the efficacy of several interventions that target the sensory systems. This article reviews the incidence, significance, examination, and interventions for sensory dysfunction following stroke and summarizes the important characteristics of interventions directed at somatosensation.

Neuromuscular electrical stimulation during task-oriented exercise improves arm function for an individual with proximal arm dysfunction after stroke.

This case report examined the effectiveness of a home program using neuromuscular electrical stimulation (NMES) during voluntary task-oriented exercise to achieve functional and impairment improvements for an individual with primarily proximal arm paresis after a stroke. The subject initially achieved a Fugl-Meyer Assessment (FMA) score of 58/66, but she reported minimal functional use of her involved, dominant arm. The 6-wk intervention consisted of NMES-assisted task practice involving repetitive reaching for and manipulation of small objects for three daily 15-min sessions. The subject applied NMES to the deltoid and triceps brachii muscles to augment shoulder flexion and abduction and elbow extension during task practice. Outcome measures included the FMA, the Action Research Arm Test (ARAT), and the Motor Activity Log Quality of Movement subscale (MAL-QOM). The FMA remained unchanged, but the ARAT and MAL-QOM showed improvements, from the beginning to the conclusion of the intervention, that were maintained at 6-wk follow-up.

Effects of home-based sensory and motor amplitude electrical stimulation on arm dysfunction in chronic stroke.

OBJECTIVE: To examine the effects of a home-based arm exercise programme of sensory and motor amplitude electrical stimulation. DESIGN: Non-concurrent, multiple-baseline, single-subject design. SUBJECTS: Ten adults with chronic arm hemiparesis following stroke. Subjects ranged in age from 38 to 74 years and were 2-16 years post stroke. Three subjects had right-sided involvement; seven had left. INTERVENTION: Subjects completed an eight-week, individualized, home programme of neuromuscular and sensory amplitude electrical stimulation. All subjects engaged in stimulation-assisted task-specific exercises for 15 minutes 2 -3 times daily. Participants with sensory deficits received an additional 15 minutes of sensory amplitude stimulation twice daily. The Action Research Arm Test was used to examine arm function; the Stroke Rehabilitation Assessment of Movement was used to examine movement quality; and the Modified Ashworth Assessment of Spasticity was used to examine muscle tone. RESULTS: A statistically significant improvement was demonstrated by six of the 10 subjects on the Action Research Arm Test, and five subjects on the Stroke Rehabilitation Assessment of Movement. Four subjects had > or = 10% improvement on the Modified Ashworth Assessment of Spasticity. Two subjects demonstrated significant improvement on all three outcome measures; six subjects improved on two or more measures; and seven subjects improved on one or more measure. Subjects who improved on two or more measures tended to have had more recent onset of stroke, were older and had higher baseline motor and functional capacity. CONCLUSION: Subjects with chronic stroke can experience impairment and functional improvements following a home-based programme of motor and sensory amplitude electrical stimulation.

A home program of sensory and neuromuscular electrical stimulation with upper-limb task practice in a patient 5 years after a stroke.

BACKGROUND AND PURPOSE: This case report describes a person with upper-extremity (UE) hemiparesis who participated in a home program that included sensory amplitude electrical stimulation (SES) to his involved arm and performance of task-specific exercises with the assistance of neuromuscular electrical stimulation (NMES). CASE DESCRIPTION: The patient was a 67-year-old man with stable sensory and motor deficits 5 years after a stroke. Sensory amplitude electrical stimulation was delivered for 2 hours per day. A daily, 15-minute course of NMES was used to help him perform UE tasks. This home program was carried out for 18 weeks and included 6 physical therapist home visits. OUTCOMES: The patient's UE score on the Stroke Rehabilitation Assessment of Movement (STREAM) improved from 10/20 to 17/20. The score on the Action Research Arm Test (ARAT) improved from 27/57 to 42/57. The patient reported that he was now able to button buttons, use a knife and fork, and tie simple fishing knots. DISCUSSION: A home program combining SES and NMES may be an effective method to increase UE function even 5 years after a stroke.

Triggering of protective stepping for the control of human balance: age and contextual dependence.

Human stepping is a commonly executed control strategy for maintaining standing balance in the natural environment. Aging changes in the initiation triggering of both voluntary (longer latency) and perturbation-induced (shorter latency) stepping are associated with falling, and are a complex function of altered sensorimotor, neuromuscular, and cognitive system factors. The aim of this study was to determine the effect of contextual uncertainty about balance stability on the triggering of protective stepping in young and older individuals. Subjects initiated forward stepping during simple reaction time and waist-pull perturbation conditions with and without contextual uncertainty about balance stability. The results showed that, regardless of age, the initiation timing for triggering both voluntary and induced stepping was delayed substantially (100-300 ms) by the presence of balance uncertainty, and that age-associated timing differences were exacerbated with contextual uncertainty. The initiation timing of the first step liftoff for perturbation-induced stepping did not reflect entirely an immediate necessity or last resort strategy to balance instability determined directly by specific sensory input, but rather a decision to step. Moreover, the time to liftoff onset for perturbation-induced stepping was similar for the old and young with contextual certainty, and occurred 130 ms earlier for the old than for the young when balance stability was uncertain. Overall, we concluded that older individuals can retain a residual capacity to sustain stationary standing stability as a function of the prevailing task conditions, and that the reduced timing threshold with age may involve a pre-selected strategy triggered earlier by non-specific event-related sensory input rather than specific movement-related information.

Step training improves the speed of voluntary step initiation in aging.

BACKGROUND: Falls related to balance dysfunction are among the major problems of older individuals. The timing characteristics of protective voluntary stepping are critically related to effective balance recovery and are often delayed and slowed with age. This study investigated the influence of step training on the timing characteristics of voluntary step initiation in younger and older adults. METHODS: Voluntary reaction time stepping was evaluated before and after training in 12 younger adults and 8 healthy community-dwelling older adults who performed a 3-week regimen of either twice weekly induced step training (destabilizing large waist pulls) or voluntary step practice to a somatosensory reaction stimulus cue (nondestabilizing small waist pulls). RESULTS: Overall, the first step initiation times were slower for the older than for the younger subjects for both the somatosensory reaction stimulus cue task and an auditory transfer cue task. Step completion time was completed earlier for the young posttraining subjects, and older subjects generally had a longer step length. Training resulted in significant reductions in step initiation timing for the old (17%) and young (15%) subjects. Across age groups, the induced training group showed greater reductions in step initiation time than the voluntary practice group for the auditory transfer cue task. CONCLUSIONS: A 3-week period of either voluntary or waist-pull-induced step training reduced step initiation time in older and younger adults. Moreover, compared with voluntary step practice, induced step training resulted in a significantly greater improvement in reaction time stepping for an auditory transfer cue task. At least in the short term, such step training has the potential to help older adults perform more like younger adults in their step initiation timing.