The psychometric properties of the toe tap test in people with stroke.

Objectives: To investigate the: (i) inter-rater and test-retest reliability of the toe tap test for people with stroke, (ii) the convergent validity of toe tap test counts with stroke-specific impairments, (iii) minimum detectable change in toe tap test counts, (iv) toe tap test cutoff counts which best discriminating the performance between stroke survivors and healthy controls.Design: Cross-sectional study.Setting: University-based rehabilitation center.Participants: Thirty-seven people with stroke and 35 healthy controls.Main Outcome Measures: The toe tap test was administered along with the Fugl-Meyer lower extremity assessment, muscle strength of ankle dorsiflexors and plantarflexors, five times sit-to-stand test, Berg Balance Scale, limit of stability test, timed up and go test, and Community Integration Measures questionnaire.Results: Excellent inter-rater and test-retest reliabilities (intraclass correlation coefficient = 0.868-0.995 on the affected side) were found. A minimal detectable change of 8.7 counts and a cutoff score of 21 counts was found on the affected side, while 12.6 counts and 25 counts were found on the unaffected side, respectively. Toe tap test counts on the affected side were significantly associated with Fugl-Meyer lower extremity assessment scores, ankle muscle strength, Berg Balance Scale scores and timed up and go test times.Conclusions: Toe tap test count on the affected side is a simple and reliable tool for assessing ankle control in people with stroke.Implications for rehabilitationToe Tap Test counts have excellent intra-rater, inter-rater, and test-retest reliabilities in people with stroke.Toe Tap Test counts on the affected side were significantly associated with Fugl-Meyer Assessment of Lower Extremity scores, ankle muscle strength, Berg Balance Scale scores, and timed Up and Go test completion times.The 95% Minimal Detectable Change for the Toe Tap Test counts was 8.7 counts of the affected side and 12.6 of the unaffected side.Toe Tap Test counts of 21 on the affected side and 25 on the unaffected side (sensitivity 70.3-83.3%; specificity 71.4-85.7%) was found to be the most representative for discriminating performance of Toe Tap Test in chronic stroke survivors and healthy older adults.Toe Tap Test is a simple and reliable tool for assessing ankle control in people with stroke.

Translation of robot-assisted rehabilitation to clinical service: a comparison of the rehabilitation effectiveness of EMG-driven robot hand assisted upper limb training in practical clinical service and in clinical trial with laboratory configuration for chronic stroke.

BACKGROUND: Rehabilitation robots can provide intensive physical training after stroke. However, variations of the rehabilitation effects in translation from well-controlled research studies to clinical services have not been well evaluated yet. This study aims to compare the rehabilitation effects of the upper limb training by an electromyography (EMG)-driven robotic hand achieved in a well-controlled research environment and in a practical clinical service. METHODS: It was a non-randomized controlled trial, and thirty-two participants with chronic stroke were recruited either in the clinical service (n = 16, clinic group), or in the research setting (n = 16, lab group). Each participant received 20-session EMG-driven robotic hand assisted upper limb training. The training frequency (4 sessions/week) and the pace in a session were fixed for the lab group, while they were flexible (1-3 sessions/week) and adaptive for the clinic group. The training effects were evaluated before and after the treatment with clinical scores of the Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), Functional Independence Measure (FIM), and Modified Ashworth Scale (MAS). RESULTS: Significant improvements in the FMA full score, shoulder/elbow and wrist/hand (P < 0.001), ARAT (P < 0.001), and MAS elbow (P < 0.05) were observed after the training for both groups. Significant improvements in the FIM (P < 0.05), MAS wrist (P < 0.001) and MAS hand (P < 0.05) were only obtained after the training in the clinic group. Compared with the lab group, higher FIM improvement in the clinic group was observed (P < 0.05). CONCLUSIONS: The functional improvements after the robotic hand training in the clinical service were comparable to the effectiveness achieved in the research setting, through flexible training schedules even with a lower training frequency every week. Higher independence in the daily living and a more effective release in muscle tones were achieved in the clinic group than the lab group.

Reliability and convergent validity of the five-step test in people with chronic stroke.

OBJECTIVES: (i) To estimate the intra-rater, inter-rater and test-retest reliabilities of the Five-Step Test (FST), as well as the minimum detectable change in FST completion times in people with stroke. (ii) To estimate the convergent validity of the FST with other measures of stroke-specific impairments. (iii) To identify the best cut-off times for distinguishing FST performance in people with stroke from that of healthy older adults. DESIGN: A cross-sectional study. SETTING: University-based rehabilitation centre. PARTICIPANTS: Forty-eight people with stroke and 39 healthy controls. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The FST, along with (for the stroke survivors only) scores on the Fugl-Meyer Lower Extremity Assessment (FMA-LE), the Berg Balance Scale (BBS), Limits of Stability (LOS) tests, and Activities-specific Balance Confidence (ABC) scale were tested. RESULTS: The FST showed excellent intra-rater (intra-class correlation coefficient; ICC = 0.866-0.905), inter-rater (ICC = 0.998), and test-retest (ICC = 0.838-0.842) reliabilities. A minimum detectable change of 9.16 s was found for the FST in people with stroke. The FST correlated significantly with the FMA-LE, BBS, and LOS results in the forward and sideways directions (r = -0.411 to -0.716, p < 0.004). The FST completion time of 13.35 s was shown to discriminate reliably between people with stroke and healthy older adults. CONCLUSION: The FST is a reliable, easy-to-administer clinical test for assessing stroke survivors' ability to negotiate steps and stairs.

Sideways walk test: Reliability and association with lower limb motor function after stroke.

OBJECTIVES: To investigate (i) the intra-rater, inter-rater and test-retest reliability of sideways walk test times and counts in individuals with stroke; (ii) their correlations with stroke-specific measures of impairment; (iii) the cut-off sideways walk test times and counts between stroke survivors and healthy controls; and (iv) the minimum detectable changes in the sideways walk test times and counts. DESIGN: Cross-sectional study. SETTING: University-based rehabilitation centre. SUBJECTS: Twenty-nine older adults with stroke and 32 healthy controls. METHODS: The sideways walk test was conducted together with Fugl-Meyer motor assessments of the lower extremities, lower limb muscle strength tests, the Five-Times-Sit-To-Stand test, Berg Balance Scale, Timed Up-and-Go test, and Activity-based Confidence and Community Integration Measure questionnaires. RESULTS: The sideways walk test times and counts demonstrated good to excellent intra-rater, inter-rater, and test-retest reliabilities. The sideways walk test times and counts were significantly correlated with motor control and ankle dorsiflexor and plantarflexor strength of the affected leg, balance performance and functional mobility. The cut-off sideways walk test time and count that best discriminated between individuals with stroke and controls were 10.74 s and 8.83 steps, respectively. The minimal detectable change in the sideways walk test time in that situation was 1.85 s, and the count minimum detectable change was 1.12 steps. CONCLUSION: The sideways walk test is a reliable and easy-to-administer clinical test for assessing sideways walking ability of individuals with chronic stroke.

Effect of acceleration and deceleration distance on the walking speed of people with chronic stroke.

OBJECTIVE: To examine the effect of acceleration and deceleration distance (0, 1, 2 and 3 m) on the comfortable and maximum walking speeds in: (i) the 5-m walk test (5mWT); and (ii) the 10-m walk test (10mWT) in people with chronic stroke. DESIGN: Cross-sectional study. SETTING: University-based rehabilitation centre. SUBJECTS: Thirty individuals with chronic stroke. METHODS: Timed walking at comfortable and maximum walking speeds in the 5mWT and 10mWT with different acceleration and deceleration distances (0, 1, 2 and 3 m). RESULTS: The comfortable walking speed in the 5mWT with 0 m acceleration and deceleration distance was significantly slower than that with 1, 2 or 3 m acceleration and deceleration distances (p < 0.0083), but there was no significant difference among 1, 2 and 3 m acceleration and deceleration distances. No significant difference was found in the maximum walking speed in the 5mWT, or in the comfortable and maximum walking speeds of the 10mWT. CONCLUSION: Adoption of 1 m acceleration and deceleration distance is recommended when measuring the comfortable walking speed in the 5mWT in people with stroke. Neither acceleration nor deceleration distance is needed when measuring the maximum walking speed in the 5mWT, the comfortable walking speed or the maximum walking speed in the 10mWT.

Reliability and validity of the sideways step test and its correlation with motor function after stroke.

[Purpose] This study investigated the intra-rater, inter-rater and test-retest reliability of the sideways step test (SST), its correlation with other indicators of stroke-specific impairment, and the cut-off count best discriminating subjects with stroke from their healthy counterparts. [Subjects and Methods] Forty-three subjects with chronic stroke and 41 healthy subjects older than 50 years participated in this study. The SST was administered along with the Fugl-Meyer motor assessment for the lower extremities (FMA-LE), the five-times sit to stand (5TSTS) test, the Berg Balance Scale (BBS), the movement velocity (MVL) by the limits of stability (LOS) test, the ten-metre walk (10mW) test, the timed "Up and Go" (TUG) test and the Activities-specific Balance Confidence (ABC) scale. [Results] The SST showed good to excellent intra-rater, inter-rater and test-retest reliability. The SST counts correlated with 5TSTS times, 10mW times, TUG times, and the FMA-LE and BBS scores. SST counts of 11 for the paretic leg and 14 for the non-paretic leg were found to distinguish the healthy adults from subjects with stroke. [Conclusion] The sideways step test is a reliable clinical test, which correlates with the functional strength, gait speed, and functional balance of people with chronic stroke.

Floor transfer test for assessing people with chronic stroke.

OBJECTIVE: To investigate: (i) intra-rater, inter-rater and test-retest reliability of the Timed Floor Transfer Test (FTT); (ii) validity of FTT times with stroke-specific impairments and functional mobility; and (iii) cut-off time that best discriminates people with stroke from healthy older adults. DESIGN: Cross-sectional study. SETTING: University-based rehabilitation laboratory. SUBJECTS: Forty-seven people with stroke and 35 healthy older adults. METHODS: FTT completion times were measured along with a Fugl-Meyer assessment of the lower extremities (FMA-LE); Five Times Sit-To-Stand Test (FTSTST) completion times, Berg Balance Scale (BBS) scores; Timed "Up & Go" (TUG) test; and assessment using the Activities-specific Balance Confidence Scale (ABC). RESULTS: FTT completion times showed good to excellent intra-rater, inter-rater and test-retest reliability. The minimal detectable change of FTT completion times was 7.7 s. A cut-off time of 8.8 s was found to discriminate well between people with stroke and healthy older adults. The FTT times showed significant negative correlation with FMA-LE scores and BBS scores, and significant positive correlation with FTSTS completion times and TUG times. CONCLUSION: The FTT is a reliable clinical test for assessing the floor-transfer ability of people with chronic stroke.

Deformation and reperfusion damages and their accumulation in subcutaneous tissues during loading and unloading: a theoretical modeling of deep tissue injuries.

Deep tissue injuries (DTI) involve damages in the subcutaneous tissues under intact skin incurred by prolonged excessive epidermal loadings. This paper presents a new theoretical model for the development of DTI, broadly based on the experimental evidence in the literatures. The model covers the loading damages implicitly inclusive of both the direct mechanical and ischemic injuries, and the additional reperfusion damages and the competing healing processes during the unloading phase. Given the damage accumulated at the end of the loading period, the relative strength of the reperfusion and the healing capacity of the involved tissues system, the model provides a description of the subsequent damage evolution during unloading. The model is used to study parametrically the scenario when reperfusion damage dominates over healing upon unloading and the opposite scenario when the loading and subsequent reperfusion damages remain small relative to the healing capacity of the tissues system. The theoretical model provides an integrated understanding of how tissue damage may further build-up paradoxically even with unloading, how long it would take for the loading and reperfusion damages in the tissues to become fully recovered, and how such loading and reperfusion damages, if not given sufficient time for recovery, may accumulate over multiple loading and unloading cycles, leading to clinical deep tissues ulceration.

Biomechanics of pressure ulcer in body tissues interacting with external forces during locomotion.

Forces acting on the body via various external surfaces during locomotion are needed to support the body under gravity, control posture, and overcome inertia. Examples include the forces acting on the body via the seating surfaces during wheelchair propulsion, the forces acting on the plantar foot tissues via the insole during gait, and the forces acting on the residual-limb tissues via the prosthetic socket during various movement activities. Excessive exposure to unwarranted stresses at the body-support interfaces could lead to tissue breakdowns commonly known as pressure ulcers, often presented as deep-tissue injuries around bony prominences or as surface damage on the skin. In this article, we review the literature that describes how the involved tissues respond to epidermal loading, taking into account both experimental and computational findings from in vivo and in vitro studies. In particular, we discuss related literature about internal tissue deformation and stresses, microcirculatory responses, and histological, cellular, and molecular observations.

Post pressure response of skin blood flowmotions in anesthetized rats with spinal cord injury.

Pressure ulcer is a common complication developed in persons with spinal cord injury (SCI) when prolonged unrelieved pressure was applied to the body/skin and underlying tissues. The objective of this study is to assess the hyperemic response of the skin blood flowmotions in anesthetized rats with spinal cord injury subjected to prolonged pressure using spectral analysis based on wavelets transform of the periodic oscillations of the cutaneous laser Doppler flowmetry (LDF) signal. A total of twenty-eight Sprague-Dawley rats were used in this study, of which 14 were normal rats and the other 14 were spinal cord injured rats with transection of the T1 spinal nerves. External pressure of 13.3 kPa (100 mmHg) was applied to the trochanter area of rats via a specifically designed indentors. The loading duration was 6 h. LDF measurement was monitored for 20 min prior to and after the prescribed compression period. Five frequency intervals were identified (0.01-0.05 Hz, 0.05-0.15 Hz, 0.15-0.4 Hz, 0.4-2 Hz and 2-5 Hz) corresponding to endothelial related metabolic, neurogenic, myogenic, respiratory and cardiac origins. The absolute amplitude of oscillations of each particular frequency interval and the normalized amplitude were calculated for quantitative assessments. Comparisons of hyperemic response were performed between SCI rats and normal ones. The results showed that the normalized amplitude in the frequency interval II (0.05-0.15 Hz) was significantly lower on SCI rats than that in normal ones (p<0.01). Also, decreased reactive hyperemic response was observed in rats suffered from spinal cord injury.

An experience on wheelchair bank management.

In this article, we described the wheelchair bank program at a local hospital and our experiences in managing the service over the past 10 years from 1996 to 2005. This article also reported statistical information related to the acquisitions of wheelchairs and adaptive components, including body support and pressure relief systems. The cost benefit of recycling seating and mobility equipments for use by children with neuromuscular diseases was revealed. With the reference of the reported data, the demands on specific types of wheelchairs and adaptive parts were disclosed to facilitate budget planning of similar services.

Wavelet analysis of the effects of static magnetic field on skin blood flowmotion: investigation using an in vivo rat model.

BACKGROUND: In the literature, various in vivo studies on animals have demonstrated that a static magnetic field (SMF) might maintain microvascular tone in the cutaneous microcirculatory system by its biphasic effects on vasomotion. Here, the effects of locally applied SMF on skin blood flowmotion within the stressed or unstressed skin in the trochanter area were evaluated using wavelet analysis of skin blood perfusion as measured by laser Doppler flowmetry (LDF) in anesthetized rats. MATERIALS AND METHODS: Forty-eight experimental trials were carried out on twelve Sprague-Dawley rats. Four experimental groups were formed at random: i) Group CNL (no loading or SMF exposure; n = 12 trials); ii) Group SMF (SMF exposure only; n = 12 trials); iii) Group L (stressed skin without SMF exposure; n = 12 trials); iv) Group L + SMF (stressed skin with SMF exposure; n = 12 trials). RESULTS: SMF significantly enhanced endothelial related metabolic activity (0.01-0.05 Hz) in the stressed skin (p = 0.03). However, SMF did not induce significant change in the flowmotion amplitude in the unstressed skin (p = 0.22). CONCLUSION: The modulating effect of SMF on skin blood flowmotion might be related to the vascular tone modified by prolonged loading.

The time effect of pressure on tissue viability: investigation using an experimental rat model.

An experimental rat model was used to investigate the time-pressure effect on tissue viability. External loading equivalent to 13.3 kPa (100 mm Hg) of pressure was applied to the greater trochanter and tibialis area of Sprague-Dawley rats using pneumatic indentors for duration of 6 hrs each day for 1 to 4 days. It was observed that postocclusive hyperemic responses were gradually increased at the trochanter throughout the 4 days of loading, whereas for the tibia there was a significant increase (P = 0.04) in postocclusive hyperemic flow between Days 2 and 3. In histologic evaluations, cutaneous tissue damage was observed at the trochanter area but not at the tibialis area after 2 consecutive days of load application. In contrast, degeneration of muscle cells characterized by numerous increases of nuclei occupying the central of the muscle fibers was observed after 2 days of load application at the tibialis. The situation was found to progress with time (P = 0.17). The presence of other histologic signs, including the internalization of peripherally located nuclei, replacement of muscle cells by fibrosis and adipose tissues, and the presence of pyknotic nuclei as well as karyorrhexis, confirmed that the affected tissues were damaged. These findings suggest that postocclusive hyperemia and the distress of tissues under loading could be closely related.

Effects of prolonged compression on the variations of haemoglobin oxygenation - assessment by spectral analysis of reflectance spectrophotometry signals.

The consequences of rhythmical flow motion for nutrition and the oxygen supply to tissue are largely unknown. In this study, the periodic variations of haemoglobin oxygenation in compressed and uncompressed skin were evaluated with a reflection spectrometer using an in vivo Sprague-Dawley rat model. Skin compression was induced over the trochanter area by a locally applied external pressure of 13.3 kPa (100 mmHg) via a specifically designed pneumatic indentor. A total of 19 rats were used in this study. The loading duration is 6 h per day for four consecutive days. Haemoglobin oxygenation variations were quantified using spectral analysis based on wavelets' transformation. The results found that in both compressed and uncompressed skin, periodic variations of the haemoglobin oxygenation were characterized by two frequencies in the range of 0.01-0.05 Hz and 0.15-0.4 Hz. These frequency ranges coincide with those of the frequency range of the endothelial-related metabolic and myogenic activities found in the flow motion respectively. Tissue compression following the above loading schedule induced a significant decrease in the spectral amplitudes of frequency interval 0.01-0.05 Hz during the pre-occlusion period on day 3 and day 4 as compared to that on day 1 (p < 0.05). In contrast, at a frequency range of 0.15-0.4 Hz, prolonged compression caused a significant increase in spectral amplitude during the pre-occlusion period in the compressed tissue on day 3 (p = 0.041) and day 4 (p = 0.024) compared to that in the uncompressed tissue on day 1. These suggested that the variations of the haemoglobin oxygenation were closely related to the endothelial-related metabolic and myogenic activities. Increased amplitude in the frequency interval 0.15-0.4 Hz indicated an increased workload of the vascular smooth muscle and could be attributed to the increase of O(2) consumption rates of arteriolar walls. The modification of vessel wall oxygen consumption might substantially affect the available oxygen supply to the compressed tissue. This mechanism might be involved in the process leading to pressure ulcer formation.

Effects of prolonged surface pressure on the skin blood flowmotions in anaesthetized rats--an assessment by spectral analysis of laser Doppler flowmetry signals.

The objective of this study is to assess the effect of prolonged surface compression on the skin blood flowmotion in rats using spectral analysis based on wavelets transform of the periodic oscillations of the cutaneous laser Doppler flowmetry (LDF) signal. An external pressure of 13.3 kPa (100 mmHg) was applied to the trochanter area and the distal lateral tibia of Sprague-Dawley rats via two specifically designed pneumatic indentors. The loading duration was 6 hours/day for 4 consecutive days. Five frequency intervals were identified (0.01-0.04 Hz, 0.04-0.15 Hz, 0.15-0.4 Hz, 0.4-2 Hz and 2-5 Hz) corresponding to endothelial related metabolic, neurogenic, myogenic, respiratory and cardiac origins. The absolute amplitude of oscillations of each particular frequency interval and the normalized amplitude were calculated for quantitative assessments. The results showed that (1) tissue compression following the above schedule induced significant decrease in the normalized amplitude in the frequency interval of 0.01-0.04 Hz both in the trochanter area (p < 0.001) and tibialis area (p = 0.023), (2) prolonged compression induced significant increase in the absolute amplitude (p = 0.004 for the trochanter area and p = 0.017 for the tibialis area) but significant decrease in the normalized amplitude (p = 0.023 for the trochanter area and p = 0.026 for the tibialis area) in the frequency interval of 0.15-0.4 Hz, and (3) at the tibialis area, the flowmotion amplitude (frequency interval 0.15-0.4 Hz) measured prior to the daily tissue compression schedule was found to be significantly higher on day 4 than the measurements obtained on day 1. However, this finding was not observed at the trochanter area. Our results suggested that prolonged compression might induce endothelial damage and affect the endothelial related metabolic activities.