Use of a Robotic Walking Device for Home and Community Mobility in Parkinson Disease: A Randomized Controlled Trial.

BACKGROUND/PURPOSE: Gait impairments in Parkinson disease (PD) contribute to decreased quality of life. This randomized controlled trial examined immediate- and longer-term effects of a single joint robotic exoskeleton device (EXOD), the Honda Walking Assist device, on gait. METHODS: Participants (n = 45) with PD (Hoehn and Yahr stages 1-3) were randomized to a robotic-assisted gait training (RAGT) group (n = 23) or control (CON) group (n = 22). The RAGT group was tested with and without the EXOD at baseline and then received supervised in-home and community training with the EXOD twice weekly for 8 weeks. The CON group received no interventions. Outcome measures included gait speed (primary), gait endurance (6-minute walk test), perceived ease of walking, and questionnaires and logs assessing performance of daily activities, freezing of gait, and daily activity levels. RESULTS: Forty participants completed the study. No significant immediate impact of EXOD usage on participants' gait measures was found. Differences in gait speed and secondary outcome measures postintervention were not significantly different between the RAGT and CON groups. Participants with greater disease severity (worse baseline motor scores) had greater improvements in stride length during unassisted walking after the intervention than those with lower severity (mean difference: 3.22, 95% confidence interval: 0.05-6.40; P = 0.04). DISCUSSION AND CONCLUSIONS: All RAGT participants could use the EXOD safely. The RAGT treatment used in this mostly low impairment population of people with PD may be ineffective and/or was insufficiently dosed to see a positive treatment effect. Our findings suggest that RAGT interventions in PD may be more effective in individuals with greater motor impairments.

The role of community paramedicine in fall prevention: A SWOT analysis.

BACKGROUND: Millions of older US adults fall annually, leading to catastrophic injuries, over 32,000 deaths and healthcare costs of over $55 billion. This study evaluated perceived benefits and limitations of using community paramedicine for fall prevention strategies from the lens of older adults, caregivers, and healthcare providers. METHODS: Semi-structured focus groups were held with individuals from three stakeholder groups: (1) community-dwelling older adults (age ≥60), (2) caregivers, and (3) healthcare providers. The Strengths-Weaknesses-Opportunities-Threats (SWOT) framework was used to quantitatively analyze stakeholder perceptions of using community paramedicine for fall prevention strategies. RESULTS: A total of 10 focus groups were held with 56 participants representing older adults (n = 15), caregivers (n = 16), and healthcare providers (n = 25). Community paramedicine was supported as a model of fall prevention by older adults, caregivers, and healthcare providers. Participants identified strengths such as visibility to the home environment, ability to implement home modifications, implicit trust in emergency medical services (EMS), and capacity to redirect resources toward prevention. Additionally, participants acknowledged opportunities such as providing continuity of care across the healthcare spectrum, improving quality and safety of care and potentially reducing unnecessary emergency department use. Participants endorsed weaknesses and threats such as funding, concerns of patients about stigma, and struggles with medical data integration. CONCLUSIONS: The results of this study illuminate the opportunity to leverage community paramedicine to address a variety of perceived barriers in order to design and implement better solutions for fall prevention efforts.

Clinical Decision Trees to Guide Physical Therapy Management of Persons with Huntington's Disease.

BACKGROUND: In 2020, our group published physical therapy clinical practice guidelines (CPG) for people with Huntington's disease (HD). The guideline recommendations were categorized according to six primary movement impairment classifications. OBJECTIVE: To facilitate implementation of this CPG, we have developed guideline-based algorithms for physical therapy assessments and interventions and recommendations for therapists to overcome barriers to CPG implementation for people with HD. METHODS: We conducted a literature review of papers that evaluated physical therapy interventions in individuals with HD (n = 26) to identify assessments for each of the primary movement impairment classifications, and then searched for papers (n = 28) that reported their clinometric/psychometric properties in HD. Assessments were evaluated using modified Movement Disorder Society Committee on Rating Scales criteria and other relevant criteria. RESULTS: We identified a "core set" of physical therapy assessments for persons with HD, including the Six Minute Walk Test, Timed Up and Go Test, Berg Balance Scale, and the Medical Outcomes Study Short Form 36 (SF-36). We then developed guideline-based decision trees to assist in decision making and implementation of the CPG into practice for persons with HD across the continuum of care. Finally, we developed strategies for overcoming barriers to implementation, such as seeking specialized training in HD, engaging caretakers or family members to help the person with HD to exercise, and establishing clinical pathways that support early physical therapy referrals. CONCLUSION: Knowledge translation documents such as this are essential to promoting implementation of the physical therapy CPGs into clinical practice.

Implementing Physiotherapy Huntington's Disease Guidelines in Clinical Practice.

BACKGROUND: The recently published clinical practice guideline for physiotherapy practice for Huntington's disease (HD) should be integrated into practice to develop interventions that enable people with HD to achieve personalised goals. The European Huntington's Disease Network Physiotherapy Working Group aims to support and enable the use of best evidence in physiotherapy for the HD community. Successful implementation of the clinical practice guidelines requires an understanding of facilitators and barriers to therapist implementation. OBJECTIVE: To explore facilitators and barriers to implementing recently published clinical recommendations that guide physiotherapy practice for HD. METHODS: An online survey was distributed globally through HD networks. Data collected included demographic information and agreement/disagreement with a series of named facilitators and barriers to implementation of each of the six physiotherapy guideline recommendations. A consensus level of≥70% agreement was set as indicative of agreement/disagreement. RESULTS: Thirty-two physiotherapists working in a range of settings responded. Support from colleagues (81-91% agreement), an individualised physiotherapy plan (72-88% agreement) and physiotherapist's expertise in HD (81-91% agreement) were reported as facilitators. The main barriers were behavioural (72-81% agreement) and cognitive (75-81% agreement) impairments and low motivation (72-78% agreement) in persons with HD. CONCLUSION: Physiotherapists agree that their expertise in HD and support from colleagues facilitate the development of individualised treatment plans. Further work needs to develop creative ways in which barriers specific to the cognitive and behavioural aspects of HD can be managed to enable treatment plans to be implemented.

Immediate effects of treadmill walking in individuals with Lewy body dementia and Huntington's disease.

BACKGROUND: Treadmill training may improve gait disorders associated with neurodegenerative diseases. In Parkinson's disease (PD), treadmill training alters gait patterns after one session, and long-term training improves gait parameters, fall risk, and quality of life. RESEARCH QUESTION: What is the feasibility and safety of using this intervention for people with Lewy body dementia (LBD) or Huntington's disease (HD)? METHODS: In this observational study, 10 individuals with HD, 8 individuals with LBD, and 10 control individuals walked for 20 min on a treadmill using a speed dependent protocol starting at a slow comfortable speed and increasing incrementally toward their normal overground speed. Feasibility was determined by compliance to protocol and safety by no incidents of abnormal vital signs or expressions of distress. Changes in gait measures, Timed Up and Go (TUG) scores and quantitative motor function measures (Q-Motor; precision grasp force variability, finger and foot tapping frequency) before and after treadmill walking were analyzed using linear models. RESULTS: Treadmill training is feasible and safe in LBD and HD; although, participants could not initiate treadmill walking at their comfortable overground speeds, and only 3 participants with HD were able to achieve their overground walking speed within the 20-minute session. No changes in gait measures, TUG times, and Q-Motor measures were found among LBD and HD participants after treadmill walking, although control participants demonstrated significant increases in several gait measures, and foot tap frequency (estimated difference = 0.290; p = 0.026). SIGNIFICANCE: Longer and more frequent treadmill sessions may be needed to see gait and motor function effects in LBD and HD. Motor and cognitive impairments associated with these diseases may make them less amenable to the effects of treadmill training.

Backward Walking and Dual-Task Assessment Improve Identification of Gait Impairments and Fall Risk in Individuals with MS.

BACKGROUND: Individuals with multiple sclerosis (MS) experience deficits in motor and cognitive domains, resulting in impairment in dual-task walking ability. The goal of this study was to compare performance of forward walking and backward walking in single- and dual-task conditions in persons with MS to age- and sex-matched healthy controls. We also examined relationships between forward and backward walking to cognitive function, balance, and retrospective fall reports. METHODS: All measures were collected in a single session. A 2 × 2 × 2 mixed model ANOVA was used to compare differences in forward and backward walking in single- and dual-task conditions between MS and healthy controls. Spearman correlations were used to examine relationships between gait and cognitive function, falls, and balance. RESULTS: Eighteen individuals with relapsing-remitting MS and 14 age- and sex-matched healthy controls participated. Backward walking velocity revealed significant differences between groups for both single-task (p = 0.015) and dual-task (p = 0.014) conditions. Persons with MS demonstrated significant differences between single- and dual-task forward and backward walking velocities (p = 0.023; p = 0.004), whereas this difference was only apparent in the backward walking condition for healthy controls (p = 0.004). In persons with MS, there were significant differences in double support time between single- and dual-task conditions in both backward (p < 0.001) and forward (p = 0.001) directions. More falls at six months were significantly associated with shorter backward dual-task stride length (r = -0.490; p = 0.046) and slower velocity (r = -0.483; p = 0.050). CONCLUSION: Differences in MS and age- and sex-matched healthy controls are more pronounced during backward compared to forward walking under single- and dual-task conditions. Future work with a larger sample size is needed to validate the clinical utility of backward walking and dual-task assessments and mitigate the limited sensitivity of the current dual-task assessments that primarily rely upon forward walking.

The Step Test Evaluation of Performance on Stairs (STEPS): Validation and reliability in a neurological disorder.

BACKGROUND: Individuals with neurological disorders often have difficulty negotiating stairs that can lead to injurious falls. Clinicians lack a clinical tool to identify impairments in stair negotiation and to assist their decision making regarding treatment plans to improve stair performance and safety. We developed a new tool called the Step Test Evaluation of Performance on Stairs (STEPS) that is designed to assess stair performance and safety in neurological populations. OBJECTIVES: This study aimed to determine interrater and intrarater reliability of STEPS and its concurrent content validity to various clinical balance and mobility measures using individuals with Huntington's disease (HD) as the first test population. METHODS: Forty individuals with HD (mean age 50.35) participated. Three observers rated live performances of the STEPS (interrater reliability) and seven observers rated videotaped performances twice (intrarater reliability). STEPS scores correlated with clinical mobility and balance test scores. RESULTS: Excellent inter- and intrarater reliability (ICCs = 0.91 and 0.89 respectively) and good internal consistency (α = 0.83) were found. Better STEPS performance correlated with better performance on co-administered motor and mobility measures and Stair Self-Efficacy scores. Per multivariable regression analysis, the Unified Huntington's Disease Rating Scale modified motor score and descent time were significant predictors of STEPS performance. CONCLUSIONS: The STEPS tool is easy to administer, requires no special devices and can be completed in less than five minutes. In the HD test population, it shows high reliability and validity making it a potentially useful tool for assessing maneuverability and safety on stairs in HD. The results suggest that the STEPS tool warrants further study to determine STEPS cut-off values for fall prediction in HD and may prove useful as an assessment tool for other neurological disorders.

Supplementary motor area connectivity and dual-task walking variability in multiple sclerosis.

BACKGROUND: Despite the prevalence of dual-task (e.g., walking while talking) deficits in people with multiple sclerosis (MS), no neuroimaging studies to date have examined neuronal networks used for dual-task processing or specific brain areas related to dual-task performance in this population. A better understanding of the relationship among underlying brain areas and dual-task performance may improve targeted rehabilitation programs. The objective of this study was to examine relationships between neuroimaging measures and clinical measures of dual-task performance, and reported falls in persons with MS. MATERIALS AND METHODS: All participants completed measures of dual-task performance, a fall history, and neuroimaging on a 3 T MRI scanner. Spearman correlations were used to examine relationships among dual-task performance, falls and neuroimaging measures. RESULTS: Eighteen females with relapsing-remitting MS [mean age = 45.5 ±â€¯8.2 SD; mean symptom duration = 12.3 ±â€¯6.7 years; Expanded Disability Status Scale median 2.25 (range 1.5-4)] participated in this study. Structural imaging measures of supplementary motor area (SMA) interhemispheric connectivity were significantly related to dual-task walking variability. CONCLUSIONS: The SMA interhemispheric tract may play a role in dual-task performance. Structural neuroimaging may be a useful adjunct to clinical measures to predict performance and provide information about recovery patterns in MS. Functional recovery can be challenging to objectively report in MS; diffusion tensor imaging could show microstructural improvements and suggest improved connectivity.

Professional Values Are Implicit in Written Reflections by DPT Students in a Short-Term International Service Learning Course.

International service learning (ISL) courses within physical therapy (PT) education programs are designed, in part, to promote the development of professional values. Assessment of students' professional values, however, is a challenge for educators. METHODS: This study focused on the reflective learning component of an elective 10-day ISL course, evaluated whether PT professional values were manifested in students' written reflections, and characterized the level of student reflections using Bradley's criteria. Twenty-one third-year PT students participated. A qualitative content analysis of each student's written assignments was conducted. RESULTS: Although explicit instruction on PT values was not provided, reflections on professional values were identified in 97% of assignments. All three of Bradley's levels were found in all three written assignments, with the highest proportion of level 2 and 3 reflections being found in unstructured journals. CONCLUSION: Although no instruction specific to PT professional values was provided, values were implicit in student written assignments during this ISL course.

Cognitive Dysfunction Contributes to Mobility Impairments in Huntington's Disease.

BACKGROUND: Huntington's disease (HD) is a progressive neurodegenerative disorder that results in a gradual decline in mobility and balance. Increasing evidence has documented an important role of executive function in the safe ambulation of the elderly and people with a variety of neurological disorders. Little is known about the contribution of cognitive deficits to decline in mobility over time in HD. OBJECTIVE: This study examined the relationships of mobility, motor and cognitive function measures at baseline, and of mobility and cognitive measures over four years. METHODS: A retrospective chart review was performed on 70 patients with genetically confirmed HD (age 20-75 years old) across 121 HD clinic visits. Correlations between Unified Huntington's Disease Rating Scale - Total Motor, Tinetti Mobility Test (TMT), and cognitive measures (Letter Verbal Fluency, Symbol Digit Modalities Test (SDMT), and Stroop Test) were analyzed. Longitudinal relationships between TMT and cognitive measures were examined using mixed effect regression models. RESULTS: Gait and balance measures representing domains of mobility (TMT scores) were significantly correlated with each of the cognitive measures with the exception of the Verbal Fluency score. Mixed effects regression modeling showed that the Stroop Interference sub-test and SDMT were significant predictors (p-values <0.01) of TMT total scores. CONCLUSIONS: Impairments in executive function measures correlate highly with measures of gait, balance and mobility in individuals with HD. Interventions designed to improve mobility and decrease fall risk should also address issues of cognitive impairments with particular consideration given to interventions that may focus on motor-cognitive dual task training.

Quantitative biomechanical assessment of trunk control in Huntington's disease reveals more impairment in static than dynamic tasks.

Postural instability is common in individuals with Huntington's disease (HD), yet little is known about control of the trunk during static and dynamic activities. We compared the trunk motion of 41 individuals with HD and 36 controls at thoracic and pelvic levels during sitting, standing, and walking using wearable iPod sensors. We also examined the ability of individuals with HD to respond to an auditory cue to modify trunk position when the pelvis moved >8° in sagittal or frontal planes during sitting using custom software. We found that amplitude of thoracic and pelvic trunk movements was significantly greater in participants with HD, and differences were more pronounced during static (i.e. sitting, standing) than dynamic (i.e. walking) tasks. In contrast to the slow, smooth sinusoidal trunk movements of controls, individuals with HD demonstrated rapid movements with varying amplitudes that continuously increased without stabilizing. Ninety-seven percent of participants with HD were able to modify their trunk position in response to auditory cues. Our results demonstrate that wearable iPod sensors are clinically useful for rehabilitation professionals to measure and monitor trunk stability in persons with HD. Additionally, auditory cueing holds potential as a useful training tool to improve trunk stability in HD.

An acute interprofessional simulation experience for occupational and physical therapy students: Key findings from a survey study.

Due to the fast pace and high complexity of managing patients in intensive and acute care units (ICUs), healthcare students often feel challenged and unprepared to practice in this environment. Simulations and standardised patients provide "hands-on" learning experiences that are realistic and help students to gain competence and confidence. This study examined the impact of an intensive case simulation laboratory using a patient simulator and standardised patients on students' perceptions of their confidence and preparedness to work in acute care settings. Second-year Masters of Occupational Therapy (MOT; n = 127) and Doctor of Physical Therapy (DPT; n = 105) students participated in a three-hour intensive care simulation laboratory comprised of four stations that were designed to simulate common ICU patient care scenarios. Data analysed were student pre- and post-simulation surveys and written comments, and clinical instructors' (CIs; n = 51) ratings on DPT students' preparedness and confidence within the first two weeks of their acute care internships obtained after the laboratory. There was a significant increase for DPT (p < 0.0001) and MOT (p < 0.10) students in median ratings of how prepared they felt to practice in acute care settings following the ICU simulation compared to before the laboratory. CIs rated the DPT students as either prepared or very prepared for and moderately confident or very confident in the acute care setting. The use of simulation training using standardised patients and patient simulators was beneficial in increasing student confidence and preparing OT and PT students to practice in the acute care setting. Health professional educators should consider using an interprofessional simulation experience to improve their students' confidence and preparedness to provide appropriate care in the acute setting.

Motor performance differentiates individuals with Lewy body dementia, Parkinson's and Alzheimer's disease.

INTRODUCTION: Differential diagnosis of dementia with Lewy bodies (DLB), Parkinson's disease with dementia (PDD), Parkinson's disease (PD) and Alzheimer's disease (AD) is challenging. Comparative motor profiles of these neurodegenerative disorders may aid in earlier diagnosis but have not been extensively studied. METHODS: Groups were rigorously matched by age, education, and sex. DLB/PDD participants were matched by Mini-Mental State Examination Score to individuals with AD and by Unified Parkinson's Disease Rating Scale motor scores to individuals with PD. Gait, balance, dual task walking and hand dexterity measures were compared between a combined group (n=21) of individuals with Lewy body dementia (LBD) consisting of those with DLB (n=11) and PDD (n=10) to individuals with PD (n=21) or AD (n=21). RESULTS: Individuals at the same disease stage with LBD walked significantly slower with shorter stride lengths (p<0.05), demonstrated poorer balance on both the Tinetti and Berg Balance Scale, and poorer performance on dual-task and figure-of-eight walking compared to PD and AD (p<0.05 for all) groups. Upper extremity coordination on the 9-hole peg test differentiated LBD from both PD and AD and was the only motor test in which individuals with AD performed worse than those with PD. Tinetti balance subscores were significantly lower in PDD compared to DLB participants (10.4±2.3 versus 12.8±2.3; p=0.027). CONCLUSIONS: Motor features distinguish individuals with LBD from those with AD and PD. Measures of gait, balance and finger dexterity provide an additional means of differentiating individuals with LBD from those with AD and PD.

Reliability and validity of a wireless accelerometer for the assessment of postural sway.

Clinicians are in need of valid and objective measures of postural sway. Accelerometers have been shown to be suitable alternatives to expensive and stationary force plates. We evaluated the test-retest reliability and balance task discrimination capability of a new wireless triaxial accelerometer (YEI 3-Space Sensor). Four testing conditions (eyes open or closed, while on a firm or compliant surface) were used to progressively challenge the static balance of 20 healthy male (n = 8) and female (n = 12) older adults (mean age 81 ± 4.3 y). Subjects completed 2 blocks of three 30-second trials per condition. The accelerometer was positioned on the lower back to acquire mediolateral (M-L) and anterior-posterior (A-P) accelerations. Intraclass correlation coefficients were all good to excellent, with values ranging from .736 to .972 for trial-to-trial and from .760 to .954 for block-to- block. A significant stepwise increase in center of mass acceleration root mean square values was found across the 4 balance conditions (F[1.49, 28.26] = 39.54, P < .001). The new accelerometer exhibited good to excellent trial-to-trial and block-to-block reliability and was sensitive to differences in visual and surface conditions and acceleration axes.

Impact of tetrabenazine on gait and functional mobility in individuals with Huntington's disease.

Chorea may contribute to balance problems and walking difficulties that lead to higher fall rates in individuals with Huntington's disease (HD). Few studies have examined the effects of tetrabenazine (TBZ), an anti-choreic drug, on function and mobility in HD. The purpose of this study was to compare: 1) gait measures in forward walking, 2) balance and mobility measures, and 3) hand and forearm function measures on and off TBZ. We hypothesized that use of TBZ would improve gait, transfers and hand and forearm function. Eleven individuals with HD on stable doses of TBZ were evaluated while off medication and again following resumption of medication. Significant improvements were found on the Unified Huntington's Disease Rating Scale (UHDRS) motor scores, Tinetti Mobility Test (TMT) total (t=4.20, p=0.002) and balance subscale (t=-4.61, p=0.001) scores, and the Five Times Sit-to-Stand test (5TSST, t=3.20, p=.009) when on-TBZ compared to off-TBZ. Spatiotemporal gait measures, the Six Condition Romberg test, and UHDRS hand and forearm function items were not changed by TBZ use. Improved TMT and 5TSST performance when on drug indicates that TBZ use may improve balance and functional mobility in individuals with HD.

Selecting measures for balance and mobility to improve assessment and treatment of individuals after stroke.

Assessment of individuals with stroke using reliable and valid outcome measures is a key component of the treatment planning process. Health care professionals may have difficulty selecting balance and mobility measures given the large number of measures to choose from. This article utilizes a case-based approach to describe the benefits of using a common set of outcome measures and a process for selecting optimal measures across body structure/function, activity, and participation domains of the International Classification of Functioning, Disability and Health (ICF) model and stages of stroke recovery. Specific measures for use in acute care, rehabilitation, outpatient, and home health care settings are discussed based on StrokEDGE task force recommendations by the Neurology Section of the American Physical Therapy Association.

Clinimetric properties of the Tinetti Mobility Test, Four Square Step Test, Activities-specific Balance Confidence Scale, and spatiotemporal gait measures in individuals with Huntington's disease.

BACKGROUND AND PURPOSE: Individuals with Huntington's disease (HD) experience balance and gait problems that lead to falls. Clinicians currently have very little information about the reliability and validity of outcome measures to determine the efficacy of interventions that aim to reduce balance and gait impairments in HD. This study examined the reliability and concurrent validity of spatiotemporal gait measures, the Tinetti Mobility Test (TMT), Four Square Step Test (FSST), and Activities-specific Balance Confidence (ABC) Scale in individuals with HD. METHODS: Participants with HD [n = 20; mean age ± SD=50.9 ± 13.7; 7 male] were tested on spatiotemporal gait measures and the TMT, FSST, and ABC Scale before and after a six week period to determine test-retest reliability and minimal detectable change (MDC) values. Linear relationships between gait and clinical measures were estimated using Pearson's correlation coefficients. RESULTS: Spatiotemporal gait measures, the TMT total and the FSST showed good to excellent test-retest reliability (ICC > 0.75). MDC values were 0.30 m/s and 0.17 m/s for velocity in forward and backward walking respectively, four points for the TMT, and 3s for the FSST. The TMT and FSST were highly correlated with most spatiotemporal measures. The ABC Scale demonstrated lower reliability and less concurrent validity than other measures. CONCLUSIONS: The high test-retest reliability over a six week period and concurrent validity between the TMT, FSST, and spatiotemporal gait measures suggest that the TMT and FSST may be useful outcome measures for future intervention studies in ambulatory individuals with HD.

Rehabilitation and functional outcomes after extensive surgical debridement of a knee infected by fusobacterium necrophorum: a case report.

BACKGROUND AND PURPOSE: Joint infection is a rare but serious complication after knee injury that should be part of a physical therapist's differential diagnosis. This case report presents the care of a 17 year-old female athlete with septic arthritis from a Fusobacterium infection after sustaining a right lateral meniscus tear. Joint pathology combined with the aggressive infectious agent led to arthrofibrosis of her knee joint and resultant activity limitations and participation restrictions. The purpose of this case report is to highlight a rare and unique pathology, the serious effects that a joint infection can have on musculoskeletal function, and the challenges encountered during the rehabilitation process. CASE DESCRIPTION: The subject was a 17 year-old volleyball player who injured her right knee while playing volleyball. Within 7 days, the subject developed a severe joint infection that spread into surrounding gluteal, quadriceps, and gastrocnemius musculature. The infection was surgically debrided eight times during a 10-week inpatient hospital stay. A manipulation under anesthesia was performed to restore range of motion in her knee joint. Outpatient physical therapy was initiated 4 days later in order to restore musculoskeletal function. OUTCOME: Over eight months of physical therapy services were utilized to address the impairments and activity limitations caused by her joint dysfunction. She met her physical therapy goals and made significant improvements on the Knee Outcome Survey and the Lower Extremity Functional Scale. Success in physical therapy and completion of additional strength training exercise allowed this subject to return to competitive softball at the club level during her freshman year of college. DISCUSSION: Though rare after musculoskeletal injury, joint infection can lead to soft tissue damage, partial or complete degradation of articular cartilage, and arthrofibrosis causing significant disability. Physical therapists must incorporate evidence-based treatment principles including eccentric exercise, core stability, and lower extremity strength training along with sports-specific rehabilitation into the treatment plan in order to address activity limitations and meet physical therapy goals. LEVEL OF EVIDENCE: Level 4-Single Case report.

Video game play (Dance Dance Revolution) as a potential exercise therapy in Huntington's disease: a controlled clinical trial.

OBJECTIVE: To investigate the feasibility, acceptability, and safety of a supervised video game exercise program administered via Dance Dance Revolution in individuals with Huntington's disease. DESIGN: A cross-over, controlled, single-blinded, six-week trial. SETTING: Home-based. PARTICIPANTS: Eighteen ambulatory individuals with Huntington's disease (seven male, mean age 50.7 SD 14.7). INTERVENTIONS: Participants played the Dance Dance Revolution game with supervision and the handheld game without supervision for 45 minutes, two days per week for six weeks. OUTCOME MEASURES: Game play performance and adherence, participant perceptions of the game, safety (vital signs, adverse health changes), spatiotemporal gait measures, Four-Square Step Test, Tinetti Mobility Test, Activities-Specific Balance Confidence Scale, and World Health Organization Quality of Life - Bref, before and after each intervention. RESULTS: Most participants improved on game play, enjoyed playing the game, and wanted to continue playing after study completion. After playing Dance Dance Revolution, participants showed significant reductions in double support percentage (adjusted mean difference (95% confidence intervals): -2.54% (-4.75, -0.34) for forward walking and -4.18 (-6.89, -0.48) for backward walking) and those with less severe motor symptoms had reductions in heel-to-heel base of support during forward walking. The remaining measures were not significantly impacted by the intervention. CONCLUSION: Dance Dance Revolution appears to be a feasible, motivating, and safe exercise intervention for individuals with Huntington's disease.

Reliability and minimal detectable change of physical performance measures in individuals with pre-manifest and manifest Huntington disease.

BACKGROUND: Clinical intervention trials in people with Huntington disease (HD) have been limited by a lack of reliable and appropriate outcome measures. OBJECTIVE: The purpose of this study was to determine the reliability and minimal detectable change (MDC) of various outcome measures that are potentially suitable for evaluating physical functioning in individuals with HD. DESIGN: This was a multicenter, prospective, observational study. METHODS: Participants with pre-manifest and manifest HD (early, middle, and late stages) were recruited from 8 international sites to complete a battery of physical performance and functional measures at 2 assessments, separated by 1 week. Test-retest reliability (using intraclass correlation coefficients) and MDC values were calculated for all measures. RESULTS: Seventy-five individuals with HD (mean age=52.12 years, SD=11.82) participated in the study. Test-retest reliability was very high (>.90) for participants with manifest HD for the Six-Minute Walk Test (6MWT), 10-Meter Walk Test, Timed "Up & Go" Test (TUG), Berg Balance Scale (BBS), Physical Performance Test (PPT), Barthel Index, Rivermead Mobility Index, and Tinetti Mobility Test (TMT). Many MDC values suggested a relatively high degree of inherent variability, particularly in the middle stage of HD. Minimum detectable change values for participants with manifest HD that were relatively low across disease stages were found for the BBS (5), PPT (5), and TUG (2.98). For individuals with pre-manifest HD (n=11), the 6MWT and Four Square Step Test had high reliability and low MDC values. LIMITATIONS: The sample size for the pre-manifest HD group was small. CONCLUSIONS: The BBS, PPT, and TUG appear most appropriate for clinical trials aimed at improving physical functioning in people with manifest HD. Further research in people with pre-manifest HD is necessary.