Effects of a hip belt on transverse plane trunk coordination and stability during load carriage.

This study examined the transverse plane kinematics of the pelvis, thorax and head while participants walked at a range of speeds on a treadmill under three load conditions: no load, with a loaded backpack with no hip belt and with a loaded backpack with a hip belt. Research has suggested that one mechanism for adapting to heavy loads carried with no hip belt is to reduce the amplitudes and relative phase of transverse plane pelvic and thoracic rotations, in order to minimize rotational torque on the loaded upper body. Transverse plane rotation amplitudes of the pelvis, thorax, backpack and head were calculated from 3D kinematic data for 12 healthy subjects, walking at speeds of 0.5, 0.9, 1.3 and 1.7 ms(-1). Relative phase relation and its variability were also computed for pelvis-thorax rotations and backpack-thorax rotations. Stability of the coordination pattern was estimated as an inverse function of the variability in relative phase. The backpack with the hip belt allowed significantly larger transverse plane rotation amplitudes, along with increased stability of the coordination pattern, than the backpack with no hip belt. Motion patterns of the backpack and thorax suggested that the backpack frame was used to assist with the deceleration and reversal of the loaded thorax, driven by the pelvis through the hip belt connection. Use of the frame in this way may have required less trunk muscle activation and allowed for improved pattern stability.

Coordination and stability of one-legged hopping patterns in patients with anterior cruciate ligament reconstruction: preliminary results.

OBJECTIVES: To investigate whether the intralimb coordination of the lower extremity during one-legged hopping in patients with anterior cruciate ligament reconstruction is different and less stable compared to control subjects. DESIGN: Measures of coordination dynamics are applied to study the coordination and stability of movement patterns of the knee and ankle in patients and control subjects. BACKGROUND: Due to several factors, such as loss of proprioceptive function and muscle weakness, the intralimb coordination of the lower extremity might be altered. METHODS: Seven patients and 13 healthy control subjects were instructed to hop in place on one leg for 10 seconds at a comfortable frequency for each leg separately. RESULTS AND CONCLUSIONS: The one-legged hopping movement pattern of patients with anterior cruciate ligament reconstruction one-year post-operative is different and less stable compared to healthy subjects, and thus is still impaired. RELEVANCE: This paper shows that patients, one year after reconstruction of the anterior cruciate ligament, have a different coordination pattern of the lower limb compared to a matched control group. Intersegmental coordination and stability, features that are often observed by eye during a rehabilitation process, are objectified in this study.

How do load carriage and walking speed influence trunk coordination and stride parameters?

To determine the effects of load carriage and walking speed on stride parameters and the coordination of trunk movements, 12 subjects walked on a treadmill at a range of walking speeds (0.6-1.6 m s(-1)) with and without a backpack containing 40% of their body mass. It was hypothesized that compared to unloaded walking, load carriage decreases transverse pelvic and thoracic rotation, the mean relative phase between pelvic and thoracic rotations, and increases hip excursion. In addition, it was hypothesized that these changes would coincide with a decreased stride length and increased stride frequency. The findings supported the hypotheses. Dimensionless analyses indicated that there was a significantly larger contribution of hip excursion and smaller contribution of transverse plane pelvic rotation to increases in stride length during load carriage. In addition, there was a significant effect of load carriage on the amplitudes of transverse pelvic and thoracic rotation and the relative phase of pelvic and thoracic rotation. It was concluded that the shorter stride length and higher stride frequency observed when carrying a backpack is the result of decreased pelvic rotation. During unloaded walking, increases in pelvic rotation contribute to increases in stride length with increasing walking speed. The decreased pelvic rotation during load carriage requires an increased hip excursion to compensate. However, the increase in hip excursion is insufficient to fully compensate for the observed decrease in pelvis rotation, requiring an increase in stride frequency during load carriage to maintain a constant walking speed.

Long term effects of intensity of upper and lower limb training after stroke: a randomised trial.

OBJECTIVE: To assess long term effects at 1 year after stroke in patients who participated in an upper and lower limb intensity training programme in the acute and subacute rehabilitation phases. DESIGN: A three group randomised controlled trial with repeated measures was used. METHOD: One hundred and one patients with a primary middle cerebral artery stroke were randomly allocated to one of three groups for a 20 week rehabilitation programme with an emphasis on (1) upper limb function, (2) lower limb function or (3) immobilisation with an inflatable pressure splint (control group). Follow up assessments within and between groups were compared at 6, 9, and 12 months after stroke. RESULTS: No statistically significant effects were found for treatment assignment from 6 months onwards. At a group level, the significant differences in efficacy demonstrated at 20 weeks after stroke in favour of the lower limb remained. However, no significant differences in functional recovery between groups were found for Barthel index (BI), functional ambulation categories (FAC),action research arm test (ARAT), comfortable and maximal walking speed, Nottingham health profile part 1(NHP-part 1), sickness impact profile-68 (SIP-68), and Frenchay activities index (FAI) from 6 months onwards. At an individual subject level a substantial number of patients showed improvement or deterioration in upper limb function (n=8 and 5, respectively) and lower limb function (n=19 and 9, respectively). Activities of daily living (ADL) scores showed that five patients deteriorated and four improved beyond the error threshold from 6 months onwards. In particular, patients with some but incomplete functional recovery at 6 months are likely to continue to improve or regress from 6 months onwards. CONCLUSIONS: On average patients maintained their functional gains for up to 1 year after stroke after receiving a 20 week upper or lower limb function training programme. However, a significant number of patients with incomplete recovery showed improvements or deterioration in dexterity, walking ability, and ADL beyond the error threshold.

Transverse plane kinetics during treadmill walking with and without a load.

OBJECTIVE: The purpose of this experiment was to determine the effects of wearing a backpack on transverse plane upper and lower body torque. BACKGROUND: During unloaded walking the upper and lower body counter-rotate to reduce the net angular momentum of the body. There is less counter-rotation while carrying a load, suggesting a more rigid link between the upper and lower body. We predicted that load carriage would result in an increase in upper body torque. Because the upper and lower body may be more rigidly linked during load carriage, we also predicted an increase in lower body torque. METHODS: Twelve subjects (5 male, 7 female, mean age=26) walked with and without a backpack containing 40% of their body mass on a treadmill at speeds from 0.6 to 1.6 ms(-1). Kinematic data were sampled for 30 s at each speed, upper and lower body torque were calculated from angular acceleration and moment of inertia. RESULTS: Higher levels of upper and lower body torque were observed during load carriage than during unloaded walking. However, the increase in upper body torque was 225%, while upper body moment of inertia increased by 400%. CONCLUSIONS: The differences in torque between loaded and unloaded walking suggest that a goal of loaded walking is to minimize upper body torque, which may reduce the likelihood of injury. RELEVANCE: Knowledge of the effects of load carriage on upper and lower body torque, and related changes in coordination may provide insight into injury reduction mechanisms during load carriage.

Rigidity decreases resting tremor intensity in Parkinson's disease: A [(123)I]beta-CIT SPECT study in early, nonmedicated patients.

Tremor is one of the clinical hallmarks of Parkinson's disease (PD). Although it is accepted that other classic symptoms of PD such as rigidity and bradykinesia result from a degeneration of the nigrostriatal system and subsequent reduction in striatal dopamine, the pathophysiology of resting tremor remains unclear. The majority of recent single photon emission computed tomography (SPECT) and positron emission tomography (PET) studies, using various radioligands, demonstrated significant correlation between striatal radioligand bindings and the degree of parkinsonian symptoms such as rigidity and bradykinesia, but not tremor. We investigate the relationship between the degeneration of the nigrostriatal pathway and the appearance of resting tremor, taking into account the possible interference of rigidity with the resting tremor. Thirty early and drug-naïve PD patients were examined. Tremor and rigidity of the arms were assessed using UPDRS, and the power of tremor was estimated using spectral analysis of tremor peaks. [(123)I]beta-CIT SPECT was used to assess degeneration of the dopaminergic system in PD patients. A comparison between asymmetry indices showed that in terms of both tremor and rigidity, the most affected arm corresponded significantly with the contralateral striatum, having the largest reduction in radioligand binding. Furthermore, tremor power accounted for a significant part of variance in the contralateral striatum, suggesting a relationship between this PD symptom and the degeneration of the dopaminergic system. Further, the degree of tremor was reduced with increasing rigidity. However, correcting for the influence of rigidity, the significant contribution of tremor in the variance in the contralateral striatal [(123)I]beta-CIT binding disappeared. When the confounding influence of rigidity is taken into account, no significant direct relationship between dopaminergic degeneration and the degree of tremor could be found. Other pathophysiological mechanisms should be similarly investigated in order to further our understanding of the origin of resting tremor in PD.

Comparing predictive validity of four ballistic swing phase models of human walking.

It is unclear to what extent ballistic walking models can be used to qualitatively predict the swing phase at comfortable walking speed. Different study findings regarding the accuracy of the predictions of the swing phase kinematics may have been caused by differences in (1) kinematic input, (2) model characteristics (e.g. the number of segments), and (3) evaluation criteria. In the present study, the predictive validity of four ballistic swing phase models was evaluated and compared, that is, (1) the ballistic walking model as originally introduced by Mochon and McMahon, (2) an extended version of this model in which heel-off of the stance leg is added, (3) a double pendulum model, consisting of a two-segment swing leg with a prescribed hip trajectory, and (4) a shank pendulum model consisting of a shank and rigidly attached foot with a prescribed knee trajectory. The predictive validity was evaluated by comparing the outcome of the model simulations with experimentally derived swing phase kinematics of six healthy subjects. In all models, statistically significant differences were found between model output and experimental data. All models underestimated swing time and step length. In addition, statistically significant differences were found between the output of the different models. The present study shows that although qualitative similarities exist between the ballistic models and normal gait at comfortable walking speed, these models cannot adequately predict swing phase kinematics.

Stability boundaries and lateral postural control in parkinson's disease.

Postural instability is a major problem in patients with Parkinson's disease (PD). We examined balance control in PD by using center of pressure (CP) variability and time-to-contact to investigate boundary relevant postural control behavior under quiet stance leaning conditions. Postural orientation was manipulated by having patients (n = 10) and healthy older controls (n = 7) lean forward and backward with varying degrees of lean on a force platform. The subjects were instructed to lean forward or backward (either halfway or as far as possible) without bending their hips or lifting their heels or toes off the ground. Time-to-contact of the CP with the geometric stability boundary defined by the feet as well as CP position and variability were analyzed. Medio-lateral CP variability was increased in the patients with PD. Medio-lateral average time-to-contact was decreased in the patients but not so in the anterior-posterior direction. In contrast to the CP variability, the medio-lateral variability of time-to-contact was lower in the patients. Patients as well as healthy older controls responded to lean manipulations with an increase in CP variability. Boundary relevant CP measures thus show clear changes in control strategies and confirm the role of lateral instability in PD.

Coordination between arm and leg movements during locomotion.

To evaluate the contrasting dynamical and biomechanical interpretations of the 2:1 frequency coordination between arm and leg movements that occurs at low walking velocities and the 1:1 frequency coordination that occurs at higher walking velocities, the authors conducted an experiment in which they quantified the effect of walking velocity on the stability of the frequency and phase coordination between the individual limb movements. Spectral analyses revealed the presence of 2:1 frequency coordination as a constant feature of the data in only 3 out of 8 participants at walking velocities ranging from 1.0 to 2.0 km/h, in spite of the fact that the eigenfrequencies of the arms were rather similar across participants. The degree of interlimb coupling, as indexed by weighted coherence and variability of relative phase, was lower for the arm movements and for ipsilateral and diagonal combinations of arm and leg movements than for the leg movements. Furthermore, the coupling between all pairs of limb movements was found to increase with walking velocity, whereas no clear signs were observed that the switches from 2:1 to 1:1 frequency coordination and vice versa were preceded by loss of stability. Therefore, neither a purely biomechanical nor a purely dynamical model is optimally suited to explain these results. Instead, an integrative model involving elements of both approaches seems to be required.

The effects of physical therapy in Parkinson's disease: a research synthesis.

OBJECTIVE: To present a critical review and meta-analysis of studies evaluating the effects of physical therapy in patients suffering from Parkinson's disease (PD), in terms of neurologic signs, activities of daily living (ADLs), and walking ability. DATA SOURCES: Articles published from 1966 to May 1999 were compiled by means of MEDLINE, Cochrane register of controlled trials, and CINAHL using combinations of the key words Parkinson's disease, exercise, exercise therapy, physical therapy, and group training. References presented in relevant publications were also examined. Articles written in English, German, or Dutch were included. STUDY SELECTION: Studies had to meet the following selection criteria: (1) patients with PD were included in the intervention study, (2) the effects of physical therapy (PT) were evaluated, (3) the study could be classified as true or quasi-experiment, and (4) the study was published in a journal or book. DATA EXTRACTION: Two reviewers assessed independently the methodologic quality of the data of each included study. One reviewer extracted relevant meta-analysis data. DATA SYNTHESIS: For each outcome measure the estimated effect size and the summary effect size (SES) were calculated, using fixed (ie, Hedges's g) and random effects models. The meta-analysis resulted in a significant homogeneous SES with regard to ADLs (.40; confidence interval [CI] = .17-.64) and stride length (.46; CI = .12-.82). The SES with regard to walking speed showed a significant heterogeneous SES, which remained significant after applying a random effects model (.49; CI = .21-.77). The SES with regard to neurologic signs was not significant (.22; CI = -.08 to .52). The small number of studies included and the shortcomings of the methodologic quality of these studies, however, bias the results of the present study. CONCLUSIONS: The results of the present research synthesis support the hypothesis that Parkinson patients benefit from PT added to their standard medication.

The intra- and interrater reliability of the action research arm test: a practical test of upper extremity function in patients with stroke.

OBJECTIVES: To determine the intra- and interrater reliability of the Action Research Arm (ARA) test, to assess its ability to detect a minimal clinically important difference (MCID) of 5.7 points, and to identify less reliable test items. DESIGN: Intrarater reliability of the sum scores and of individual items was assessed by comparing (1) the ratings of the laboratory measurements of 20 patients with the ratings of the same measurements recorded on videotape by the original rater, and (2) the repeated ratings of videotaped measurements by the same rater. Interrater reliability was assessed by comparing the ratings of the videotaped measurements of 2 raters. The resulting limits of agreement were compared with the MCID. PATIENTS: Stratified sample, based on the intake ARA score, of 20 chronic stroke patients (median age, 62yr; median time since stroke onset, 3.6yr; mean intake ARA score, 29.2). MAIN OUTCOME MEASURES: Spearman's rank-order correlation coefficient (Spearman's rho); intraclass correlation coefficient (ICC); mean difference and limits of agreement, based on ARA sum scores; and weighted kappa, based on individual items. RESULTS: All intra- and interrater Spearman's rho and ICC values were higher than .98. The mean difference between ratings was highest for the interrater pair (.75; 95% confidence interval, .02-1.48), suggesting a small systematic difference between raters. Intrarater limits of agreement were -1.66 to 2.26; interrater limits of agreement were -2.35 to 3.85. Median weighted kappas exceeded .92. CONCLUSION: The high intra- and interrater reliability of the ARA test was confirmed, as was its ability to detect a clinically relevant difference of 5.7 points.

Disorders in trunk rotation during walking in patients with low back pain: a dynamical systems approach.

OBJECTIVE: (1) To introduce an evaluation tool for the assessment of walking disorders in low back pain patients. (2) To investigate whether walking patterns in low back pain patients are different from those of control subjects. DESIGN: Relative phase measures of movement coordination are applied in the assessment of trunk function in a small group of patients with non-specific low back pain and in control subjects. BACKGROUND: Normal subjects change the coordination of pelvic and thoracic rotations from an in-phase to an out-of-phase pattern with increasing walking speed. Low back pain patients may have a reduced ability to counter rotate pelvis and thorax at higher walking speeds (from 1.0 m/s onwards) as a result of hyperstable coordination patterns. METHODS: Six patients with non-specific low back pain and six healthy control subjects walked on a treadmill at comfortable walking speeds and during a systematic variation of the treadmill velocity. Coordination of arm and leg movements as well as of pelvic and thoracic rotations was analyzed using a relative phase algorithm. RESULTS AND CONCLUSIONS: The comfortable walking speed was reduced in the patient group. In contrast to the control subjects, four of the six patients were not able to establish an out-of-phase coordination pattern between thorax and pelvis at higher walking speeds. This coincided with an increased stability of movement coordination, indicating guarded behavior. In addition, an increased asymmetry between the phase-relations of left and right side of the body was found in some of the patients.

Exercise therapy for arm function in stroke patients: a systematic review of randomized controlled trials.

OBJECTIVE: Assessment of the available evidence for the effectiveness of exercise therapy to improve arm function in patients who have suffered from a stroke. METHODS: A systematic search of bibliographical databases and reference checking were performed to identify publications on randomized controlled trials (RCTs) which evaluated the effect of exercise therapy on arm function in stroke patients. The methodological quality was assessed systematically by two raters, based on a standardized list of methodological criteria. Study characteristics, such as the chronicity and severity of impairment of the patient population, the amount and duration of interventions, and specific methodological criteria, were related to reported effects. RESULTS: Thirteen RCTs were identified, six of which reported positive results on an arm function test. In five of these six studies there was a contrast in amount or duration of exercise therapy between groups. Methodological scores ranged from 5 to 15 (maximum possible score: 19 points). CONCLUSION: Insufficient evidence made it impossible to draw definitive conclusions about the effectiveness of exercise therapy on arm function in stroke patients. The difference in results between studies with and without contrast in the amount or duration of exercise therapy between groups suggests that more exercise therapy may be beneficial.

Coordination disorders in patients with Parkinson's disease: a study of paced rhythmic forearm movements.

Whereas the consequences of Parkinson's disease (PD) for the performance of single-limb movements are well documented (i.e., bradykinesia, akinesia, rigidity, and tremor), fairly little is known about its implications for the coordination between limb movements. To help resolve this situation an experiment was conducted in which 11 PD patients and 11 control subjects performed rhythmic forearm movements at a comfortable amplitude in the in-phase, antiphase, and single-arm mode at pacing frequencies ranging from 0.5 to 3 Hz. The PD group displayed marked coordination problems over and above the known clinical motor symptoms of PD. The performance of both the in-phase and antiphase modes was significantly affected in the PD group compared to the control group; furthermore, the variability of relative phase was significantly increased in this group. These observations were not caused by problems to synchronize the movements with the external pacing signal. In addition to the bimanual coordination problems, involuntary mirror movements (MM) were observed in the single-arm control trials that were significantly larger in the PD group (4.4% of the amplitude of the moving arm) than in the control group (2.3%), suggesting a reduced ability to suppress a basic in-phase coupling of the arms. In the PD group, MM were largest during movements of the least-affected arm. These parkinsonian coordination problems are interpreted in terms of recent evidence on the neural organization of bimanual coordination, suggesting that they are due to cortical rather than callosal dysfunction.

Resonant frequencies of arms and legs identify different walking patterns.

The present study is aimed at investigating changes in the coordination of arm and leg movements in young healthy subjects. It was hypothesized that with changes in walking velocity there is a change in frequency and phase coupling between the arms and the legs. In addition, it was hypothesized that the preferred frequencies of the different coordination patterns can be predicted on the basis of the resonant frequencies of arms and legs with a simple pendulum model. The kinematics of arms and legs during treadmill walking in seven healthy subjects were recorded with accelerometers in the sagittal plane at a wide range of different velocities (i.e., 0.3-1. 3m/s). Power spectral analyses revealed a statistically significant change in the frequency relation between arms and legs, i.e., within the velocity range 0.3-0.7m/s arm movement frequencies were dominantly synchronized with the step frequency, whereas from 0.8m/s onwards arm frequencies were locked onto stride frequency. Significant effects of walking speed on mean relative phase between leg and arm movements were found. All limb pairs showed a significantly more stable coordination pattern from 0.8 to 1.0m/s onwards. Results from the pendulum modelling demonstrated that for most subjects at low-velocity preferred movement frequencies of the arms are predicted by the resonant frequencies of individual arms (about 0.98Hz), whereas at higher velocities these are predicted on the basis of the resonant frequencies of the individual legs (about 0.85Hz). The results support the above-mentioned hypotheses, and suggest that different patterns of coordination, as shown by changes in frequency coupling and phase relations, can exist within the human walking mode.

Accuracy of physical and occupational therapists' early predictions of recovery after severe middle cerebral artery stroke.

INTRODUCTION: The ability of physical therapists (PTs) and occupational therapists (OTs) to predict level of outcome accurately was investigated prospectively in 91 severely disabled stroke patients with a first-ever middle cerebral artery (MCA) stroke. METHODS: Within the second and fifth week after stroke onset, 364 predictions were made by 59 PTs and 47 OTs about walking ability, dexterity, activities of daily living (ADL), need for additional care in ADL, time required to achieve independent walking ability and maximal level of ADL, and destination of discharge at six months after stroke. The functional recovery patterns of stroke patients were assessed by an independent observer. The accuracy of the therapists' predictions was compared with that of derived prediction models. In addition, the influence of characteristics of patients and therapists on the accuracy of the predictions was investigated. RESULTS: Compared to observed outcomes at six months after stroke, therapists' lowest accuracies of prediction were found for the moment at which maximal ADL score was achieved (rs = 0.07; p = NS), and highest accuracy was for level of dexterity of the hemiplegic arm (rs = 0.78; p <0.01). Therapists' predictions of functional outcome at six months tended to be too pessimistic. No significant differences were observed for dexterity and walking ability when the predictions by PTs and OTs were compared with those of regression models, whereas significant differences were found for the accuracies of OTs' and PTs' first prediction of destination of discharge and second predictions of outcome in ADL and need for additional care in ADL. No significant differences were found between the accuracy of PTs' and OTs' predictions, and their ability to predict functional outcome was not significantly influenced by the characteristics of patient and therapists. CONCLUSIONS: At two and five weeks after stroke, OTs and PTs can accurately predict level of walking ability and dexterity at six months. The prediction of time required for achieving maximal level of recovery, destination of discharge, outcome of ADL as well as need for additional care in ADL leaves room for improvement.

Effects of prosthetic mass and mass distribution on kinematics and energetics of prosthetic gait: a systematic review.

OBJECTIVE: To introduce the theoretical models used in literature that describe the relation between prosthetic inertial loading and amputee gait and to derive specific predictions from these models: to systematically review experimental studies on the relation between prosthetic inertial loading and energetics and kinematics of lower-limb prosthetic gait; and to compare the review outcomes with predictions derived from theoretical models. DATA SOURCES: Studies selected from Medline and from examining references in the selected Medline publications. STUDY SELECTION: Theoretical models were selected that are used in the present literature to predict the effects of prosthetic mass and mass distribution on kinematics and energetics of prosthetic gait. Experimental studies were selected that investigated the effects of prosthetic mass or center of mass location on the economy, self-selected walking speed, stride length, or stride frequency of lower limb amputee patients. DATA EXTRACTION: The design and methodologic quality was assessed using a checklist of nine criteria. Data on economy, self-selected walking speed, stride frequency, and stride length were extracted from the studies selected. DATA SYNTHESIS: The predictions of the theoretical models suggest that inertial loading of the present lightweight prostheses need not be decreased and sometimes may need to be increased to improve the gait of amputee patients. The methodologic quality of most of the experimental studies was limited. Review of the experimental studies suggests that the inertial loading of the present lightweight prostheses need not be further reduced. The discrepancy between theoretical models and experimental findings may be related to both the poor methodologic quality of the experiments as well as to the limited predictive value of the existing models.

Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial.

BACKGROUND AND PURPOSE: Of all stroke survivors, 30% to 66% are unable to use their affected arm in performing activities of daily living. Although forced use therapy appears to improve arm function in chronic stroke patients, there is no conclusive evidence. This study evaluates the effectiveness of forced use therapy. METHODS: In an observer-blinded randomized clinical trial, 66 chronic stroke patients were allocated to either forced use therapy (immobilization of the unaffected arm combined with intensive training) or a reference therapy of equally intensive bimanual training, based on Neuro-Developmental Treatment, for a period of 2 weeks. Outcomes were evaluated on the basis of the Rehabilitation Activities Profile (activities), the Action Research Arm (ARA) test (dexterity), the upper extremity section of the Fugl-Meyer Assessment scale, the Motor Activity Log (MAL), and a Problem Score. The minimal clinically important difference (MCID) was determined at the onset of the study. RESULTS: One week after the last treatment session, a significant difference in effectiveness in favor of the forced use group compared with the bimanual group (corrected for baseline differences) was found for the ARA score (3.0 points; 95% CI, 1.3 to 4.8; MCID, 5.7 points) and the MAL amount of use score (0.52 points; 95% CI, 0.11 to 0.93; MCID, 0.50). The other parameters revealed no significant differential effects. One-year follow-up effects were observed only for the ARA. The differences in treatment effect for the ARA and the MAL amount of use scores were clinically relevant for patients with sensory disorders and hemineglect, respectively. CONCLUSIONS: The present study showed a small but lasting effect of forced use therapy on the dexterity of the affected arm (ARA) and a temporary clinically relevant effect on the amount of use of the affected arm during activities of daily living (MAL amount of use). The effect of forced use therapy was clinically relevant in the subgroups of patients with sensory disorders and hemineglect, respectively.

Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial.

BACKGROUND: We investigated the effects of different intensities of arm and leg rehabilitation training on the functional recovery of activities of daily living (ADL), walking ability, and dexterity of the paretic arm, in a single-blind randomised controlled trial. METHODS: Within 14 days after stroke onset, 101 severely disabled patients with a primary middle-cerebral-artery stroke were randomly assigned to: a rehabilitation programme with emphasis on arm training; a rehabilitation programme with emphasis on leg training; or a control programme in which the arm and leg were immobilised with an inflatable pressure splint. Each treatment regimen was applied for 30 min, 5 days a week during the first 20 weeks after stroke. In addition, all patients underwent a basic rehabilitation programme. The main outcome measures were ability in ADL (Barthel index), walking ability (functional ambulation categories), and dexterity of the paretic arm (Action Research arm test) at 6, 12, 20, and 26 weeks. Analyses were by intention to treat. FINDINGS: At week 20, the leg-training group (n=31) had higher scores than the control group (n=37) for ADL ability (median 19 [IQR 16-20] vs 16 [10-19], p<0.05), walking ability (4 [3-5] vs 3 [1-4], p<0.05), and dexterity (2 [0-56] vs 0 [0-2], p<0.01). The arm-training group (n=33) differed significantly from the control group only in dexterity (9 [0-39] vs 0 [0-2], p<0.01). There were no significant differences in these endpoints at 20 weeks between the arm-training and leg-training groups. INTERPRETATION: Greater intensity of leg rehabilitation improves functional recovery and health-related functional status, whereas greater intensity of arm rehabilitation results in small improvements in dexterity, providing further evidence that exercise therapy primarily induces treatment effects on the abilities at which training is specifically aimed.

Identification of axial rigidity during locomotion in Parkinson disease.

OBJECTIVES: To identify coordination changes and stability in the movements of the trunk during locomotion in Parkinson disease (PD) as a function of walking velocity. STUDY DESIGN: Comparison of treadmill locomotion with an opto-electronic tracking device. PATIENTS: Newly diagnosed patients with PD (n = 27) and a group of healthy control subjects (n = 11). RESULTS: Coordination between transversal pelvic and thoracic rotations showed significantly smaller changes in mean relative phase (p < .0001) and lower variability in relative phase (p < .0001) in the PD group. No significant differences were found in stride duration and variability in stride duration. CONCLUSIONS: The relative phase data contradict traditional notions of increased variability in motor control in PD and pinpoint the importance of the trunk in identifying axial rigidity. This discrepancy may be due to lack of control for walking velocity in earlier studies. It is concluded that systematic manipulation of walking velocity can identify coordination deficits and rigidity in trunk movement. This coordination of trunk movement can also be a sensitive measure for (early) diagnosis and the assessment of movement and pharmacological therapy in PD.