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169 JNPT is Officially Indexed in MEDLINE!!. PDF (70 K)
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ARTICLE
170 Center of Pressure Measures during Standing Tasks in Minimally Impaired Abstract
Persons with Multiple Sclerosis. HTML
Gregory M. Karst, PT, PhD; Dawn M. Venema, PT, MPT; Tammy G. Roehrs, PT, MA, NCS; Amy E. PDF (252 K)
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181 Age- and Gender-related Test Performance in Community-dwelling Adults. HTML
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189 HETERONYMOUS REFLEXES IN THE PRIMARY AGONIST ARE ENHANCED HTML

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189 VIBRATION OF THE BICEPS BRACHII TENDON REDUCES TIME TO FAILURE HTML
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190 INFLUENCE OF AGE ON NEUROMUSCULAR CONTROL OF THE KNEE.. PDF (342 K)
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190 DE-COUPLING GAIT PARAMETERS TO INVESTIGATE THE CONTRIBUTION OF HTML

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190 INFLUENCE OF HAMSTRING LOW FREQUENCY FATIGUE ON NEU-

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190 CHANGES IN SELF-PERCEPTION OF TURNING FOLLOWING ROTATING HTML

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G Earhart; S Wang; M Hong; E Stevens

191 RELATIONSHIP BETWEEN CHANGES IN MUSCLE SIZE FOLLOWING 12

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191 PERIPHERAL QUANTITATIVE COMPUTERIZED TOMOGRAPHY (PQCT):

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191 CHANGES IN SOLEUS MUSCLE FORCE and FATIGUE AFTER SPINAL CORD HTML
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192 EXAMINATION OF SPASTICITY OF THE KNEE FLEXORS and KNEE

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192 TREADMILL EXERCISE TRAINING INDUCES ANGIOGENESIS and IMPROVES

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Journal of Neurologic Physical Therapy - December 2005, Volume 29, Issue 4 Page 2 of 4

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M. D. Al-Jarrah; L. Novikova; L. Stehno-Bittel; Y. Lau

192 ADAPTATION OF VOLUNTARY STEP INITIATION IN PERSONS WITH

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193 EVIDENCE FOR ACTIVITY-DEPENDENT NEUROPLASTICITY IN AN

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193 FUNCTIONAL REACH: IS THIS A VALID MEASURE OF RECURRENT FALLS IN HTML

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193 RELIABILITY and VALIDITY OF THE TINETTI MOBILITY TEST FOR HTML
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194 REPRESENTATION OF IMAGINED and EXECUTED SEQUENTIAL FINGER HTML

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194 RECOVERY FROM STROKE: WHAT IS THE ROLE OF THE UNDAMAGED, HTML
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195 BRAIN ACTIVATION DURING KINESTHETIC and VISUAL IMAGERY OF HTML

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195 EFFECT OF WALKING VS SHAM TREATMENT ON FINGER MOVEMENT HTML

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195 INFLUENCE OF MOTOR-IMAGERY ABILITY ON SMA and PSMA CORTICAL HTML

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196 MOVEMENT CONTROL and CORTICAL ACTIVATION IN FUNCTIONAL ANKLE HTML

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196 SPLIT-BELT TREADMILL ADAPTATION and GAIT SYMMETRY POST-STROKE.. PDF (342 K)
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196 PARETIC LOWER EXTREMITY LOADING and WEIGHT TRANSFER HTML

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197 SINGLE LIMB BODY WEIGHT SUPPORTED TREADMILL TRAINING.. PDF (342 K)
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197 THE EFFECTS OF SPEED and LEVEL OF VOLUNTARY MUSCLE ACTIVATION HTML
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197 DYNAMIC WALKING STABILITY IN HEMIPARETIC CHRONIC STROKE HTML

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K. P. Brady; J. M. Hidler; M. C. Sinopoli

198 LOWER LIMB STRENGTH and COORDINATION PATTERNS OF CHRONIC HTML

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M M Pelliccio; N Neckel; D Nichols; J Hidler

198 GAIT PARAMETERS ASSOCIATED WITH RESPONSIVENESS TO A TASK- HTML

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T. Klassen; S. J. Mulroy; K. J. Sullivan

198 HIP JOINT POSITION AFFECTS VOLITIONAL KNEE EXTENSOR ACTIVITY HTML
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M. Lewek; T. Hornby; Y. Dhaher; B. Schmit

199 DEVELOPMENT and VALIDATION OF CIRCUMDUCTION ASSESSMENT SCALE HTML

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J L Moore; H R Roth; M. Lewek; Y Y. Dhaher; T G. Hornby

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Journal of Neurologic Physical Therapy - December 2005, Volume 29, Issue 4 Page 3 of 4

199 SENSORIMOTOR IMPAIRMENTS and REACHING PERFORMANCE IN

PERSONS WITH HEMIPARESIS: RELATIONSHIPS DURING THE ACUTE and HTML
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J M. Wagner; C E. Lang; S A. Sahrmann; D. F. Edwards; A W. Dromerick

199 NEUROMUSCULAR STIMULATION IMPROVES GRASPING FUNCTION IN HTML

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B. Quaney; L H. Zahner; M J. Santos; Z. Kadivar; B. McKiernan

200 BILATERAL MOTOR OUTPUTS FROM THE RETICULOSPINAL SYSTEM TO HTML

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J A. Buford; A G. Davidson

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200 TELEREHABILITATION FOR MOTOR RETRAINING IN PATIENTS WITH HTML

STROKE.. PDF (342 K)
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M K. Holden; T. Dyar; E. Bizzi; L. Schwamm; L. Dayan-Cimadoro

200 EFFECTS OF RANDOM and BLOCKED ORDER PRACTICE ON MOTOR HTML

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C. Lin; C J Winstein; K J Sullivan; A D Wu

201 LEARNING EFFECT ASSESSMENT ON SUBSEQUENT SUBJECT HTML

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B. Gilliam; D. Charles; S. Kathmann; J. Smith; N. S. Darr; D. Greathouse

201 UPPER LIMB FUNCTIONAL RESPONSE TO MOTOR LEARNING ALONE and

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J J Daly; J. Rogers; I. Brenner; E. Perepezko; M. Dohring; E. Fredrickson; J. Gansen

202 PROCEDURAL LEARNING OF FUNCTIONAL MOBILITY TASKS IN THE

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K. A. Volk; R. O. Myers; E. Fitzpatrick-DeSalme

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202 VASOMOTOR INNERVATION PATTERNS OF PERIPHERAL NERVES HTML

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R J Allen; E M Jefferson; V K Bhangu

202 LASER MICRODISSECTION OF BRAIN STEM NEURONS TO EXAMINE HTML

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S R Allen; J D Houle

202 MOVEMENT CONTROL and CORTICAL ACTIVATION IN FUNCTIONAL ANKLE HTML

INSTABILITY.. PDF (342 K)
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K. Anderson; J. R. Carey

203 EFFECT OF WALKING VS SHAM TREATMENT ON FINGER MOVEMENT HTML

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S. Anderson; H. Aldrich; S. Knight; C. Battles

203 ASSESSING FACTORS IMPACTING COMMUNITY MOBILITY AFTER STROKE: HTML

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203 DIAZEPAM TOLERANCE EFFECTS ON VESTIBULAR FUNCTION TESTS HTML

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203 THE EFFECTS OF BODY WEIGHT SUPPORTED GAIT TRAINING and

FUNCTIONAL ELECTRICAL STIMULATION ON GAIT SPEED and CONTROL IN HTML
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204 RECOVERY FROM STROKE: WHAT IS THE ROLE OF THE UNDAMAGED, HTML
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L. Boyd; E. D. Vidoni

204 DYNAMIC WALKING STABILITY IN HEMIPARETIC CHRONIC STROKE HTML

SUBJECTS.. PDF (342 K)
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K. P. Brady; J. M. Hidler; M. C. Sinopoli

204 RISK and PROTECTIVE FACTORS FOR FALLS AMONG INDIVIDUALS WITH HTML
INCOMPLETE SPINAL CORD INJURY.. PDF (342 K)
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S S Brotherton; J. S. Krause; P. J. Nietert

204 BILATERAL MOTOR OUTPUTS FROM THE RETICULOSPINAL SYSTEM TO HTML

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J. A. Buford; A. G. Davidson

204 EFFECT OF TYPE 2 DIABETES MELLITUS ON DECISION-MAKING and

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S. D. Burns

204 BRAIN ACTIVATION DURING KINESTHETIC and VISUAL IMAGERY OF

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204 THE PATIENT-REPORTED IMPACT OF SPASTICITY MEASURE (PRISM): A

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205 UPPER LIMB FUNCTIONAL RESPONSE TO MOTOR LEARNING ALONE and

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205 CONSTRAINT INDUCED MOVEMENT THERAPY FOR AN INDIVIDUAL

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S. B. Davis; L. G. Richards; A. L. Behrman

205 REPRESENTATION OF IMAGINED and EXECUTED SEQUENTIAL FINGER

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J E Deutsch; S. Fischer; W. Liu; A. Kalnin; K. Mosier

205 VELOCITY OF VERTICAL and HORIZONTAL EYE MOVEMENTS IN

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169 J ournal of N eurological P hysical T herapy Vol. 29 • No. 4 • 2005

Journal of Editor’s Note: JNPT is Officially

Neurologic Indexed in MEDLINE!
Physical Judith E. Deutsch, PT, PhD, Editor JNPT
Therapy
EDITOR
It is official, JNPT is indexed in MEDLINE. The national library of med-
Judith E. Deutsch, PT, PhD icine has confirmed that we meet all of the electronic formatting
UMDNJ/SHRP
PT Program
requirements for inclusion in the index.We were also notified that index-
Bergen Bldg, Rm 110
Executive ing will begin with the March 2005 issue. Only journals that are less than
P.O. Box 1709
3 years old are backward indexed.
Newark, NJ 07101-1709
(W) 973/972-2373
Committee When I accepted the position of Neurology Report Editor, I was
(Fax) 973/972-3717
deutsch@umdnj.edu
PRESIDENT asked how long I would do it. I really had no idea but ventured to guess
Katherine Sullivan, PT, PhD
Dept. of Biokinesiology & PT that it would be a 5-year commitment. My long-term goal was to prepare
EDITORIAL BOARD University of Southern California the journal for indexing in MEDLINE. Five years seemed like a reasonable
1540 E Alcazar St, Chp-155
ABSTRACTS & REVIEWS Los Angeles, CA 90089-0103 time frame. I thought that in fact I had estimated quite well and with the
EDITOR (W) 323/442-2651
Kathleen Gill-Body, DPT, MS, NCS (FAX) 323/442-1515
publication of this issue I would complete 5 years of service, only to find
Boston, MA kasulliv@usc.edu out that this was the sixth year! Now I am asked how much longer will
kgillbody@mghihp.edu
VICE PRESIDENT
I stay on as Editor of JNPT? I still really do not know.We have a lot more
Edelle Field-Fote, PT, PhD Mike Studer, PT, MHS, NCS work to do with the journal. It relates to streamlining our operation and
Miami, FL Northwestern Rehabilitation
Associates transferring some of the responsibilities that have been shouldered by
James Gordon, PT, EdD 1380 Liberty St SE volunteers to paid staff as well as continuing to raise the level of the pub-
Los Angeles, CA Salem, OR 97302
(W) 503/371-0779 lication and increase access and communication related to the journal
Susan Herdman, PT, PhD, FAPTA (Fax) 503/371-0886 by improving our electronic venue.
Atlanta, GA mike@northwestrehab.com
For now though, we can take a moment to reflect on achieving our
Patricia S. Pohl, PT, PhD SECRETARY goal of MEDLINE inclusion.This goal could only be achieved by working
Kansas City, KS Karen Mccullough, PT, PhD, NCS
Univ. of NC Chapel Hill with committed members of the Section. The Editorial Board and peer
Mark Rogers, PT, PhD Divisionof PT, CB 7135
Chicago, IL Chapel Hill, NC 27599-0001
reviewers and electronic media liaison (aka Jim Cavanaugh) formed the
(W) 919/843-8783 core of that group. Of course the authors who have worked patiently
Margaret Schenkman, PT, PhD (Fax) 919/966-3678
Denver, CO kmac@med.unc.edu
with us and represent both the new and more seasoned contributors to
our field deserve credit as well. I think however, in the end, the reason
CONSULTING EDITORS TREASURER
Rebecca Craik, PT, PhD, FAPTA Edelle Carmen Field-Fote, PT, PhD for being considered in MEDLINE has to do with the evolution of our
Glenside, PA University of Miami - PT specialty, neurologic physical therapy. The journal is just the reflection
5915 Ponce De Leon Blvd, 5th Floor
Carol Richards, PT, PhD Coral Gables, FL 33146-2435 of the Section and its members who are clinicians, educators, and re-
Quebec, Canada (W) 305/243-7119 searchers that can converge and benefit from our singular publication.
(Fax) 305/284-6128
PUBLISHER edee@miami.edu
Sharon Klinski
Orthopaedic Section,APTA PROGRAM CHAIR
2920 E Ave S, Suite 200 Dorian Rose, PT, PhD
LaCrosse,WI 54601-7202 N Florida/S Georgia Veterans-
(W) 608/788-3982, ext 202 Health System
(Fax) 608/788-3965 1601 SW Archer Rd (151 B)
sklinski@orthopt.org Gainesville, FL 32608-1197
(W) 352/376-1611, ext 4955
WEB MASTER (Fax) 352/271-4540
CaduceusWebs Co. drose@phhp.ufl.edu
P.O. Box 2272
Tallahassee, FL 32316 EDITOR
800/951-9327 Judith E. Deutsch, PT, PhD
webmaster@neuropt.org
EXECUTIVE OFFICER
Janice M. Ford
Neurology Section
1111 N Fairfax Street
Alexandria,VA 22313
(W) 1-800/999-2782, ext 3237
(FAX) 703/706-8575
neuro@apta.org
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
Center of Pressure Measures during Standing Tasks in Minimally
Impaired Persons with Multiple Sclerosis
Gregory M. Karst, PT, PhD;1 Dawn M.Venema, PT, MPT;2 Tammy G. Roehrs, PT, MA, NCS;3 Amy E. Tyler, PhD4
ABSTRACT
Background and Purpose: Balance impairments are
common in persons with multiple sclerosis (MS), but clini-
cal balance tests may not detect subtle deficits in adults
with MS who are not yet experiencing functional limita-
tions or disability. The purpose of this study was to deter-
mine if center of pressure (COP) displacement during
standing tasks could be a useful performance-based evalua-
tive measure for adults with MS who have minimal or no
balance deficits on clinical examination using the Berg
Balance Scale (BBS). Subjects and Methods: Twenty-one
adults with MS were compared with 21 age- and gender-
matched healthy adults. Subjects with MS were tested with
the BBS, Mini-mental State Exam, Expanded Disability Status
Scale (EDSS), and Multiple Sclerosis Functional Composite
(MSFC). They also performed voluntary leaning and reach-
ing movements while kinematic and kinetic data were col-
lected. Control subjects performed the same tasks with the
exception of the EDSS and MSFC. Results: COP displace-
ment during reaching and leaning was less in adults with
MS when compared to control subjects. There were no dif-
ferences in anthropometric, kinematic, or foot position vari-
ables that could account for this difference. Furthermore,
there was no difference between groups when COP dis-
placement during reaching was expressed as a percentage
of the maximum COP displacement during leaning.
Discussion and Conclusion: COP measures show clear
differences when comparing healthy adults with minimally
impaired adults with MS. The lack of between-group differ-
ences when COP displacement during reaching was
expressed as a percentage of the maximum COP displace-
ment during leaning suggests that the subjects with MS
adopt a reaching strategy that allows them to stay within
their reduced limits of stability. COP measures during
standing tasks appear well-suited to quantifying changes in
postural control over time or in response to intervention for
minimally impaired persons with MS.
Key Words: balance, reaching, postural control
INTRODUCTION
Multiple sclerosis (MS) is a chronic neurological disease
characterized by demyelination and inflammation of the cen-
tral nervous system (CNS).1-4 The often progressive nature
and variable sites of CNS involvement lead to varied presen-
1
Associate Professor and Associate Director, Division of Physical Therapy Education, University of Nebraska Medical Center,
Omaha, NE (gmkarst@unmc.edu)
2
Graduate Teaching Assistant, Division of Physical Therapy Education, University of Nebraska Medical Center
3
Assistant Professor, Division of Physical Therapy Education, University of Nebraska Medical Center
4
was an Assistant Professor, Division of Physical Therapy Education, University of Nebraska Medical Center
170
tations of neurological dysfunction.1-3 People with MS often
experience difficulty with mobility, extremity function,
somatosensation, vestibular function, vision, cognition, and
bowel and bladder control.1-3 Balance is the result of complex
interactions between musculoskeletal and neuromuscular
systems, including sensory, motor, and integrative compo-
nents.5,6 Because these components are frequently affected
by MS, many persons with MS have balance deficits.2,3,7-11
One objective of rehabilitative interventions for persons
with MS is to address balance impairment.12-14 Clinically
based tests such as the Berg Balance Scale (BBS), Tinetti
Performance Oriented Mobility Assessment, and Functional
Reach test, among others, have been used to test balance
impairment and functional mobility in persons with
MS.9,11,12,15,16 These measures indicate whether or not an indi-
vidual can perform a given task and can identify individuals
at risk for falls. However, they may not be sensitive to min-
imal impairments of balance in those persons not yet expe-
riencing functional limitations or disability. An assessment
of balance that could identify subtle impairments before
they lead to functional decline could promote earlier inter-
vention and possibly prevent or delay functional limitation
and disability.
Laboratory measures offer the potential to identify sub-
tle deficits in postural control that may not be otherwise
apparent based on clinical tests.17 Force platforms are one
laboratory assessment tool that have been used to assess
postural control in individuals with MS during quiet stance
conditions7-10,18 or in dynamic conditions, namely in
response to external perturbations such as support surface
movements.8,10,19 In individuals with MS who demonstrate
minimal or no balance impairment on clinical exam, some
studies have shown force plate measures in static and
dynamic conditions to be sensitive to subtle balance impair-
ments.8,10,18,19 However, some studies have shown static
stance to be less discriminating than dynamic testing.
Nelson et al identified abnormal scores with sensory orga-
nization testing in only 30% of subjects with MS in a ‘high
function’ group (defined as those who scored at least 24 out
of 26 points on the Tinetti Performance Oriented Mobility
Assessment).9 Similarly, Daley and Swank found only 6% of
subjects with MS who were free from functional limitations
had abnormal sway in quiet stance with eyes open, and this
percentage increased to only 15% when the same subjects
stood with eyes closed.7 These results suggest that force
171 J ournal of N eurological P hysical T herapy
plate measures under static conditions may not be a very
sensitive measure in minimally impaired persons with MS,7-
9
but that dynamic testing shows promise.8,10,19
In contrast to testing postural control in response to
external perturbations of the support surface, no studies to
date have used a force platform to assess postural control in
persons with MS during voluntary movements such as those
used during performance of daily activities. Voluntary upper
extremity movements cause internally-generated perturba-
tions to balance due to inertial effects and changes in the
position of the center of mass. It has been well documented
that there is an anticipatory phase of postural activity in the
trunk and lower extremities prior to the initiation of arm
movements in standing.20-27 These anticipatory postural
adjustments (APAs) include EMG activity in the trunk and
legs20-25,27 and changes in kinetic variables measured by a force
platform.20-22,24,26 Researchers have hypothesized that the CNS
employs APAs to provide postural control in anticipation of
the potentially destabilizing effects of the arm movement.20-23
One laboratory measure that can reflect an attempt by
the CNS to maintain an upright posture is the center of
pressure (COP).22,24-27 Center of pressure is the point of
application of the vertical ground reaction force.28 The COP
displacement can be determined while subjects stand qui-
etly on the force platform, or as they respond to perturba-
tions, either internal or external, imposed on their bodies.
Assessing COP displacement during a task such as standing
and reaching provides a means for assessing postural con-
trol in response to internally-generated perturbations in the
context of a common functional activity.
The purpose of this study was to determine if the labora-
tory measure of COP displacement during standing reaches
could identify subtle changes in postural control in a group
of individuals with MS who showed minimal or no balance
deficits on clinical examination using the BBS. The task we
analyzed consisted of standing and reaching to various dis-
tances, both within and beyond arms’ length. We also exam-
ined limits of stability as reflected by the maximum COP
excursion in the sagittal plane while the subjects voluntarily
leaned as far anterior and posterior as possible without loss
of balance. We hypothesized that the COP displacement vari-
ables during rapid, bilateral reaching movements and leaning
movements would be different in minimally impaired sub-
jects with MS when compared to a control group consisting
of age- and gender-matched adults with no known orthope-
dic or neurological impairments. A preliminary report of
these results has been published in abstract form.29
METHODS
Subjects
Subjects with MS were recruited through the University
of Nebraska Medical Center (UNMC) MS clinic. Potential
subjects were required to have a definite diagnosis of MS,30
be able to stand unassisted for 5 minutes, and be able to
reach forward with both arms in standing without assis-
tance. (Although there are newer criteria for the diagnosis
Vol. 29 • No. 4 • 2005
of MS,31 our subjects were recruited before these criteria
were published.) We operationally defined ‘minimal or no
balance impairment’ as a score of 48 or greater on the BBS
based on our desire to have some heterogeneity in our sam-
ple of subjects with MS while avoiding subjects likely to
require an assistive device.15 As such, exclusion criteria
included a score on the BBS less than 48 out of 56, a score
on the Mini-mental State Exam (MMSE) less than 20 out of
30, the presence of coexisting neurological or orthopedic
conditions that limited the subjects’ ability to perform the
testing protocol, or the use of an assistive device while
standing or walking. Twenty-one subjects with MS, 15
women (44.1 ± 8.38 years) and 6 men (50.2 ± 8.61 years)
met the criteria for the study and were tested.
Control subjects were recruited through advertisements
on the UNMC campus and website, and the local newspa-
per. Recruitment of control subjects followed the recruit-
ment and testing of subjects with MS, so that control sub-
jects could be age- (± 2 years) and gender-matched. Control
subjects were eligible to participate if they met the same
inclusion criteria as the subjects with MS, with the excep-
tion of having a diagnosis of MS. The same exclusion crite-
ria also applied to the control group. Twenty-one control
subjects, 15 women (45.3 ± 8.56 years) and 6 men (49.7 ±
8.41 years) met the criteria for the study and were tested.
The study protocol was approved by the UNMC
Institutional Review Board. All subjects provided written
informed consent prior to participating in testing proce-
dures, and all subjects participated in 2 testing sessions.
Clinical Measures
Berg Balance Scale
The performance-based BBS consists of 14 tasks, with
performance rated on each task from 0 (cannot perform) to
4 (normal performance) for a total of 56 possible points.32
The BBS has been shown to be a reliable32 and valid33 pre-
dictor of fall status in older adults and patients with acute
stroke. When combined with fall history, it has been shown
to be a powerful predictor of fall risk in community-
dwelling older adults.34 Reliability and validity of the BBS
have not been established in persons with MS. However,
the BBS has been found to change in response to rehabili-
tation in adults with clinically stable MS.12 Also, a prelimi-
nary study found a modest correlation (r = -0.498) between
the BBS score and self-reported falls in this population, as
well as a difference in mean BBS score between adults with
MS who used an assistive device (mean = 42.1) and those
who did not (mean = 49.3).15
Mini-mental State Exam
The MMSE is a 7-item test of general cognitive ability.35
Possible scores range from 0 to 30, with higher scores indi-
cating better cognition.
Expanded Disability Status Scale
The Expanded Disability Status Scale (EDSS) is an 11-
point scale (0 = normal neurological examination; 10 =
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
death due to MS) of general impairment and disability spe-
cific to persons with MS.36 The EDSS has been widely used
for many years to classify disease severity,37 but it has been
criticized because it is an ordinal scale based on subjective
evaluation,38 it has poor inter-rater reliability,39,40 and it
mixes components of impairment and disability.39,40
Additionally, the EDSS appears to be less sensitive to
changes in function than other scales.41-43 We included the
EDSS, despite its limitations, to allow for comparison with
prior studies that have characterized persons with MS in
terms of EDSS scores.
Multiple Sclerosis Functional Composite
Due to the limitations of the EDSS, the Multiple Sclerosis
Functional Composite (MSFC) was devised as a multidi-
mensional tool to reflect the varied clinical presentations of
MS.37 It consists of 3 performance tests that measure 3 clin-
ical dimensions of function: a Timed 25-Foot Walk (leg func-
tion), the 9-Hole Peg Test (arm and hand function), and the
Paced Auditory Serial Addition Test (cognitive function).
The scores from these 3 dimensions are combined to form
a composite Z-score that can be used to detect change over
time relative to the general population of persons with MS.
Laboratory Measures
Accelerometry
The TSD 109C tri-axial piezoelectric accelerometer (out-
put ± 5g, 400 mV/g; BIOPAC Systems, Inc., Santa Barbara,
Calif) was calibrated prior to data collection according to its
manufacturer. The accelerometer was attached to the radial
side of each subject’s left wrist, with one of its axes ori-
ented in the sagittal plane and perpendicular to the long
axis of the forearm. Onset of arm movement was deter-
mined from the signal from this axis.
Target
The target consisted of two 7.6 cm by 15.2 cm carbon
rubber electrodes mounted individually to a flexible foam
bar attached to a free-standing, lightweight metal frame.
The frame could be adjusted so that the target was at shoul-
der height and at appropriate distances for each subject.
Two targets were used to promote symmetrical reaching
with both hands, however contact data were collected from
only the left target. Subjects wore a metal thimble on their
left index finger. Touching the thimble to the target closed
a low-voltage circuit to indicate target acquisition.
Force platform
During the leaning and reaching movements, subjects
stood on a strain gauge force platform (Advanced Mechanical
Technology, Inc.,Watertown, Mass) with their feet in a com-
fortable stance and arms resting at their sides with their
palms facing medially. Subjects were barefoot to minimize
variability in performance that may occur due to differences
in footwear. The position of each subject’s feet on the force
platform was marked to maintain consistent foot position
172
during testing and so that individual characteristics such as
foot length and position could be determined. A research
assistant stood by the subject during testing to ensure main-
tenance of foot position as well as to assist the subject in the
event of a loss of balance. Signals were collected for the ver-
tical ground reaction force (Fz) and the moment of force
about the mediolateral axis (Mx). Center of pressure move-
ment in the sagittal plane (COPy) was calculated using the
following equation: COPy = Mx/Fz.
Kinematic data
In order to assess movement velocity, 3-dimensional
kinematics of the hand were recorded using the WATS-
MART 2-camera infrared motion analysis system (Northern
Digital, Waterloo, ON, Canada) with an infrared emitting
diode (IRED) placed on the left index fingertip. The 2 cam-
eras were placed approximately 3 m away from the subjects
and oriented at approximately 60º apart. The cameras were
calibrated prior to data collection according to the manu-
facturer’s specifications using a cubic calibration frame, and
calibration parameters were deemed acceptable if the over-
all root-mean-square error for marker positions was less
than 5 mm.
Data capture
MP100 Workstation hardware and Acknowledge® soft-
ware (BIOPAC Systems, Inc., Santa Barbara, Calif) were used
with one computer system to collect and store signals from
the accelerometer, target circuit, and force platform ampli-
fier. These signals were all sampled at a rate of 1000 Hz
using a 16-bit analog-to-digital converter. Electromyograph-
ic data were collected simultaneously, but will be reported
in a separate communication. A second computer system
was used to collect and store kinematic data from the
infrared motion analysis system using WATSMART hardware
and software. These signals were sampled at 250 Hz. Data
collection was synchronized between the two systems
using a 5-volt electronic trigger signal.
Testing Procedure
Test sessions for subjects with multiple sclerosis
During the first test session, each subject with MS under-
went a neurological examination consisting of the adminis-
tration of the EDSS and the MMSE by a board-certified neu-
rologist. The neurologist determined subjects’ ability to
perform the standing and reaching task, and interviewed
them about current medications, age of onset, recent
(within 6 months) fall history, and relevant orthopedic con-
ditions. Additional clinical tests during the first test session
included the BBS and MSFC, both conducted by a licensed
physical therapist.
Within 7 days of the clinical test session, subjects with
MS returned for a second testing session to collect labora-
tory data. Three items from the BBS were repeated to deter-
mine the stability of the subject’s balance performance
across test sessions. These items were: Item 1, sitting to
173 J ournal of N eurological P hysical T herapy
standing; Item 8, reaching forward with outstretched arm;
and Item 14, standing on one foot. Arm’s length (AL) was
measured from the acromion to the tip of the index finger,
and height measurements were taken.
The first laboratory task consisted of anterior and poste-
rior leans. The subjects stood on the force platform and
were instructed to lean as far forward and backward as pos-
sible without falling and to hold this position for 5 seconds.
Subjects were asked to keep their feet flat on the floor and
aligned with respect to the frontal plane, but stance width
and toe-out were not dictated to the subjects. Center of
pressure movement in the sagittal plane measurements
were recorded for a total of 4 leaning trials, 2 backward and
2 forward.
The second laboratory task consisted of a series of
reaching movements performed from the same stance posi-
tion as the leaning trials with the eyes open. Following the
indication that the subject was ready, data collection was
initiated after a random interval of 1 to 3 seconds. Five hun-
dred milliseconds (ms) after the initiation of data collection,
an audible tone was generated as the signal for the subject
to perform the movement. The subject was instructed to
reach forward with both arms to touch a target placed at
shoulder height. The subject was told to move as fast as
possible to minimize variation in the reaching activity,44 but
that reaction time in response to the tone was not impor-
tant. The final reach position was held until the 3 second
data collection period was complete. Subjects were pro-
vided opportunities to rest at any point during testing.
Five reaches were performed to each of 7 different tar-
get distances, some within and some beyond AL. In order to
place the target at AL and control for differences in the
amount of scapular protraction the subjects may have used
to reach the target, a rigid yardstick was used to measure
from the anterior aspect of each subject’s acromion to the
target as the subject stood on the force platform with their
arms held at their side. Distances of the target beyond and
within AL were then determined from the AL position using
a tape measure placed on the floor under the frame on
which the target was mounted. Target distance varied by 5
cm increments from AL minus 10 cm to AL plus 20 cm (AL-
10, AL-5, AL, AL+5, AL+10, AL+15, AL+20). A Latin Square
design45 was used to vary the order of target distance across
subjects. One subject with MS (subject M13) was unable to
safely reach the furthest target distance, and therefore per-
formed only 30 reaches to 6 target distances. Subjects were
allowed up to 5 practice reaches to the AL+10 distance
prior to data collection. If visible movement of the subject’s
arms or trunk occurred prior to the auditory ‘go’ signal, if
the movement appeared markedly slower than other trials
at the same distance, or if the target was missed, the trial
was repeated.
Test sessions for control subjects
Control subjects also participated in 2 testing sessions.
During the first session, the control subjects’ orthopedic
Vol. 29 • No. 4 • 2005
and neurologic health was confirmed by the same board-
certified neurologist that examined the subjects with MS.
The second testing session occurred within 60 days of the
first test session. At the second test session, a licensed phys-
ical therapist administered the BBS and the MMSE. Testing
of leaning and reaching movements for control subjects
involved the same instrumentation and protocol as that
described for subjects with MS.
Data Reduction
Foot position data
Figure 1 provides operational definitions for foot posi-
tion characteristics from one representative control sub-
ject. The following variables were determined from the foot
tracings for all subjects: foot length (the distance from the
great toe to the mid-point of the calcaneus), toe distance
(the distance between the great toes), heel distance (the dis-
tance between the mid-points of the calcanei), and anterior-
posterior base of support (AP BOS; the sagittal plane dis-
tance between the most anterior and most posterior point
of contact on the force plate). Foot position was defined as
the ratio of in- or out-toeing determined by dividing the toe
distance by the heel distance, with ratios greater than one
indicating a toe-out position.
Toe Distance
AP BOS
Foot Length
Heel Distance
Figure 1. Foot tracing for a representative control subject with
operational definitions for foot placement characteristics. Foot
length is defined as the distance from the great toe to the mid-point
of the calcaneus. Heel distance is defined as the distance between
the mid-point of the calcanei. Toe distance is defined as the dis-
tance between the great toes. Anterior-posterior base of support
(AP BOS) is defined as the sagittal plane distance between the most
anterior and most posterior point of contact on the force plate.
Kinematic data
Three-dimensional position data from the IRED placed at
the tip of the index finger were low pass filtered (12 Hz)
and differentiated to determine peak tangential velocity of
the fingertip and time to peak tangential velocity relative to
movement onset for each trial. Averages of peak tangential
velocity and time to peak tangential velocity for each reach
distance for each subject were calculated. The two groups
were compared across distances.
Arm movement onsets were identified for each trial for
each subject from the accelerometer signal using a com-
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy 174

puter algorithm. The algorithm identified peak wrist accel-

eration, and then searched backwards in time to when the
acceleration trace first exceeded the baseline. Baseline of
the acceleration trace was defined as the mean value of the
signal over the first 250 ms of the sampling period (the sam-
pling period having started 500 ms prior to the tone). The
onsets identified by the computer were visually confirmed
by one of the investigators. If the onset was uncertain
because of artifacts that may have been due to backward
movement of the hand or slow hand movement prior to
onset of the reach, the trial was rejected. Out of a total of
1465 trials, 27 (2%) were rejected because of difficulties in
identifying the onset of arm movement.
Kinetic data
Center of pressure movement in the sagittal plane data
were averaged for the reaching trials to each distance (max-
imum of 5 trials, minimum of 3 trials to each distance) rela-
tive to the onset of arm movement and examined for peak-
to-peak and net displacement in the sagittal plane. Figure
2A shows the change in COPy position over time (0 cm =
initial starting position of the subject) during reaching to
distance AL+20 for one representative healthy subject. This
trace represents the average of 5 reaches, aligned to the
onset of arm movement (time = 0 ms), and illustrates how
COPy displacements were calculated. Negative values
(COPy-) represent movement of COPy in the posterior
direction, and positive values (COPy+) represent movement
of COPy in the anterior direction. Peak-to-peak COPy dis-
placement was defined as the difference between the max-
imum COPy- and COPy+ positions. Net COPy displacement Figure 2. A. Change in center of pressure in the sagittal plane
was defined as the difference between the COPy position in (COPy) position over time during reaching to a distance of arm’s
the subject’s initial resting posture and the COPy position length plus 20 cm (AL+20). Data are from a representative control
subject. The trace represents the average of five trials to this dis-
in the final reach posture. Initial COPy position was calcu- tance. The x-axis depicts time in ms, with the five trials aligned so
lated as the mean value over 250 ms prior to the ‘go’ signal that zero ms is the point in time that arm movement began. The
and final COPy position was based on the mean value over y-axis shows COPy position in cm relative to the initial starting
250 ms after the subject had attained the final reach pos- position (0 cm) of the subject. Negative values (COPy-) indicate
movement of the subject’s COPy in the posterior direction, while
ture. When comparing groups, the peak-to-peak and net positive values (COPy+) indicate movement in the anterior direc-
COPy displacements were adjusted for each subject to tion. The dotted lines indicate the initial and final COPy positions.
account for differences in foot length and placement by The initial COPy position was calculated as the mean value over
dividing these values by the subject’s AP BOS. 250 ms prior to the “go” signal. The final COPy position was deter-
mined from the mean value over 250 ms after the subject had
Figure 2B shows COPy position data from one represen- attained the final reach posture. COPy net is the difference
tative subject with MS during 2 leaning trials (1 backward between the initial and final positions of COPy. Dashed lines indi-
and 1 forward). Zero on the x-axis represents the initial cate the maximum COPy- and COPy+ positions. COPy peak-to-
starting position of the subject. Changes in COPy position peak is the difference between the maximal COPy- and COPy+
positions. COPy+ and COPy- are calculated relative to the initial
in the positive direction on the y-axis represent anterior COPy position. B. Changes in COPy position for a representative
leans, while posterior leans result in negative values of subject with MS during leaning trials. Data are shown for 2 leans,
COPy position. The limit of stability in the anterior-poste- one anterior and one posterior. Data were collected for a total of
rior direction (LOSAP) was defined as the difference 5 seconds (x-axis). The y-axis depicts COPy position relative to the
initial starting position (0 cm) of the subject. The limit of stability
between a subject’s most anterior and most posterior posi- in the anterior-posterior direction (LOSAP) is defined as the differ-
tion of the COPy during the leaning trials. The percentage ence between the most anterior and most posterior position of the
of the LOSAP used during the reaching task was also calcu- COPy during the leaning trials.
lated as: (peak-to-peak COPy/LOSAP) x 100.
had an influence on the task: height, arm length, foot
Statistical Analysis length, foot position, and AP BOS. Paired two-tailed t-tests
Paired two-tailed t-tests were used to compare the 2 were also used to compare groups on LOSAP during the lean-
groups of subjects on the following variables that may have ing trials. Two-way ANOVAs (group x target distance) with
175 J ournal of N eurological P hysical T herapy Vol. 29 • No. 4 • 2005

one repeated measure (target distance) were used to evalu- Table 1. General Characteristics of Subjects. Subjects were matched for
age (± 2 years) and gender. Groups did not differ on other variables listed.
ate group differences and the effects of target distance on
COPy net, COPy+, COPy- and COPy peak-to-peak displace- Control Subjects Subjects with
Multiple Sclerosis
ment, percentage of LOSAP used during the reaching task,
Gender 6M/15F 6M/15F
peak tangential velocity of the fingertip, and time to peak
Age (years)
tangential velocity of the fingertip. Tukey’s test was used for (mean ± SD) 46.6 ± 8.8 46.0 ± 8.7
post-hoc multiple comparisons for the variable of reach dis- (range) 28 – 65 28 - 65
tance. The alpha level was set at P ≤ 0.05. Microsoft® Excel Height (cm)
2002 (Microsoft Corporation, Redmond,WA) and SigmaStat (mean ± SD) 169.3 ± 8.4 169.3 ± 8.7
(range) 153.7 – 185.4 156.2 – 185.4
for Windows Version 2.03 (SPSS, Inc., Chicago, Ill) were used
for data analysis. Arm Length (cm)
(mean ± SD) 73.4 ± 3.7 73.5 ± 4.7
(range) 67.3 – 81.3 66.0 – 83.8
RESULTS Foot Length (cm)
Subject Characteristics (mean ± SD) 25.4 ± 1.6 26.0 ± 1.4
Descriptive characteristics (mean ± SD) for all subjects (range) 22.9 – 28.5 23.9 – 28.8
are listed in Table 1. Subjects were matched for age (± 2 Foot Position (toe
distance/heel distance)
years) and gender. Paired two-tailed t-tests revealed that (mean ± SD) 1.41 ± 0.31 1.24 ± 0.36
subjects with MS did not differ from control subjects on any (range) 0.98 – 2.33 0.81 – 2.35
of the other variables listed in Table 1. AP BOS* (cm)
Table 2 provides clinical characteristics for all subjects (mean ± SD) 25.9 ± 1.8 26.7 ± 1.5
(range) 23.4 – 29.4 24.1 – 29.4
with MS. These subjects scored well on the various clinical
*AP BOS = anterior-posterior base of support (the sagittal plane
tests. Ten out of the 21 subjects scored the maximum num- distance between the most anterior and most posterior point of
ber of points (56) on the BBS, with a median score of 55 contact on the force plate)

Table 2. Clinical Characteristics of Subjects with Multiple Sclerosis

Subject Gender Age Fall History* EDSS† BBS‡ MMSE§ MSFC||
M1 M 43 0 2.0 56 24 -0.25
M2 F 53 0 0.0 54 28 -0.06
M3 F 48 0 0.0 56 30 0.41
M4 F 48 0 6.0 48 30 -1.37
M5 M 45 0 1.5 56 30 0.19
M6 F 29 0 0.0 56 30 0.62
M7 M 45 2 0.0 56 30 0.77
M8 M 51 0 3.5 53 30 -0.27
M9 F 44 0 2.5 55 30 -0.06
M10 F 43 0 3.0 53 30 -0.85
M11 M 55 0 4.0 56 30 0.37
M12 F 44 0 2.0 56 29 0.24
M13 M 66 0 1.5 53 30 0.23
M14 F 34 0 2.0 56 30 0.76
M15 F 45 0 1.5 56 30 0.72
M16 F 57 0 4.0 52 30 0.42
M17 F 46 2 2.5 56 27 0.16
M18 F 39 0 0.0 54 30 0.17
M19 F 30 5 3.0 51 30 0.34
M20 F 53 0 3.0 50 30 0.04
M21 F 52 0 2.5 55 30 0.84
Mean 2.1 54.2 29.4 -0.16
SD 1.6 2.3 1.5 0.54
Median 2.0 55 30 0.23
Range 0.0 – 6.0 48 - 56 24 - 30 -1.37 – 0.84
* Number of falls within the previous 6 months as reported by the subject
† Expanded Disability Status Scale; range of 0 – 10; a higher score indicates greater impairment and disability
‡ Berg Balance Scale; range of 0 – 56; a higher score indicates better balance performance
§ Mini Mental State Examination; range of 0 – 30; a higher score indicates better cognitive performance
|| Multiple Sclerosis Functional Composite overall z-score; a positive score indicates function better than the average for persons with multiple sclerosis
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy 176

(one control subject scored 55, all other control subjects

scored 56 on the BBS). The median score on the EDSS was
2.0 on a scale of 0 to 10, with lower scores indicating bet-
ter function. Fifteen of the 21 subjects with MS had a posi-
tive MSFC overall z-score, indicating function better than
the average of the general population of persons with MS.
The subjects with MS also appeared stable in their per-
formance between sessions on the BBS. During the second
test session, only 4 subjects differed on the 3 items that
were repeated, and only by one point each.
Kinematic variables
There were significant main effects of reach distance on
peak tangential velocity of the fingertip and time-to-peak
tangential velocity (P < 0.001 for each variable). There was
no between-group difference in peak tangential velocity or
time-to-peak tangential velocity, and no group x distance
interaction.
Center of Pressure Movement in the Sagittal Plane:
Lean Trials
Table 3 shows the mean (± SD) of LOSAP during the max-
imum anterior and posterior lean trials for both groups.
When leaning, the control subjects moved their COPy over
a greater (P = 0.008) distance (14.2 ± 2.6 cm) than the sub-
jects with MS (11.9 ± 2.9 cm). There was also a difference
(P = 0.002) between groups when the AP BOS was taken
into account and the LOSAP was expressed as a percentage
of the base of support.

Table 3. Group Differences During Lean Trials. Control subjects

demonstrated a larger LOSAP (p = 0.008) than subjects with MS. This dif-
ference was also apparent when the AP BOS was taken into account (p =
0.002).
Group LOSAP* (cm) LOSAP/ AP BOS† (%)
(mean±SD) (mean±SD)
Subjects with Multiple
Sclerosis (n =21) 11.9 ± 2.9 44.8 ± 10.9
Control Subjects (n = 21) 14.2 ± 2.6 54.6 ± 9.3
* LOSAP = Limit of Stability in the Anterior-posterior Direction
† AP BOS = Anterior-posterior Base of Support

Center of Pressure Movement in the Sagittal Plane:

Reach Trials
Figure 3A depicts mean (± SD) net and Figure 3B shows
mean (± SD) peak-to-peak COPy displacements for both
groups of subjects across reach distances after AP BOS was
taken into account. For both groups, COPy net displace-
ment increased as target distance increased (P < 0.001), but
there was no difference between groups and no group x
distance interaction. Figure 3B illustrates that there was a
difference in peak-to-peak COPy displacement between
groups (P < 0.001), with control subjects showing greater
peak-to-peak COPy displacement. The greater peak-to-peak
COPy displacement in the control group was primarily due
to a significant difference in COPy+, while COPy- did not
differ significantly between groups. Peak-to-peak COPy dis-
placement increased as target distance increased (P <
0.001), but there was no group x distance interaction.
Figure 3. A. Mean net COPy displacement for both groups during
reaches to each distance. Reach distance in cm relative to arm’s
length is depicted along the x-axis. Reach distances varied by 5 cm
increments and ranged from 10 cm short of arm’s length to 20 cm
beyond arm’s length. (AL-10, AL-5, AL, AL+5, AL+10, AL+15, AL+20).
COPy displacement is expressed as a percentage of each subject’s
AP BOS and is represented along the y-axis as means (±SD) of each
group. The black bars represent subjects with MS and the white
bars represent control subjects. B. Mean peak-to-peak COPy dis-
placement for both groups during reaches to each distance. Axes
are the same as in Fig 3A. The black bars represent subjects with
MS, while the white bars represent control subjects. C. Mean per-
centage of LOSAP used during reaching for both groups to all target
distances. The x-axis is as in Figure 3A. The percentage of LOSAP
used during reaching was calculated by dividing the COPy peak-to-
peak displacement during reaching by the LOSAP determined from
the leaning trials for each subject. These values are expressed as
means (±SD) for each group along the y-axis. The black bars rep-
resent subjects with MS, while the white bars represent control
subjects.
177 J ournal of N eurological P hysical T herapy
The percentage of the LOSAP used during the reaching
task was evaluated for each group. Figure 3C illustrates the
mean (± SD) percentage of the LOSAP used for peak-to-peak
COPy displacement during the reaching task to each dis-
tance. Percentage of LOSAP used increased as target distance
increased, with means approaching 100% for both groups
for the longest distance. For the longest reaches, some indi-
vidual subjects in each group demonstrated peak-to-peak
COPy displacement greater than the LOSAP they demon-
strated during the leaning task. There was an effect for
distance on the percentage of LOSAP used during reaching
(p < 0.001), but there was no difference between groups
and no group x distance interaction.
Secondary Analysis of Center of Pressure Movement
in the Sagittal Plane During Reaching
A secondary analysis was performed in order to deter-
mine if significant differences in COPy measures could still
be seen when comparing healthy subjects to those subjects
with MS who had the least balance impairments based on
BBS scores. To do this, we divided the subjects into 3
groups: Healthy subjects with a BBS score of 55 or 56 (n =
21; 1 with a BBS score of 55), subjects with MS and a BBS
score of 55 or 56 (n = 12; 2 with a BBS score of 55), and sub-
jects with MS and a BBS score < 55 (n = 9; mean ± SD BBS
score of 52 ± 2). Both groups with MS still differed signifi-
cantly (P ≤ .02) from the Healthy group on COPy peak-to-
peak and COPy+ measures. The mean values for 2 groups
with MS did not differ significantly, but the test was under-
powered after dividing the subjects with MS into 2 groups.
DISCUSSION
We found differences in COPy measurements between a
group of minimally impaired adults with MS and age- and
gender-matched control subjects, during rapid reaches to
various target distances and during leaning movements.
These differences persisted even when the control subjects
were compared only to the 12 subjects with MS who
scored the highest (55 or 56) on the BBS. Specific variables
that these groups differed on included their LOSAP during
maximum leans and their peak-to-peak COPy and anterior
(COPy+) displacement during the reaching tasks. These dif-
ferences cannot be explained by differences in anthropo-
metric variables, differences in foot position, or differences
in movement kinematics as assessed by peak tangential
velocity of the fingertip and time to peak tangential veloc-
ity.
Variations in foot position in quiet standing have been
found to affect postural sway and mean position of COP.46
Kaminski and Simpkins26 found increases in COPy displace-
ments in healthy subjects using a step stance (right foot
ahead of the left at a distance equal to 40% of leg length),
when compared to subjects in parallel stance during stand-
ing reaches to distances greater than AL. They suggested the
increase in COPy displacement occurred to assist whole
body motion to the target. We examined AP BOS in our
Vol. 29 • No. 4 • 2005
study and did not find a difference between groups. We fur-
ther controlled for this variable by dividing each subject’s
LOSAP and COPy displacements by their AP BOS before com-
paring groups. Additionally, there was no difference
between groups in foot position variables (heel distance,
toe distance, or ratio of toe distance to heel distance).
Therefore, differences in stance configuration cannot
account for differences in LOSAP or peak-to-peak COPy
between the two groups.
Greater arm velocity during reaching movements is asso-
ciated with earlier activation of postural muscles and
greater response magnitude.44 However, in our study, kine-
matic variables of peak tangential velocity of the fingertip
and time to reach peak tangential velocity did not differ
between groups. Consequently, the greater COPy excur-
sions observed in healthy individuals do not appear to be
due to differences in movement speed.
The Functional Reach (FR) was developed as a test of
balance in response to the voluntary movement of reach-
ing, and was found to correlate with COP excursion (r =
0.71).47 Frzovic et al found that the FR was a useful test to
differentiate between adults with MS and control subjects.11
In contrast to the relatively slow, unilateral reaches per-
formed in the FR test, the reaching task used in this study
was intended to produce greater postural control demands
during a task of reaching while standing. Horak et al found
that postural muscle activity was more variable, was some-
times absent, and did not always precede arm movement
when subjects were asked to raise their arms slowly com-
pared to quick arm movements.44 They speculated that less
stabilization force is necessary during low velocity move-
ments. While the FR is destabilizing in that subjects must
displace their center of mass to perform reaches to their
maximal distance, the rapid arm movements used in this
study would generate larger inertial forces in addition to dis-
placing the body center of mass. Furthermore, consistent
with previous findings,20-22,24,26 changes in COPy occurred
prior to the internal perturbation of rapid arm movement,
indicating anticipatory behavior. Thus, we would suggest
that the rapid, goal-directed reaching paradigm used in this
study provides additional information not gained with the
FR alone.
Subjects with MS demonstrated smaller LOSAP than our
control group. The smaller LOSAP demonstrated by subjects
with MS in our study suggests that our subjects were less
willing and/or able to deviate from their initial COP posi-
tion in the sagittal plane when compared to individuals
with no neurological impairment, indicating a voluntary or
involuntary self-limiting strategy. Interestingly, there were
no differences between groups in the percent of LOSAP used
for peak-to-peak COPy displacement during the reaching
tasks. For both groups, percent of LOSAP used during reach-
ing increased as target distance increased, nearing 100% for
the longest distances. The fact that there was no difference
between groups on this variable suggests that the subjects
with MS were instinctively aware of their limitations, and
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
were able to find a strategy to achieve the same task as the
controls, despite their decreased LOSAP.
Reach distance had a main effect for many of the vari-
ables in our study, including net COPy displacement, peak-
to-peak COPy displacement, COPy+ and COPy- displace-
ment, percentage of LOSAP used during reaching, peak
tangential velocity of the fingertip, and time to peak tan-
gential velocity of the fingertip. Systematic differences in
COPy displacement with reach distance have been previ-
ously found in healthy young adults25-27 as well as healthy
elderly.25 In these studies, COPy trajectories were qualita-
tively similar across reach distances, with COPy initially
moving posteriorly, then anteriorly, then to a relatively
steady final position. In addition, these authors found that
as target distance increased, net and peak-to-peak COPy dis-
placement increased. Our findings are consistent with
these qualitative patterns of COPy during reaching as well
as the main effect of reach distance on net and peak-to-peak
COPy displacement. In addition, we found the qualitative
pattern of the COPy displacement during reach to be iden-
tical in all subjects tested, regardless of whether or not they
had a diagnosis of MS.
In the interest of simplicity, we chose not to report each
pair-wise difference found with post-hoc testing. In gen-
eral, differences were found between most pairs of reach
distances for all of the COPy variables, with the exception
of the two shortest distances (AL-10 and AL-5). This finding
is in agreement with previous studies of healthy sub-
jects.25,27 We suggest that in future studies, the task could be
streamlined to include only one short and one long distance
without losing the salient features of the data. Furthermore,
because of the complex and multidimensional nature of bal-
ance, there is no single test that adequately assesses bal-
ance.5 Streamlining this reaching task would allow more
time to assess patients or subjects with other types of bal-
ance tests such as sensory manipulation, external perturba-
tions, or functional scales.
Our study found that healthy subjects demonstrated sig-
nificantly more peak-to-peak COPy displacement than sub-
jects with MS during reaching movements. However, no dif-
ferences were found between groups in net COPy
displacement (the difference between the initial and final
COPy positions). The fact that there was no difference in
net COPy between groups indicates that both groups were
able to successfully reach the target and maintain contact
with it. Since the peak-to-peak COPy gives insight into the
pattern of COPy movement prior to reaching the target, the
significant difference in peak-to-peak COPy displacement
suggests that subjects with MS used different movement
strategies to achieve target acquisition.
The adults with MS in this study appeared minimally
affected when assessed with standard clinical tests (see
Table 2). For instance, a clinician scoring most of these sub-
jects on the BBS would not document a substantial balance
impairment based on their scores. However, the subjects
with MS demonstrated differences from healthy control
178
subjects on COPy variables, implying that the BBS had a ceil-
ing effect and failed to detect subtle balance deficits in this
population. Other studies have suggested a ceiling effect in
the BBS with elderly persons.48,49 Furthermore, the BBS may
lack sensitivity to change for subjects such as those in our
study, with little room left for improvement in response to
intervention.
The instrumented measures used here may be more sen-
sitive than common clinical tests for objectively document-
ing both deficits and improvements in balance. With force
plate technology becoming more common in physical ther-
apy clinics, these variables would be easy to capture as part
of a physical therapy examination. Because MS is a pro-
gressive disease, tools to measure balance impairments dur-
ing early stages of the disease may lead to identification of
persons at risk for future decline and lead to earlier inter-
vention.
CONCLUSION
Our data demonstrate that peak-to-peak COPy and
COPy+ displacement during reaching, as well LOSAP during
leaning, are less in minimally impaired adults with MS than
in age- and gender-matched control subjects. However,
there was no difference between these groups when the
COPy displacement during reaching was expressed as a per-
centage of the LOSAP during leaning. This suggests that per-
sons with minimal impairments due to MS were instinctively
aware of their limitations, and were able to find a strategy to
achieve the same task as the controls, while staying within
their decreased LOSAP. These center of pressure measures
show clear differences in persons with MS who show little
or no deficit on clinical measures such as the BBS when
compared to a healthy control group.The usefulness of COP-
related variables to measure change, either over time or in
response to intervention, is worth further exploration.
ACKNOWLEDGEMENTS
This work was supported in part by a Pilot Research
Award from the National Multiple Sclerosis Society. The
Nebraska Bankers Association provided funding for the
force platform. We would also like to thank Eliad Culcea,
MD; Grace Johnson, PT, OCS; Janis McCullough, PT, DPT;
Wade Lucas, PT, DPT; and Thomas Spray, PT, DPT for assis-
tance with data collection and analysis.
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181 J ournal of N eurological P hysical T herapy
Age- and Gender-related Test Performance in Community-dwelling
Adults
TM Steffen, PT, PhD;1 LA Mollinger, PT, MS2
ABSTRACT
Objective: Interpretation of patient scores on func-
tional tests is enhanced by an understanding of test perfor-
mance in reference groups. The purpose of this study was
to expand performance values, by age and gender, on bal-
ance tests [the Multi-Directional Reach (MDRT); Berg
Balance (BBS); Sharpened Romberg, eyes open (SREO), eyes
closed (SREC); Activities-Specific Balance Confidence
(ABC)], and a general mobility test [Physical Performance
Test, (PPT-7, PPT-9)].The study also examined relationships
between test performance and subject characteristics.
Design and Subjects: Eighty-three community-dwelling
adults over 50 participated in the study and completed the
5 functional tests during one test session. Means, standard
deviations, and confidence intervals were calculated for
each of the tests. Multiple linear regression analysis was
used to examine relationships between test scores and age,
gender, height, and weight. Results: Test performance is
reported by gender, within 10-year age cohorts. Regression
analysis showed that age contributed significantly to pre-
diction of performance on all of the tests and gender con-
tributed significantly to prediction of scores on the Berg,
SREO, and SREC. Conclusions:Test performance values, in
a sample of community-dwelling adults, is provided by age
and gender cohorts to provide additional reference data
that can be used by clinicians for comparison with client
data. The small sample size for subjects over 80 years limits
the reference value of data for this age group. In regression
analyses, age and gender help predict outcomes on the
dependent variables used in the study.
Key Words: Multi-directional Reach Test, Berg Balance Scale,
Sharpened Romberg,Activities-specific Balance Confidence
Scale, Physical Performance Test
INTRODUCTION
In the patient examination, physical therapists include
tests at the disablement levels of impairment and functional
limitation in order to determine a physical therapy diagno-
sis, prognosis, and plan of care.1 These tests can be used to
document progress during therapy and to compare the
patient’s performance with that of a target reference group.
As tests of functional limitations develop, there is a need for
parallel development of performance data in reference
groups.
Several functional-level tests that are practical for clinical
use and of interest to the authors are the subscales of the
1
Program Director in Physical Therapy, Concordia University Wisconsin, 12800 N Lake Shore Dr., Mequon, WI
(teresa.steffen@cuw.edu)
2
Assistant Professor in Physical Therapy, Concordia University Wisconsin, 12800 N Lake Shore Dr., Mequon,WI
Vol. 29 • No. 4 • 2005
Multi-directional Reach Test (MDRT), the Berg Balance Scale
(BBS), the Sharpened Romberg test with eyes open (SREO)
or with eyes closed (SREC), the Activities-Specific Balance
Confidence Scale (ABC), and 2 versions of the Physical
Performance Test (PPT-7 and PPT-9).The MDRT, BBS, SREO,
SREC, and ABC were all designed to capture aspects of bal-
ance performance or perceived balance confidence. The
PPT was designed to measure aspects of general physical
mobility. The literature provides varying levels of study
regarding the reliability and validity of these tests and some
mean group data.A brief review of this literature follows as
background for the main purpose of this study which was
to provide additional reference data for clinicians using
these tests with patient groups.
Multi-directional Reach Test
This clinical test of the limits of postural stability in 4
directions during standing2 has been shown to have good
intra-rater reliability in community-dwelling older adults.3
For the lateral reaches, inter-rater reliability4 and test-retest
reliability5 were also high. The forward reach has shown
high intra- and inter-rater reliability6-14 and high test-retest
reliability.15 Construct validity was supported with signifi-
cant correlations between laboratory measures of excur-
sion of the center of pressure with lateral reach5 and for-
ward reach.9 Concurrent validity of the MDRT was
supported with correlations with other functional tests.3
Brauer et al5 found an inverse correlation between the
MDRT results and age. Newton3 has reported mean data for
the MDRT (n = 254) in an ethnically-mixed sample of com-
munity-dwelling older adults, although these data are not
categorized by age or gender. Other reference data are avail-
able for older females for lateral reach.4,5
Berg Balance Scale
This performance-oriented measure of balance during
standing activities16 has been shown to have high intra- and
inter-rater reliability17-21 and good internal consistency16,22 in
populations of healthy or disabled older adults living in the
community or in residential care facilities. Concurrent
validity has been supported by moderate to high correla-
tions between the BBS and other functional measures
among older adults at different functional levels (ie, institu-
tionalized, hospitalized, community-dwelling, post-stroke,
fallers, or with a range of balance abilities).11,18-21,23,24
Increasing age was shown to relate to decreasing BBS
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
scores in a study of community-dwelling elderly.25 An aver-
age summary test score for older adults living in the com-
munity has been reported by Newton3 and Hatch et al.26
Reference data by gender and 10-year age cohorts for com-
munity-dwelling seniors has been reported once for the
BBS.25
Sharpened Romberg
This measure of ability to maintain balance during tan-
dem standing, with eyes open and eyes closed,27 has been
shown to have good intra- and inter-rater reliability in
healthy older women7 and good test-retest reliability in
healthy young adults.28 Significant correlations of the SREO
and SREC with other balance tests support concurrent
validity of the Romberg tests.7 Age and SREC were inversely
related in community-dwelling male subjects.29 Mean data
have been reported for community-dwelling males,29
females,30,31 and active or inactive former athletes.32
Activities-specific Balance Confidence Scale
This self-report measure of an individual’s confidence in
performing common mobility tasks33 has been shown to
have good test-retest reliability and internal consistency in
community seniors.33 Correlations between the ABC and
the Dizziness Handicap Inventory support concurrent valid-
ity.34 Myers et al35 found no significant difference between
males and females on ABC scores. In subjects from inde-
pendent senior facilities (n = 287), Kressig et al36 found no
correlation between age and ABC scores. Hatch et al26
reported a mean score for 50 community dwelling older
adults.
Physical Performance Test
The PPT is available in a 9- (PPT-9) or 7-item (PPT-7)
form. Both versions share the same first 7 items. This per-
formance measure of multiple aspects of upper and lower
extremity function37 has been shown to have good inter-
rater reliability and internal consistency in community-
dwelling older adults for the PPT-7 and PPT-937,38 and good
test- retest reliability for the PPT-7 in persons with
Parkinson disease.39 Validity of the PPT-7 has also been
shown through correlations with functional tests.38,40 The
PPT-7 was shown to be negatively correlated with age in
older adults.37 A mean score for the PPT-9 has been reported
for community-dwelling older men.41 Mean values for the
PPT-7 have been reported for community-dwelling seniors42-
44
and for various groups of frail elderly persons.38,39,45-48
Reference data in community-dwelling women by age
cohort on the PPT-7 have been reported.49
Although the literature currently provides some refer-
ence data for these tests of function, it is seldom reported
by age and gender cohorts. Based on literature suggesting
relationships between test scores and age,5,25,29,37 it seems
valuable to provide clinicians with reference data catego-
rized by age. It is also reasonable to expect gender differ-
ences in functional performance, as reported for some func-
182
tional tests not included in this study.50-53 Of the functional
tests examined in this study, the MDRT is the most recently
introduced and has the least amount of literature support-
ing its interpretation.
The purposes of this study were to: (1) provide addi-
tional reference values for clinical tests of balance and
mobility using a sample of independently functioning com-
munity-dwelling adults over age 50; (2) present test perfor-
mance values in age and gender categories; (3) identify
whether age, gender, height, or weight contribute to pre-
diction of test scores.
METHODS
This study was approved by the University Institutional
Review Board. Community-dwelling adults were recruited
via notices in churches, University bulletins, flyers around
the local area, and contacts with local senior centers. Eighty-
three community-dwelling adults between the ages of 50
and 90, volunteered for the study. All volunteers were
screened by telephone for inclusion in the study. Inclusion
criteria included: ability to stand for one minute indepen-
dently, ability to walk 50 feet without sitting to rest, no use
of an assistive device, no heart condition that would limit
activity, and no fainting spells or extended dizziness. These
criteria assured that all subjects would be able to complete
the tests. No volunteer was excluded based on the screen-
ing.All subjects provided informed consent.
Data collection was completed within a 50-minute ses-
sion for each subject. Descriptive data were collected,
including age, height, weight, medical diagnoses, number of
medications used, and number of falls in the past 6 months.
All subjects completed the functional tests in the following
order: ABC Scale, BBS, SREO, SREC, MDRT (forward, right,
left, backwards), and the PPT-9. All subjects were offered
rests and water during the session and completed the 50
minute testing protocol without complaint of fatigue or dis-
comfort. Throughout the data collection period, each test
was administered by the same testers. These testers were
physical therapy students who were experienced in the test
protocols and had completed a pilot study of the tests on 15
subjects prior to initiation of data collection for this study.
MDRT. This test requires the subject to lean maximally
forward, backwards, to the right, and to the left.2 Distance
of the lean was measured as the excursion of the third
metacarpal head from the start to end positions, with the
arm extended forward (or to the side), during the leaning
trials. The subject stood with the heels 10 cm apart and
each foot angled at 15° of out-toeing. For each direction of
the MDRT, 1 practice and 3 recorded trials were performed.
Subjects were instructed to keep feet flat on the floor, raise
the dominant arm to match the height of a yardstick
clamped onto a camera tripod set at acromion height, and
make a fist with the extended hand (Figure 1). Subjects
were instructed to “lean as far forward (…or backwards,
right, left) as possible without lifting your heels or losing
your balance.” The change in the position of the third
183 J ournal of N eurological P hysical T herapy
Figure 1. Multidirectional reach.
metacarpal head along the yardstick was indicated by a
wooden marker that the researcher slid along a level track
as the subject performed each leaning trial. The difference
between the initial and final positions for each attempt was
recorded. Reproducibility of 3 same day trials of the MDRT
was high: ICC (3,1) for forward = 0.94, backwards = 0.96, right
= 0.95, left = 0.90. An average of the 3 recorded trials was
used in data analysis similar to previous research.9
Berg Balance Scale. The BBS includes 14 tasks challeng-
ing body stability.16 The test was administered according to
standard protocol, except for item #8 (forward reach) which
was scored with the first forward reach trial from the MDRT.
Each task is scored on an ordinal scale of 0 to 4, with a max-
imum score of 56 points indicating the best performance.
Sharpened Romberg. This test required that a subject
perform a tandem stand with arms free and the nondomi-
nant foot ahead of the dominant foot for up to 60 sec-
onds.30,31 Up to 3 trials were attempted with eyes open,
then with eyes closed. The test ended when a subject
achieved the 60 second maximum time, opened the eyes
during an eyes closed trial, moved the feet, or needed assis-
tance to prevent a fall. The test was scored as the maximum
seconds achieved during the best trial.
ABC Scale. This 16-item questionnaire asks a subject to
estimate how confident he/she would be in performing 16
common mobility tasks without losing balance.33 Each item
is scored from 0% to 100%, indicating increasing levels of
confidence about each task. A tester read each question
aloud and asked the subject to respond using only incre-
ments of 10% (ie, 0%, 10%, 20%, …100%).
Physical Performance Test.The PPT-9 has 9 items, mea-
suring upper extremity fine motor coordination, balance,
mobility, and endurance.37 Total scores can range from 0 to
Vol. 29 • No. 4 • 2005
36. Another version of the test, PPT-
7, includes only the first 7 items of
the PPT –9, with a total possible
score of 28. For each item a 5-point
ordinal scale (0–4) is used to record
performance, with 0 indicating
“unable to do” and 4 indicating high-
est functioning. Seven of the 9 items
are timed and the time to complete
the task corresponds with an ordinal
scoring category. Scores for both
versions of the PPT were used in
data analysis.
Data Analysis
The data were analyzed using
SPSS for Windows (Version 11.5;
SPSS, Ind., Chicago, Ill). Descriptive
statistics were performed to calcu-
late means, standard deviations, and
95% confidence intervals for each of
the tests by age decades and gender
cohorts. One-way ANOVA and Tukey’s HSD post hoc test
were used to examine differences between the age and gen-
der cohorts on demographic variables. Multiple linear
regression analysis (Enter method) was used to determine
whether the demographic variables (age, gender, height,
weight) were significant predictors of test outcomes. An
independent t-test was used to compare right and left reach
scores in the MDRT. An alpha level of 0.05 was used to
determine significance in all statistical tests. To further char-
acterize the properties of the tests with multiple items on
ordinal scales (BBS,ABC, PPT), Cronbach alphas were calcu-
lated as a measure of internal consistency.
RESULTS
For the total sample, the average age of the subjects was
69 (SD = 11; range = 50-90) years. The average height for
males was 177 cm (SD = 8) and for females was 161 cm (SD
= 6). Subjects reported use of an average of 2 medications
per day (range 0-12) and had a variety of diagnoses includ-
ing: 45% with hypertension; 46% arthritis; 18% heart dis-
ease; 17% history of cancer; and 16% thyroid disorders. One
subject reported falling twice and 12 subjects (15%)
reported falling once in the 6 months prior to the study.
Three participants identified themselves as smokers and 13
of the 83 reported a “bone or joint problem that could be
aggravated by walking.” Table 1 shows mean demographic
characteristics for each age cohort in the sample. One-way
ANOVA between age cohorts showed significant main
effects for height (F = 3.2, p = 0.028), number of diagnoses
(F = 5.2; p = 0.002) and number of daily medications (F =
3.2, p = 0.026).Tukey’s post hoc testing showed that height
was significantly greater for the youngest compared to the
oldest group (p = 0.047), number of diagnoses was signifi-
cantly greater for the oldest compared to the youngest
group (p = 0.001), and showed that number of medications
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy 184

was significantly greater for the 60-69 year olds than the 50-
59 year olds (p = 0.024). There was no significant differ-
ence between age cohorts on weight or number of
reported falls in the previous 6 months.
MDRT. The mean test scores, standard deviations, and
95% confidence intervals by age and gender cohorts for
each direction of the MDRT are shown in Table 2. There
was no significant difference between the mean right and
left reach scores (t = 0.15; p = 0.88). Age was a significant
variable in regression models predicting MDRT scores in
each direction, with increasing age associated with a
decrease in reach scores (Table 3). Height was significant
in the model for predicting backward reach only, with
increasing height associated with increased backward
reach scores.
Berg Balance Scale. Table 4 reports the means, standard
deviations, and 95% confidence intervals for the BBS results
by age and gender cohorts. Internal consistency for the 14-
item BBS, indicated by Cronbach’s alpha, was 0.81. Age, gen-
der, and height were all significant predictor variables for
BBS scores (Table 3). Thirty six percent (30 persons) of the
subjects achieved a maximum score of 56, with only 5 of
these in the oldest two age groups. Only 3 subjects, all over
80 years, scored below the commonly used cutoff of 45 for
predicting fall risk.54
Sharpened Romberg Tests. Means, standard deviations,
and 95% confidence intervals for the SREO and SREC tests
are reported in Table 4. The confidence intervals for both
tests showed a wide range of variability. Age, gender, and
height were significant predictors for SREO scores, whereas
only age and gender were significant predictor variables in
the regression model for SREC (Table 3). A maximum score
of 60 seconds was achieved by 77% of the subjects for the
SREO and by 31% for the SREC. Most subjects achieving the
ceiling score were in the two younger age groups.
ABC Scale. Results from the ABC Scale are summarized
in Table 4 by age and gender cohorts. The internal consis-
tency of the 16-item ABC Scale, based on Cronbach’s alpha,
was high (α = 0.93). Age and weight were significant pre-
dictors of ABC scores (Table 3). The mean ABC score for the
total sample was 91% out of a maximum 100% confidence
in performing the mobility tasks. The mean ABC score for

Table 1. Demographic Characteristics of the Study Sample by Age Cohort

Age Cohort Gender (% female) Height* (cm) Weight* (kg) Number of Falls in Number of
Diagnoses* Prior 6 Months* Medications*
50-59 N = 24 63 171 (11) 82 (17) 1.5 (1.4) .04 (.20) 1.3 (1.2)
60-69 N = 19 53 170 (12) 81 (22) 2.3 (1.8) .11 (.32) 3.0 (2.8)
70-79 N = 24 58 165 (10) 79 (12) 2.5 (1.4) .25 (.44) 2.2 (1.4)
80-89 N = 16 75 162 (10) 73 (22) 3.4 (1.4) .31 (.60) 2.6 (2.1)
*Values presented are means and (standard deviations)

Table 2. Means (X), Standard Deviations (SD), and 95% Confidence Intervals (CI) of the Multi-directional Reach Test by Age and Gender
Cohorts (in centimeters)
Forward (cm) Backward (cm) Right (cm) Left (cm)
Age (yrs) Gender N X SD CI X SD CI X SD CI X SD CI
50-59 Male 9 37 6 32-41 28 6 24-32 22 4 19-25 22 4 19-26
Female 15 32 6 28-35 20 6 16-23 18 4 16-20 18 4 16-20
60-69 Male 9 30 5 27-34 25 9 17-32 20 3 19-23 19 3 17-21
Female 10 30 5 24-30 20 8 14-25 15 5 13-18 17 5 13-20
70-79 Male 10 29 5 26-32 19 7 14-24 17 4 15-19 18 4 15-21
Female 14 29 7 25-33 15 7 11-19 16 7 12-19 15 7 11-19
80+ Male 4 27 9 13-40 16 4 9-23 16 7 8-23 17 7 6-28
Female 12 22 6 18-26 11 4 8-13 13 3 11-15 12 3 10-14
Total Sample 83 29 7 28-29 19 8 17-20 17 5 16-18 17 5 16-18

Table 3. Multiple linear regression results (standardized coefficients & significance) for the Multidirection Reach (MDRT), Berg Balance Scale
(BBS), Sharpened Romberg-Eyes Open (SREO), Sharpened Romberg-Eyes Closed (SREC), Activities Specific Balance Confidence Scale (ABC), and
Physical Performance Tests (PPT-7 & 9).
MDRT
Forward Backward Right Left BBS SREO SREC ABC PPT-7 PPT-9
R2 .31 .52 .35 .31 .38 .35 .26 .22 .38 .40
Age -.39a -.31a -.36a -.32b -.64a -.58a -.54a -.35b -.58a -.61a
Gender .00 .11 -.14 -.18 -.42b -.51a -.33c -.23 .04 .01
Height .27 .70a .28 .18 -.33c -.35c -.28 -.10 .07 .07
Weight .04 -.18 .01 .07 .02 -.01 -.02 -.24c .05 .01
a
p<.001
b
p<.01
c
p<.05
185 J ournal of N eurological P hysical T herapy Vol. 29 • No. 4 • 2005

Table 4. Means (X), Standard Deviations (SD), and 95% Confidence Intervals (CI) of test results for the Berg Balance Scale (BBS), Sharpened
Romberg-Eyes Open (SREO), Sharpened Romberg-Eyes Closed (SREC), Activities Specific Balance Confidence Scale (ABC), and Physical
Performance Tests (PPT-7 & 9) by Age and Gender Cohorts
Total BBS Total SREO (sec) Total SREC (sec) Total ABC (%) Total PPT-7 Total PPT-9
Age Gender N X SD CI X SD CI X SD CI X SD CI X SD CI X SD CI
50-59 Male 9 56 0 56-56 60 0 60-60 51 18 37-60 93 7 88-98 24 2 23-25 31 2 30-33
Female 15 55 1 55-56 56 15 48-64 37 22 24-49 95 5 92-98 24 1 24-25 32 1 31-33
60-69 Male 9 55 1 54-56 60 0 60-60 32 26 12-52 96 6 92-100 24 2 22-25 31 2 29-33
Female 10 55 2 54-56 60 0 60-60 42 23 26-59 93 5 89-96 23 1 22-23 31 1 30-31
70-79 Male 10 53 2 52-55 54 17 42-60 26 20 12-40 96 4 93-98 22 2 20-24 29 2 27-31
Female 14 52 4 50-54 44 24 30-58 23 21 11-35 86 15 77-95 22 2 20-23 29 2 27-30
80+ Male 4 52 5 45-59 48 24 9-60 20 25 0-60 91 13 71-100 20 1 18-22 27 2 25-30
Female 12 48 7 44-53 19 20 7-32 5 6 1-9 82 16 72-92 20 3 19-23 27 3 25-30
Total Sample 83 53 4 52-54 49 21 45-54 29 24 24-35 91 11 89-93 22 2 22-23 30 3 29-30

males was 94% and for females was 89%.Ten percent of the
subjects reached the ceiling of 100% on this test, with all
age groups similarly represented in this distribution.
Physical Performance Tests. Results of both the PPT-7
and PPT-9 are reported by age and gender cohorts in Table
4. Internal consistency, as measured by Cronbach’s alpha,
was 0.70 for the PPT-7 and 0.75 for the PPT-9. Age was the
only significant variable in the regression models predicting
PPT-7 or PPT-9 scores (Table 3). No subject achieved the
ceiling score for either version of this test. Only one sub-
ject scored at the cut off of 15 used for identifying fallers.55
DISCUSSION
For all of the functional tests in this study, age was a sig-
nificant predictor variable for test outcome scores. This find-
ing is supportive of the practice of providing reference data
in age cohorts so that individual patient results can be com-
pared to age-appropriate group data. Gender, height, and
weight were not consistently significant predictors of test
scores. Because the men in our sample were, on average,
taller than the women, one might expect that gender and
height would have similar predictive influence on test
scores. In most, but not all, cases, these 2 variables were the
same in their predictive significance or lack of significance.
Gender and height were both significant predictors for BBS
and SREO scores. Conversely, neither gender nor height was
a significant predictor for scores on the MDRT (forward,
right, left), the ABC, or the PPT. Hypothesizing that height
and position of the center of mass are the salient features dif-
ferentiating males and females, it may be that these features
provided additional challenges to taller persons (males) dur-
ing the varied static balance tasks of the BBS and SREO. It is
not clear, however, why such a hypothesis about height/gen-
der doesn’t hold for the static balance tasks of the MDRT.
Further studies and larger sample sizes are needed to con-
firm or refute these findings on gender and height.
MDRT. Of the tests studied here, the MDRT was most
recently introduced into the literature, with Newton2,3 pro-
viding the first data. The test is a logical expansion of the
Forward Functional Reach test developed by Duncan et al9
and was designed to provide a clinical measure of a per-
son’s margins of stability. We found that repeated measures
of the components of the MDRT within the same day were
highly reproducible, as has been reported for the Forward
Functional Reach test.9 Compared to Duncan’s forward
reach data in men, our male subjects had slightly lower
scores. In her subjects under 70 years, this may be
explained by her inclusion of subjects, age 41-50 years. The
slight differences may also be due to test positions. Duncan
had subjects stand comfortably while we used a predeter-
mined foot position. In Newton’s original study2 the sub-
jects’mean age was 74 (SD = 8) while in this study mean age
was slightly younger (69 years, SD = 11).The age differences
in the 2 studies may explain why the mean forward and
backwards reaches are higher in our study (29 ± 7 cm and
19 ± 8 cm, respectively) than in Newton’s sample (23 ± 8
cm [8.9 ± 3.3 inches] and 12 ± 8 cm [4.6 ± 3.0 inches],
respectively). There also could be the factor that our sub-
jects were taller on average. However, regression analysis
showed height as a significant variable only for predicting
backward reach, not forward. Any biomechanical hypothe-
sis related to size of base of support or position of the cen-
ter of mass in tall versus short persons should seem to apply
to both forward and backward reaches similarly. Both tall
and short persons have a longer lever arm for forward reach
than for backward reach. However, perhaps there is an
interaction between lever length and base of support that
influences backward, but not forward, reach.The mean val-
ues of the lateral reaches between the two studies are
within 0.4 cm. Our study, as in previous studies, demon-
strated no significant differences between the right and left
reaches,3-5 suggesting that asymmetries in the lateral reaches
for a given client are an abnormal finding.
Berg Balance Scale. Our current study confirmed pre-
vious findings of Steffen et al25 on the BBS for each of 3 age
cohorts (60-69, 70-79, and 80+ years). In contrast, Newton3
and Hatch et al26 found slightly lower average BBS scores in
slightly older samples of community-dwelling adults. We
found it interesting that only 36% of our essentially nondis-
abled or high functioning sample achieved a maximum
score on the BBS. Clinicians performing fall risk screenings
in community populations of older adults need to be cau-
tious in making assumptions that a perfect score is to be
expected in these age groups.
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
Sharpened Romberg. Briggs et al31 reported SREO and
SREC scores in 5 year age cohorts for community-dwelling
females (mean age = 72). Although their total mean scores
were the same as ours, their average scores for subjects in
the 80-85 year cohort were substantially higher (SREO = 45
seconds, SD = 21; SREC = 23 seconds, SD = 21) than ours.
Perhaps this difference was due to the strict exclusion in
their study of participants with neurologic disorders and
some musculoskeletal disorders. Our mixed-gender SREO of
49 seconds falls between that of Heitmann et al30 who
reported a mean score of 37 seconds (SD = 27) for females
(mean age = 74) and Iverson et al29 who reported a mean
score of 55 seconds (SD = 15) for males (mean age = 71).
For SREO, some subjects in all age cohorts achieved a max-
imum score of 60 seconds. No subjects in the oldest age
group achieved a maximum score on the SREC. Scores
showed much more variability for the SREC, across all age
groups, than for the SREO. Also, the ceiling effect for the
SREC occurred much less frequently than for the SREO or
the Berg. Thus the SREC may detect minimal impairments
in balance better than these other two tests.
ABC. Of those reporting reference data for the ABC, our
study had subjects with the lowest mean age and the high-
est average score. In a similar but older community-
dwelling sample (average age = 82), Hatch et al26 reported a
lower mean score (79%, SD = 19). Kressig et al36 found a
lower average score of 52% (SD = 20) in their sample of
seniors in independent living facilities (mean age = 81).
Comparisons of these studies appear to reinforce the find-
ing of a relationship between age and ABC test score. It is
of interest that even subjects in our youngest age cohort did
not all report 100% confidence in balance.
PPT. The values on the PPT-7 are similar to those
reported by Puggaard49 in 3 age groups of community-
dwelling older adults. Other reports of average PPT-7 scores
in community-dwelling seniors are also similar to ours,42,43
although samples in these other studies were slightly older
than ours on average. Our average data on the PPT-9 are
also similar to the only other reported values in a study of
men (mean age = 76 years).41 Interestingly, none of our sub-
jects reached the ceiling on these tests, although Brach et
al43 found that 7% of their subjects did so on the PPT-7.
Although our data are intended to expand available ref-
erence data, this use of the data is limited by the relatively
small number of subjects in each age and gender category,
especially for subjects over 80. In particular, cautious inter-
pretation is required when the sample size is small and con-
fidence intervals are large, as is the case for males over 80
on all tests. More studies with diversity in subject ethnicity
and with larger sample sizes, especially for the oldest age
groups, are needed. Although none of the participants
reported fatigue during the study, future studies should ran-
domize the order of the tests.
In summary, this study provides age- and gender-related
values for the performance of older adults on tests of func-
tional balance and mobility. These data can be used by clin-
186
icians in interpreting test results of clients. A relationship
between increased age and decline in test performance has
been demonstrated. Additional research would be benefi-
cial to determine if using all 4 directions of the MDRT pro-
vides more valuable information about balance ability and
fall risk than just the Forward Functional Reach alone.
Further research is also needed to establish larger databases
of reference values on all functional tests and to establish
the validity of the MDRT for predicting likely direction of
potential falls, so that treatment can focus on each client’s
direction-specific deficits of stability.
ACKNOWLEDGEMENTS
A special thank you to Jill Kison, Sarah Lindau,Al Meives,
and Zachary Sommermeyer who assisted with data collec-
tion while they were physical therapy students at
Concordia University Wisconsin and Lina La Licata for cler-
ical support.
Dr Steffen provided concept/research design, project
management, fund procurement, subject recruitment, facili-
ties/equipment, data analysis, and writing. Ms Mollinger pro-
vided consultation and writing.
This study was approved by the Institutional Review
Board of Concordia University Wisconsin and was sup-
ported by the Program in Physical Therapy, Concordia
University Wisconsin.
The main findings were presented as a poster presenta-
tion at the Wisconsin Physical Therapy Association
Conference 2002 and the 14th International WCPT
Congress, Barcelona, Spain 2003.
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189 J ournal of N eurological P hysical T herapy
Platforms, Thematic Posters, & Posters for CSM 2006
PLATFORMS: Biomechanics and Motor Control
Saturday 8:00-11:00 am
HETERONYMOUS REFLEXES IN THE PRIMARY AGONIST ARE
ENHANCED WHEN SUPPORTING AN INERTIAL LOAD. K.S. Maluf1,
Z.A. Riley2, M.K.Anderson2, B.K. Barry2, S.S.Aidoor2, R.M. Enoka2, 1Graduate
Program in Physical Therapy and Rehabilitation Science, University of
Iowa, Iowa City, IA, 2Department of Integrative Physiology, University of
Colorado, Boulder, CO.
Purpose/Hypothesis: Previous studies indicate that stretch reflexes in
the human upper limb are influenced by the stability of the load sup-
ported during an isometric contraction. Our purpose was to assess
whether changes in the sensitivity of spinal motor neurons to afferent
feedback from accessory muscles contribute to reflex modulation when
supporting an inertial load compared with exerting an equivalent force
with the limb restrained. Number of Subjects: 13 healthy adults (aged 18-
47 years, 9 men) participated in the study. Materials/Methods:
Heteronymous reflexes were evoked in the first dorsal interosseus (ago-
nist) and second palmar interosseus (antagonist) muscles by stimulating
the median nerve at the wrist (1 ms pulse width; 3-5 s inter-stimulus inter-
val) as subjects performed two motor tasks with the index finger. One task
required subjects to exert a constant isometric force by pushing up against
a rigid restraint, whereas the other task required subjects to maintain a
constant angle at the metacarpophalangeal joint while supporting an iner-
tial load suspended from the finger. Net torque (20% of maximum), the
position of the index finger (0 degrees abduction), and the intensity of
peripheral nerve stimulation were the same for both tasks. Twenty-four
reflex responses were recorded in each muscle using surface or intramus-
cular electrodes, and the averaged EMG records were compared using a 2-
factor ANOVA for repeated measures. Results: Heteronymous reflex
responses were observed in 10/13 subjects (77%) for the first dorsal
interosseus, but only 2/11 subjects (18%) in the second palmar interosseus.
Despite similar tonic EMG of the agonist and antagonist muscles across
tasks (P = 0.27), peak amplitudes of the short-latency (SL 28.6 ± 5.6 ms)
and long-latency (LL 52.2 ± 3.5 ms) reflexes in the first dorsal interosseus
were greater when subjects supported the inertial load (SL = 0.45 ± 0.19
vs. 0.57 ± 0.28 mV; LL = 0.32 ± 0.11 vs. 0.41 ± 0.19 mV; main effect of task
P = 0.02). Conclusions: Agonist motor neurons exhibit heightened sen-
sitivity to afferent feedback from median-innervated accessory muscles
when controlling the position of an inertial load. Clinical Relevance:
Findings indicate that the type of load used in strength and endurance
training programs can influence the response of the primary agonist to
concurrent activity of accessory musculature.
VIBRATION OF THE BICEPS BRACHII TENDON REDUCES TIME TO
FAILURE WHEN MAINTAINING LIMB POSITION DURING A FATIGU-
ING CONTRACTION. C Mottram, KS Maluf, MK Anderson, JL Stephenson,
RM Enoka, Integrative Physiology, University of Colorado, Boulder , CO.
Purpose/Hypothesis: Vibration reduces the tendon jerk, and the
Hoffmann and stretch reflexes in the muscle exposed to the vibration
(Bove et al, 2003; Cresswell and Ludieroscher et al, 2000; Lance et al, 1966),
but does not alter the time to task failure when exerting a submaximal
force against a rigid restraint (Cresswell and Ludieroscher 2000). Because
the amplitude of the stretch reflex can be enhanced when the limb acts
against a compliant load compared with a rigid restraint (Akazawa et al.
1983; De Serres et al. 2002), the purpose was to determine the influence
of tendon vibration on the time to task failure when light loads were sup-
ported while maintaining limb position (position task) with the elbow
flexor muscles. Number of Subjects:Twenty-five healthy adult men (22
± 4 yr; range, 18 - 39 yr) performed the position task at 20% MVC force by
maintaining a 90º elbow position until task failure. Materials/Methods:
Subjects visited the laboratory for three sessions to perform the position
task with two different levels of vibration (100 Hz, 2.5 N force, sub-thresh-
old and supra-threshold for the tonic vibration reflex), and without vibra-
tion of the biceps brachii tendon. Results: MVC force prior to task perfor-
Vol. 29 • No. 4 • 2005
mance was similar across the three sessions (313 ± 54 N, P = 0.83), indi-
cating that the net torque exerted by the limb during the fatiguing con-
tractions was similar.The EMG for the short and long heads of the biceps
brachii, brachioradialis, and brachialis was similar across conditions (P >
0.05). Despite the similar criteria for task failure and a similar decline in
MVC force (18.0 ± 8.0 %, P > 0.05), the time to task failure differed for each
condition: supra-threshold vibration = 3.7 ± 1.4 min, sub-threshold vibra-
tion = 4.3 ± 2.1 min, and no-vibration conditions = 5.0 ±2.2 min (P < 0
.001).The standard deviation (SD) for the vertical fluctuations in accelera-
tion was greater at the start (0.27 ± 0.13 m/s2) and at 25% of task duration
(0.28 ± 0.15 m/s2) for the supra-threshold condition compared with the
no-vibration (0.13 ± 0.06 and 0.16 ± 0.09 m/s2; P = 0.03) condition, but was
similar at task termination (0.83 ± 0.50 m/s2) for the three conditions.
Conclusions: These findings indicate that both low and high levels of
vibration applied to the biceps brachii tendon reduced the time to failure
when maintaining limb position, which has implications for work-place
activities. Clinical Relevance: Documenting evidence for early fatigue
during tasks performed with prolonged vibration confirms the importance
of afferent input during sustained tasks, and has implications for work and
ergonomic environments.
CUTANEOUS CUING DECREASES REACTION TIMES FOR STEP INITI-
ATION. CG Kukulka, E Olson, A Peters, K Podratz, C Quade, Phys Med &
Rehab, University of Minnesota, Minneapolis, MN.
Purpose/Hypothesis:The purpose of this study was to assess the effect of
visual and sural nerve stimulation cuing on reaction times to step initiation
(SI) in young, healthy subjects. We hypothesized that these times would
decrease with a cutaneous go cue as compared to a visual cue. Number of
Subjects:Thirteen subjects, 9 women and 4 men between the ages of 23 and
30 years (mean = 23 yrs), participated in the study. Materials/Methods:
EMG was recorded from tibialis anterior (TA) of the right stepping leg.The
sural nerve was stimulated with a train of 300/s, 1 ms pulses delivered for 20
ms at an intensity of 1.5 radiating threshold. Subjects stood with their right
leg on a force platform with weight equally distributed and were instructed
to take three steps as fast as possible. A warning visual cue was first deliv-
ered followed at random intervals (1-3 s) by either a visual go cue or the
sural stimulation cue. Twenty repetitions for SI were randomized by cue.
After a 5 min rest, 20 additional steps were obtained. SI is characterized by
an abrupt loading of the stepping limb and this loading was used to deter-
mine 3 response times relative to the go signal (load onset, peak load, and
load offset). The onset time of TA onset relative to the go signal was also
determined.Two way ANOVAs (p<.05) were used to evaluate the interaction
effect of trial versus cue and the main effects of trial and cue. Results: No
statistically significant interactions were found for any of the loading times
and the main effect of trail was also not statistically significant. Significant
differences were found between visual and cutaneous cue for all loading
times. Time to load onset decreased on average from 254.2 ms with the
visual cue to 186.5 ms with the sural cue.Time to peak loading decreased
on average from 482.7 to 391.7 ms and time to unloading decreased from
688.1 to 610.9 ms. TA onset was found to decrease from 194.6 ms (visual
cue) to 131.5 ms (cutaneous cue). Conclusions:The results of these exper-
iments indicate that reaction times to a cutaneous cue are significantly
shortened for SI in healthy subjects.These findings raise two important neu-
rophysiological questions. Could a cutaneous cue be priming the motor cor-
tex via a cortical pathway (Christensen et al, Prog Neurobiol 62:251, 2000)
to heighten cortical excitability thereby resulting in a faster reaction.
Alternatively, could the cutaneous cue be acting as a startle (Valla-Sole, et al,
J Physiol 516:931, 1999) to release the stepping response via subcortical
structures. The latter possibility is currently being investigated in our labo-
ratory. Clinical Relevance: Previous experiments have shown that reaction
time is a strong predictor of falls in the elderly and that a sural go cue can
increase center of pressure changes during SI in both young and elderly sub-
jects.The current results therefore raise the possibility that a cutaneous cue
might be used to decrease reaction times and positively alter ground reac-
tion forces in elderly subjects who fall. It will be necessary to first replicate
the current findings in the elderly.
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
INFLUENCE OF AGE ON NEUROMUSCULAR CONTROL OF THE
KNEE. S Madhavan, S Burkart, G Carpenter, K Read, T Teckenburg, M
Zwanziger, R Shields, Graduate Program in Physical Therapy and
Rehabilitation Science, University of Iowa, Iowa City, IA.
Purpose/Hypothesis: An increased incidence of injury has made neuro-
muscular control of the knee joint a focus of attention in motor control
research. The central nervous system (CNS) controls the knee against
unpredictable perturbations that occur during movement. Age associated
changes in the musculoskeletal, neuromuscular and sensory systems com-
promise the ability of the elderly to respond effectively to a perturbation,
thereby placing the older population at a higher risk of injury.Weight bear-
ing exercises have been primarily used to re-educate neuromuscular con-
trol of the knee following pathology. Limited information is available on
the strategies used by the elderly to control the knee during dynamic activ-
ities.This study examined the effect of age on the neuromuscular control
of the knee by examining accuracy of performance, muscle synergies and
long latency reflexes (LLR) during a functional weight bearing exercise.We
hypothesized that the elderly would show greater impairment in neuro-
muscular control than the young. Number of Subjects:Ten young and ten
elderly subjects performed a single leg squat exercise (SLS) while tracking
a sinusoidal target with knee motion at different levels of resistances (4%,
8% and 12% body weight). Materials/Methods: Subjects first performed a
set of learning trials to gain proficiency with the task. Later, they performed
the SLSs with random perturbations (drop in resistance level to 0% BW)
during the knee flexion phase.A split plot repeated measures ANOVA was
used to assess between and within group differences in movement accu-
racy, synergistic activation patterns (EMG), and long latency reflexes.
Results:The elderly group 1) had a 50% greater absolute error in tracking
the target angle when compared to the younger group (p<0.05); 2)
showed a 60% greater activation of the quadriceps and hamstrings at all
levels of resistances as compared to the younger group (p<0.05); and
showed 15% greater LLR for the quadriceps and biceps femoris when com-
pared to the younger group (p <0.05). Conclusions:These results indicate
that the elderly recruit higher percentages of MVC and have greater error
when performing the SLS weight bearing exercise. Clinical Relevance:
Age associated changes of the sensorimotor system necessitates greater
muscle activity to help stabilize the knee in the elderly.These findings pro-
vide important clinical implications when developing rehabilitation pro-
grams for the young and elderly.
DE-COUPLING GAIT PARAMETERS TO INVESTIGATE THE CONTRI-
BUTION OF STEP LENGTH TO FALL RISK. D Espy,Y Pai, F Yang, J Sun,
Physical Therapy (M/C 898), University of Illinois at Chicago, Chicago, IL.
Purpose/Hypothesis: Background and Purpose. It is generally accepted
that, as people age, their gait becomes slower and of shorter step-length
and that both improve stability against balance threats. Recent studies have
suggested that a faster gait velocity may provide more stability against a
slip induced backward loss of balance than the benefit gained by shorter
step-lengths. Since they are tightly coupled, the individual contributions of
step-length and gait velocity to stability are unknown.The purpose of this
study was to pioneer a gait training approach that enables us to de-couple
this relationship. Number of Subjects: Thirty-five. Materials/Methods:
Subjects and Methods.Thirty-five healthy, young adults participated in this
randomized, experimental comparison study. Subjects were slipped unex-
pectedly while walking on a walkway at one target gait velocity and either
a short or a long target step-length. Motion and force data were used to cat-
egorize each first slip as a fall or non-fall. Results: Four of the 19 subjects
in the long step-length group, but none of the 16 in the short step-length
group, fell upon the first unexpected slip (chi2 3.803; p = .05).
Conclusions: Discussion and Conclusion. De-coupling of the gait parame-
ters was successful; at gaits of similar velocity, the subjects taking shorter
step-lengths were less likely to fall upon initial slip than those with longer
step lengths. Clinical Relevance: Understanding the individual contribu-
tions to stability of both gait speed and step length will allow Physical
Therapists to refine gait training recommendations to enhance stability.
INFLUENCE OF HAMSTRING LOW FREQUENCY FATIGUE ON NEU-
ROMUSCULAR CONTROL OF THE KNEE DURING WEIGHT BEARING
190
EXERCISE. M. Iguchi,A. Ganju, B. Ballantyne, R. Shields, Graduate Program
in Physical Therapy and Rehabilitation Science, University of Iowa, Iowa
City, IA.
Purpose/Hypothesis: Muscle fatigue may be a predisposing factor to
injury during athletic competition. Low frequency fatigue (LFF), which is
due to long duration exercise, is most characteristic of the type of fatigue
induced during sports activities. Altered neuromuscular control as a result
of LFF may increase the risk of injury to the knee.The purposes of this study
were to examine the extent to which LFF could be induced in the ham-
string muscles and test whether LFF altered the neuromuscular control of
the knee during a single limb weight bearing exercise. We hypothesized
that LFF of the hamstrings alters the neuromuscular control of the knee
during weight bearing exercise. Number of Subjects: 10 healthy male sub-
jects performed a fatigue protocol consisting of repetitive eccentric con-
tractions of the left hamstring muscles using an isokinetic dynamometer.
Materials/Methods: The work/rest velocity of 13º/sec-1 / 7º/sec-1 respec-
tively, over an arc of movement from 30º -70º flexion (0º = full extension)
was administered until the subject was fatigued. The fatigue protocol was
terminated when the peak torque decreased 25% from the largest value of
the three pre-fatigue eccentric MVCs. Hamstring peak twitch torques were
obtained by double pulse stimulation at 40 Hz followed by a train of four
pulse stimulation at 166 Hz.The twitch torques were calculated pre-fatigue,
immediately post fatigue and then at 5, 10, 15 and 20 minutes into recov-
ery.The ratio of the twitch torque at 166 Hz to 40 Hz was calculated and
averaged. Before and after the fatigue protocol, a subgroup of subjects per-
formed a lateral step down weight bearing exercise to a predetermined tar-
get on a custom built device designed to assess neuromuscular control of
the knee. Absolute error to knee movement (accuracy), EMG synergistic
activation patterns (quad/hamstring ratio), and triggered long latency
reflexes were assessed.A Split Plot Repeated Measures Analysis of Variance
was used to compare within and between groups. Results: The average
number of eccentric contractions performed before the torque decreased
to 75% of the pre-fatigue value was 35 ±9.3. Immediately after the fatigue
task, the ratio increased, on average, by 15.6% ±7.3 of its pre-fatigue value
(p < 0.05), and stayed elevated at 20 min post fatigue (12.4% ± 4.9). The
eccentric contraction torque immediately after fatigue was 69.9% ± 6.0 and
remained depressed at 20 min post fatigue (80.1% ± 9.0). Absolute error
during the weight bearing exercise was increased 50%; the quadriceps to
hamstring ratio was unchanged; and the biceps femoris and vastus medialis
long latency response was increased 20% after fatigue. Conclusions: We
conclude that LFF can be induced in the hamstring muscles using repetitive
eccentric contractions and that this fatigue alters the neuromuscular con-
trol of the knee during weight bearing exercise. Clinical Relevance:These
findings have important clinical implications for the prevention and reha-
bilitation of injuries in individuals involved in athletic competition.
Funding: NIH R01HD39445.
CHANGES IN SELF-PERCEPTION OF TURNING FOLLOWING ROTAT-
ING TREADMILL STIMULATION. G Earhart1, S Wang1, M Hong1, E
Stevens2, 1Program in Physical Therapy, Washington University School of
Medicine, St. Louis, MO, 2Biology Department,Washington University in St.
Louis, St. Louis, MO.
Purpose/Hypothesis: The purpose of this work was to determine
whether rotating treadmill stimulation, which has been shown to cause
unintentional turning during attempts to step in place, would also cause
changes in behavior when subjects knowingly turn in place.We hypothe-
sized that, following stepping on a rotating treadmill, 1) subjects asked to
actively turn in place would overshoot their targets when turning in the
direction opposite treadmill rotation and undershoot their targets when
turning in the other direction and 2) there would be no change in per-
ception of passive whole body turning. Number of Subjects:We tested 10
healthy control subjects. Materials/Methods: Subjects wore a blindfold
and earplugs and completed trials of active and passive turning in place.
For active conditions, subjects were told the direction and amplitude of
the desired turn and then attempted to turn in place the specified amount
(e.g. ‘turn 90 degrees to your left’). For passive conditions, subjects were
told that the disc they stood on would turn and they were to press a but-
ton when they perceived that they had traveled the specified amplitude
191 J ournal of N eurological P hysical T herapy
(e.g.‘the disc will turn to your left, press the button when you think you
have gone 90 degrees’). Subjects completed active and passive trials to the
left and right with amplitudes of 90, 180, 270, and 360 degrees for a total
of 16 trials. Subjects then stepped in place for 15 min on a disc rotating
clockwise at 90º /s. Subjects then repeated the 16 trials of active and pas-
sive turning. All trials were presented in random order and the order was
different for each subject. We recorded the total excursion that subjects
went through during active trials and the excursion from start position to
the time of button press in passive trials.These excursions were compared
within each condition (e.g. 90 degrees left active) for pre- vs. post-treadmill
stimulation using paired t-tests (p<.05). Results: Subjects asked to turn in
the direction opposite disc rotation (i.e., to the left) consistently and sig-
nificantly overshot their targets in the active trials.There were no changes
in the accuracy of active turning to the right or passive turning in either
direction. Conclusions: Adaptation to the rotating disc is expressed even
when subjects have a conscious intent to turn.The positive after-effects of
the rotating disc appear to add to the intended active turning in the direc-
tion of the after-effect, increasing the amplitude of the turn. There is no
negative interaction of after-effects with intended turning in the opposite
direction. Clinical Relevance:This demonstration that rotating disc after-
effects are still expressed even when there is conscious intent to turn sug-
gests that rotating disc stimulation may be useful in the treatment of turn-
ing difficulties experienced by individuals with Parkinson disease. Subjects
who have difficulty turning in one direction more than the other may ben-
efit from this intervention, which could enhance turning in one direction
while not reducing turning in the other direction.
RELATIONSHIP BETWEEN CHANGES IN MUSCLE SIZE FOLLOWING
12 WEEKS OF NMES INDUCED RESISTANCE TRAINING USING MRI
AND FIBER SPECIFIC ANALYSES IN PERSONS WITH COMPLETE
SPINAL CORD INJURY. A. Jayaraman1, K. Vandenborne1, E.M. Mahoney2,
G.A. Dudley2, C.M. Gregory3, S.C. Bickel4, 1Physical Therapy, University of
Florida, Gainesville, FL, 2Kinesiology, University of Georgia,Athens, GA, 3VA
RR&D Brain Rehabilitation Research Center, 3Malcom Randall VA Medical
Center, Gainesville, FL, 4Physical Therapy, Louisiana State University, New
Orleans, LA.
Purpose/Hypothesis: Chronic spinal cord injury (SCI) results in extreme
atrophy of skeletal muscle below the level of lesion. We previously
reported substantial muscle hypertrophy measured via magnetic reso-
nance imaging (MRI) resulting from a neuromuscular electrical stimulation
(NMES) induced resistance training program (RT).The purpose of this fol-
low-up study was to determine the relationship between changes in mus-
cle cross-sectional area (CSA) via magnetic resonance imaging (MRI) and
fiber CSA measured using in-vitro histochemical techniques after 12 weeks
of NMES-induced RT in subjects with chronic complete SCI. Number of
Subjects: Three men (35.6 ± 4.9 yrs, 76.6 ± 21.5kg) with chronic
(13.±6.5yrs post-injury) complete SCI (ASIA A, C5-T10) participated in this
study. Materials/Methods: Subjects performed four sets of ten NMES-
induced knee extensions, two days per week for 12 weeks with resistance
progressively increased over the training period. Percutaneous skeletal
muscle biopsies from the m. vastus lateralis and MR images of the thigh
were obtained from each subject both pre- and post- resistance training.
Histological staining of individual fibers in muscle cross-sections was per-
formed and fiber specific CSA was determined using computerized
planimetry (NIH Scion Image Program (Version 4.0.2). Transaxial MR
Images of the thighs were collected with a 1.5-T magnet (TR=500ms;
TE=14ms; FOV=20cm; encoding matrix=256x256; 1cm slice thickness sep-
arated by 0.5cm) from the hip joint to the knee joint using the whole body
coil. Linear regression analysis was used to determine the relationship
between changes in whole muscle CSA and changes in individual fiber
CSA. Dependent samples t-tests were used to assess for differences in fiber
area pre- and post-NMES training. Significance was set at p ≤ 0.05. Results:
Changes in muscle CSA explained 99.5% of the variance in fiber hypertro-
phy following NMES induced RT (y = 2.215x - 0.0128; R2 = 0.9956). In addi-
tion, following RT, average muscle fiber CSA increased from (2807 ±
327cm2) at baseline to (4581 ± 510cm2) after training (p ≤ 0.05).
Conclusions:The main finding of this study was that 12 weeks of NMES-
induced RT elicited substantial hypertrophy in individual muscle fibers in
subjects with complete SCI. In addition, the relationship between these
Vol. 29 • No. 4 • 2005
changes and improvements in whole muscle CSA via MRI were extremely
strong. Clinical Relevance: These data provide further evidence of the
responsiveness of skeletal muscle to RT in the SCI population as well as
support the use of NMES as a training modality capable of eliciting sub-
stantial hypertrophy in human skeletal muscle.
PERIPHERAL QUANTITATIVE COMPUTERIZED TOMOGRAPHY
(PQCT): MEASUREMENT SENSITIVITY IN INDIVIDUALS WITH AND
WITHOUT SPINAL CORD INJURY. S. Dudley-Javoroski,T. Corey, D. Fog,
K. Hanish, J. Ruen, R. Shields, Graduate Program in Physical Therapy and
Rehabilitation Science, University of Iowa, Iowa City, IA.
Purpose/Hypothesis: Individuals with spinal cord injury (SCI) experi-
ence rapid trabecular bone loss within the first year after their injury.The
distal tibia is a common fracture site after SCI; however, at this site the stan-
dard bone density measurement method, Dual Energy X-ray
Absorptiometry (DEXA), has significant limitations. Peripheral quantitative
computerized tomography (pQCT) holds much promise, but the sensitiv-
ity associated with repeated scans has not been established for the distal
tibia. The purposes of this study were to: 1) establish the between and
within tester error in measuring tibia length as needed during pQCT analy-
sis; 2) determine the error in distal tibia trabecular bone density when mea-
suring three different scan sites in individuals with and without SCI; and 3)
determine the magnitude of distal tibia bone loss as a result of SCI.
Number of Subjects: Repeated tibia length measurements were taken
from 8 able-bodied subjects using a newly developed operationally defined
protocol. Bone analysis (pQCT) was performed on 7 male subjects with
SCI and 7 age-matched male able-bodied subjects. Materials/Methods:An
investigator marked the distal tip of the medial malleolus and the proximal
margin of the tibial plateau in order to obtain tibia length. Subjects in the
two scan groups underwent pQCT analysis at 3 sites along the distal tibia
(4% of total length, ±3mm). Three subjects in the SCI group were con-
currently enrolled in electrical stimulation training of the soleus. Results:
Results revealed no significant difference between average repeated tibia
length measurements (p=0.94). Absolute inter-rater error for tibia length
was 0.61 cm with an r2 = 0.94.An ICC (1, k) showed that there was strong
intra-tester agreement (0.94).Average change in bone density across 3 mm
for individuals with SCI was 3.77%. Individuals with SCI had 50.6% less tra-
becular bone density than the able-bodied group (p<0.0001). Interestingly,
there was a 26.7% increase in bone density in the subset of SCI subjects
who trained their extremities (p<0.05). Conclusions:We conclude: 1) that
the error in measuring limb length is a minor contributor to repeated
pQCT measurement analysis; 2) the effect of SCI on bone loss at the distal
tibia can be readily measured using pQCT, and; 3) pQCT may detect effects
of early electrical stimulation training in individuals with SCI. Clinical
Relevance:A sensitive method to measure bone properties is important as
physical therapists strive to develop new technologies to prevent the dele-
terious effects of bone loss after SCI.
Funding: NIH R01HD39445, the Christopher Reeve Paralysis Foundation,
and the Foundation for Physical Therapy.
CHANGES IN SOLEUS MUSCLE FORCE AND FATIGUE AFTER SPINAL
CORD INJURY WITH TREADMILL LOCOMOTOR TRAINING IN RATS.
JE Stevens1,WA O’Steen1, DK Anderson1, M Liu2, K Vandenborne2, P Bose3, FJ
Thompson3, 1Malcom Randall VA Medical Center, Gainesville, FL,
2
Department of Physical Therapy, University of Florida, Gainesville, FL,
3
Department of Neuroscience, University of Florida, Gainesville, FL.
Purpose/Hypothesis: Currently, a major therapeutic problem centers
around several issues related to profound atrophy of the primary locomo-
tor skeletal muscles following spinal cord injury (SCI).The purpose of this
study was to further study the influence of SCI on skeletal muscle atrophy
and to evaluate therapeutic influence of early treadmill locomotor training
on soleus muscle force and fatigability following spinal cord injury in rats.
Our hypothesis was that locomotor training would attenuate some of the
functional changes in muscle seen early after injury by improving muscle
force and decreasing muscle fatigue. Number of Subjects: Twenty four
adult Sprague Dawley rats (female, 16-20 weeks, weighing 220-260g) were
used. Eight rats served as controls and sixteen received a moderate T8
spinal cord contusion injury using a standard NYU impactor. Eight injured
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
rats received treadmill locomotor training starting 1 week after SCI for 5
consecutive days, 20 minutes/trial, 2 trials/day.The additional eight injured
rats received no exercise intervention. Materials/Methods: In situ soleus
force measurements were performed 2 weeks after SCI (following 1 week
of training). Maximum tetanic force was electrically elicited in the soleus
muscle using a single train, 1500ms in duration at 100 Hz with a 5 min inter-
val between trails.The maximum tetanic force of 3 attempts was recorded.
Similarly, the fatigue test was electrically elicited and consisted of a modi-
fied Burke fatigue test with 300ms trains delivered every second for 2 min-
utes. Fatigue was calculated as (initial-final force)/initial force. A one-way
ANOVA with post hoc testing was used for statistical analysis of data and a
p value of less than 0.05 was considered significant. Results: One week of
training after SCI significantly increased soleus muscle force (178+19mN)
compared to SCI rats without training (117+29mN) (p<0.05), an improve-
ment of 52.1%.The force of trained animals was not different from that of
uninjured animals (201+14mN) (p<0.05). Injured rats that received train-
ing also demonstrated comparable fatigue to control animals (27+0.04%
and 26+0.09% respectively) compared to rats without training (36+0.1%)
(p<0.05). Conclusions: One week of therapeutic locomotor treadmill
training initiated at 1 week following SCI produced soleus muscle forces
that were 52.1% stronger than recorded in injured/untrained control ani-
mals. In addition, compared with normal controls, the injured/trained ani-
mals retained 100% of their fatigue resistance measures; whereas a 27.2%
decrease was recorded in the injured/untrained control animals. Clinical
Relevance: One week of therapeutic locomotor treadmill training initiated
at 1 week following SCI produced soleus muscle forces that were 52.1%
stronger than recorded in injured/untrained control animals. In addition,
compared with normal controls, the injured/trained animals retained 100%
of their fatigue resistance measures; whereas a 27.2% decrease was
recorded in the injured/untrained control animals.
EXAMINATION OF SPASTICITY OF THE KNEE FLEXORS AND KNEE
EXTENSORS USING ISOKINETIC DYNAMOMETRY AND CLINICAL
SCALES IN CHILDREN WITH SPINAL CORD INJURY. S. Pierce, T.E.
Johnston, R.T. Lauer, Research, Shriners Hospital for Children, Philadelphia,
PA.
Purpose/Hypothesis:The management of spasticity is a common goal for
children with spinal cord injury (SCI).A better understanding of spasticity
is important for clinicians working with this population. The purpose of
this study is to examine the electromyography (EMG) responses of the
knee flexors and knee extensors during the examination of spasticity
using an isokinetic dynamometer and to correlate peak passive resistance
torque with clinical scales of spasticity in children with SCI. Number of
Subjects: A convenience sample of 14 children with chronic SCI (mean
age = 9.1 years; 13 ASIA A, 1 ASIA B) was recruited. Materials/Methods:
One set of ten passive movements from 90 degrees of knee flexion to 25
degrees of knee flexion and from 25 degrees of knee flexion to 90 degrees
of knee flexion was completed using an isokinetic dynamometer at 15, 90,
and 180º/s with a return speed of 5 degrees per second to assess knee
flexor and knee extensor spasticity respectively. Surface EMG was col-
lected from the vastus lateralis (VL) and medial hamstrings (MH) concur-
rent with the dynamometry data. Gravity corrected peak passive torque for
each repetition was calculated. EMG onset was defined as three standard
deviations above baseline level. Spasticity was clinically assessed using the
Ashworth Scale (AS) and Spasm Frequency Scale (SFS). Descriptive analy-
sis of the EMG responses was completed. Non-parametric correlational
analyses between peak passive resistive torque and the clinical measures
of spasticity were calculated. Results: During passive knee extension,
reflexive muscle activity in the MH occurred in less than 4% of trials while
reflexive muscle activity in the VL occurred in less than 6% of trials with
movements at each velocity. During passive knee flexion, reflexive muscle
activity in the VL occurred in less than 5% of trials while reflexive muscle
activity in the VL occurred in less than 8% of trials with movements at each
velocity. The median AS for the knee flexors and knee extensors was 0.5
and 0 respectively while the median SFS was 2.There were no significant
correlations (p<0.05) between peak passive torque of the knee flexors and
knee extensors at each velocity,AS, and SFS with the exception of a signif-
icant negative correlation (p=0.034) between SFS and peak passive torque
of the knee flexors with movements at 15º/sec. Conclusions : Reflexive
192
muscle activity of the MH and VL appears to have a minor role during the
measurement of spasticity of the knee flexors and knee extensors using
dynamometry in children with SCI, which suggests that passive muscle
stiffness may be more important than increased reflexes. Quantitative and
clinical examination tools for spasticity appear to be measuring different
aspects of spasticity. Clinical Relevance: Examination of spasticity should
incorporate both quantitative and clinical tools in order to have a more
complete understanding of spasticity. Interventions for spasticity in chil-
dren with SCI may benefit from addressing non-reflexive muscle stiffness.
PLATFORMS: Parkinson Disease
Saturday 1:30-3:30
TREADMILL EXERCISE TRAINING INDUCES ANGIOGENESIS AND
IMPROVES ENDURANCE AND NEURONAL INDICATORS IN CHRONIC
MOUSE MODEL OF PARKINSON’S DISEASE. M.D.Al-Jarrah1, L. Novikova1,
L. Stehno-Bittel1,Y. Lau2, 1Physical Therapy and Rehabilitation Sciences,The
University of Kansas Medical Center, Kansas City, KS, 2Department of
Pharmacology,The University of Missouri, Kansas City , Kansas City, MO.
Purpose/Hypothesis:The goal of this study was to determine whether a
4-week treadmill running protocol could induce angiogenesis and improve
endurance and neuronal indicators in a chronic MPTP/probenecid mouse
model of Parkinson’s disease. Number of Subjects:Twenty-three C57BL/6
mice were randomly assigned in 4 groups: sedentary control, exercise-
trained control, sedentary PD, and exercise-trained PD. Materials/
Methods: The PD was induced by 10 chronic injections of 25 mg/kg
MPTP and 250 mg/kg probenecid, which exhibited many symptoms of
human PD. Exercised groups of mice were trained to run 40 min, 5
days/week for 4 weeks at an average speed of 18 m/min on a treadmill.
Citrate synthase activity, cardiovascular parameters, dopamine level in sub-
stantia nigra, tyrosine hydroxylase contents and blood vessels density in
the striatum were analyzed and compared between the animal groups.
Results: Compared to the respective sedentary groups, the soleus muscle
citrate synthase activity increased by 21% in the exercise-trained PD group
and 18% in the exercise-trained control group (p<0.05). Citrate synthase
activity in the gastrocnemius produced similar results. Resting heart rates
declined significantly in both exercise-trained groups. PD showed a
decrease in the resting heart rate by about 10%. Substantia nigra tyrosine
hydroxylase content and striatal dopamine levels were increased nearly
30% in the exercise-trained PD over the sedentary PD mice, whereas these
levels were indifferent between sedentary and exercise-trained controls.
Exercise also resulted in a significant increase in blood vessel density in the
striatum of trained PD animals compared to the sedentary group (P<
0.003). Conclusions: In summary, our study demonstrated that improve-
ment in endurance and neuronal parameters as well as angiogenesis could
be achieved in PD mice with a 4-week exercise training protocol. Clinical
Relevance:According to our results, aerobic exercise could be beneficial
for limited functional recovery in subjects with debilitating neurodegener-
ative disorders, including Parkinson’s disease
ADAPTATION OF VOLUNTARY STEP INITIATION IN PERSONS WITH
PARKINSON’S DISEASE. J. Spears1, K. Ryczek1, S. Schumacher1,A. Orzel1,
J. Zhang1, K. Martinez1, M.E. Johnson1, M. Mille1, M.W. Rogers1, T. Simuni2,
1
Physical Therapy & Human Movement Sciences, Northwestern University,
Chicago, IL, 2Neurology, Northwestern University, Chicago, IL.
Purpose/Hypothesis: Difficulties with gait initiation and other locomo-
tion activities are characteristic and often debilitating problems for people
with Parkinson’s disease (PD).Anticipatory postural adjustments (APAs) for
lateral weight shift and stability normally precede and accompany step ini-
tiation. Patients with PD demonstrate prolonged and reduced APAs and
delayed step initiation.A lateral postural assist at the pelvis has been shown
to acutely decrease APA duration and step onset time in PD.The aim of this
study was to determine if patients with PD would adapt to lateral assist
training by demonstrating decreases in APA duration and step onset time
following removal of lateral assist. Number of Subjects: 6 patients with
early-stage PD (Hoehn and Yahr stage 1 & 2) and 6 age-matched controls.
Materials/Methods: Ground reaction forces were recorded with two force
platforms to determine APA characteristics based on the net medio-lateral
193 J ournal of N eurological P hysical T herapy
center of pressure displacement.Whole body kinematic data were recorded
using a 6-camera infrared motion analysis system to determine step charac-
teristics.The lateral assist training session consisted of 3 blocks of trials dur-
ing rapid forward stepping: 10 baseline trials, 50 trials with lateral assist, and
10 post-assist trials without assist. Ten retention trials without assist were
collected one week after the initial session.The lateral assist was provided
by a motor driven robotic system with a cable attachment hooked onto a
belt around the subject’s pelvis. The assist was applied when 55% of the
subject’s weight was on the swing limb to aid with weight transfer during
the APA phase of step initiation. Data was analyzed using ANOVA (p <
0.05).Results: There were no significant group effects between PD and
control subjects. However, PD subjects tended to show longer APA duration
and slower step onset times compared to controls. Significant condition
effects between baseline and lateral assist trials, indicated a decrease in total
APA duration (p < 0.01), thrust phase (APA onset to peak amplitude (p <
0.02), unloading phase (peak APA amplitude to end of APA, (p < 0.02), and
step onset time (p < 0.01).There was a significant decrease in thrust dura-
tion between baseline and retention (p = 0.01).A decrease in APA duration
between baseline and retention was marginally significant (p = 0.06) and a
shorter step onset time approached significance (p = 0.11).Conclusions :
This study supports previous research that a lateral assist can acutely
improves step initiation characteristics, in patients with PD.A trend for sub-
jects to retain shorter APA duration and step onset with practice suggested
a potential for adaptation. Greater significance may have been achieved
with larger sample size. Clinical Relevance: The approach illustrates
application of current theories of neural plasticity pertaining to adaptive
mechanisms of posture and locomotion interactions and their management
in people with PD. To attain greater training effects patients may benefit
from increased practice time and additional rest breaks to optimize neural
adaptation and minimize fatigue.
EVIDENCE FOR ACTIVITY-DEPENDENT NEUROPLASTICITY IN AN
INDIVIDUAL WITH PARKINSON’S DISEASE: A TRANSCRANIAL MAG-
NETIC STIMULATION STUDY. M.S. Fong1, T.L. Brown1, K.R. Wolcott1, J.
Lin1, B.E. Fisher1,A.Wu2, 1Biokinesiology and Physical Therapy, University of
Southern California, Los Angeles, CA, 2Neurology Department of the Keck
School of Medicine, University of Southern California, Los Angeles, CA.
Background & Purpose: Few studies have investigated the effect of high-
intensity exercise such as Body-weight-supported treadmill training
(BWSTT) on functional improvement in Parkinson’s disease (PD). Further,
the role of neuroplasticity as the underlying mechanism of functional
improvement has not been examined. An important recent advance is the
demonstration of activity-dependent neuroplasticity in animal models of
PD. Currently we are determining the application of these findings to the
human condition. Single-pulsed Transcranial Magnetic Stimulation (TMS)
has been used to evaluate corticomotor excitability in PD compared with
healthy individuals. In PD, the amplitude of the motor-evoked potential
(MEP) is higher at low stimulation intensities with a blunted response to
increasing stimulation compared to healthy individuals.The purpose of this
preliminary study was to determine the effect of high intensity exercise on
neuroplasticity and functional recovery in an individual with PD.This case
is part of a larger study designed to investigate the underlying neural
processes by which BWSTT promotes functional changes in PD. To our
knowledge this is the first report that has used TMS to identify central
changes post physical therapy intervention. If exercise induces neuroplas-
ticity we might expect to see ‘normalization’ of TMS measures. Case
Description:The subject was a 74 year old functionally independent male
who had been diagnosed with PD within the last 3 years. He participated
in 24 sessions of BWSTT (3 x/week for 8 weeks). PD symptoms primarily
affected the left (L) extremities. Over training, weight support was gradually
reduced (30% to 5%); treadmill speed and incline were increased (2.0 to 7.0
meters/second, 0 to 3% grade).The following measures were taken pre and
post exercise: 1) gait parameters using a motion analysis system and 2) cor-
ticomotor excitability (CE) over L and right (R) primary motor cortex with
TMS. CE was characterized by slope of the input-output recruitment regres-
sion line (RL Slope) for MEP amplitude during active contraction of the first
dorsal interosseous muscle. Outcomes: A 14% and 16% increase in speed
and single limb support time respectively were accompanied by an 84%
change in RL Slope for MEP amp of the R (more affected) hemisphere. Pre
Vol. 29 • No. 4 • 2005
exercise RL Slope was 17 with a minimal increase in MEP amplitude with
increasing stimulation. Post exercise MEP amplitude increased with stimu-
lation intensity in a near linear fashion (RL Slope = 107) approximating
what is seen in healthy individuals. Discussion:To our knowledge, this is
the first demonstration of exercise-induced changes in recorded TMS values
in conjunction with functional improvement. Our data suggests that there
is an effect of high-intensity exercise on measures of both brain and behav-
ior in PD. By understanding the effects of exercise on neuroplasticity, novel,
non-pharmacological therapeutic modalities may be designed to delay or
reverse disease progression in Idiopathic Parkinson’s disease.
FUNCTIONAL REACH: IS THIS A VALID MEASURE OF RECURRENT
FALLS IN INDIVIDUALS WITH PARKINSON’S DISEASE? J. Robichaud1,
Pfann, D.M. Corcos2, C. Cindy3, 1Physical Therapy, Indiana University,
Indianapolis, IN; K.D, 2Movement Sciences, University of Illinois at Chicago,
Chicago, IL, 3Department of Neurological Sciences, Rush University,
Chicago, IL.
Purpose/Hypothesis: Functional reach (FR) of less than 25.4cm has pre-
dictive validity in identifying elderly frail subjects at risk for recurrent falls
(when adjusted for age, Folstein mental score and depression). In contrast,
this measure has not been shown to be a sensitive measure for identifying
medicated individuals with Parkinson’s disease (PD) who were at risk for
recurrent falls. However, movement disorders associated with PD that pre-
disposes these individuals to slips, trips, and falls, become exacerbated dur-
ing the ‘off’ or coming ‘off’ medication conditions. The purpose of this
study was to determine the effect medication has on the predictive valid-
ity of FR in determining the risk of recurrent falls in individuals with PD.
Number of Subjects: Forty subjects with PD were tested both off med-
ication (12-hour overnight withdrawal of anti-parkinsonian medications)
and then after the subject’s regular medication was resumed. Materials/
Methods: Subjects underwent a clinical evaluation, which consisted of the
motor (part III) subclass of the Unified Parkinson’s Disease Rating Scale
(UPDRS) and the FR test. Individuals were also asked if they had experi-
enced 1 or more falls in the past year.A fall was defined as an incident that
resulted in the person unexpectedly coming to the ground.The FR test was
administered according to the procedure established by Duncan and col-
leagues. Each subject performed 1 practice trail and 3 test trials.The mean
difference between the initial position and the end position for the three
trials was calculated as the FR. Data was analyzed using analysis of variance
and regression analysis.The independent variables were medication status
(off, on), the motor subsection of the UPDRS and history of falls.
Dependent variable was FR. All levels of significance were designated at
p < 0.05.Results: Individuals with PD exhibited greater FR and higher
UPDRS scores in the ‘off’ as compared to ‘on’ medication condition. FR, as
a measure of the risk for recurrent falls in the ‘off’ medication condition
revealed a test sensitivity of 100% and test specificity of 74%. Further, there
was a significant correlation (R = .79) between ‘off’ medication UPDRS
score and FR. In contrast, in the ‘on’ medication condition test validity for
the FR test (measure of the risk of recurrent falls) revealed a test sensitiv-
ity of 30% and test specificity of 100%. Further, no correlation (R = .30) was
revealed between the ‘on’ medication UPDRS score and FR. Conclusions:
FR measured in the off medication condition, can identify individuals with
PD who are at risk for recurrent falls.This study also illustrates the differ-
ing conclusions that can be reached when these individuals are tested in
the ‘off’ as compared to the ‘on’ medication condition. Clinical
Relevance: FR in the ‘off’ medication condition is a simple test that clini-
cians may use to identify individuals with PD who are at risk for recurrent
falls. Due to the progressive nature of PD, individuals who are identified at
risk should be enrolled in a fall risk intervention program.
RELIABILITY AND VALIDITY OF THE TINETTI MOBILITY TEST FOR
INDIVIDUALS WITH PARKINSON DISEASE. D. Kegelmeyer1, A.D.
Kloos1, S.K. Kostyk2, K.M. Thomas2, 1Physical Therapy, The Ohio State
University, Columbus, OH, 2Movement Disorders Division, The Ohio State
University, Columbus, OH.
Purpose/Hypothesis: Individuals with Parkinson disease (PD) develop
progressive gait and balance problems that often result in falls. The Tinetti
Mobility Test (TMT) is a clinical balance and gait test that predicts fall risk
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
in elderly individuals.The aims of this study were to determine the inter-
rater (Part 1) and intrarater (Part 2) reliability of TMT scores of individuals
with PD, the construct validity of the TMT as a measure of balance and gait
impairment severity (Part 3), and the predictive validity of the Tinetti
Mobility Test as a screening tool to identify individuals with PD at risk for
falls (Part 4). Number of Subjects:Thirty individuals with a diagnosis of
PD (mean age=65.47 ±11.17; male/female ratio=23/7; mean Hahn and Yahr
score =2.41 ± .39) who attended the Madden/NPF Center of Excellence
(Columbus, Ohio) were recruited to voluntarily participate in all portions
of this study. Inclusion criteria were Hoehn and Yahr stages I-III or early
stage IV, and ability to independently ambulate with or without the use of
an assistive device. Subjects who had any other neurological diagnosis or
paralysis from another condition were excluded. Materials/Methods:
Two physical therapists and 3 physical therapy students rated subjects live
performances of the TMT (Part 1). During the gait portion of the test, time
for each subject to ambulate 25 feet was recorded.Two physical therapists
and 4 physical therapy students rated subjects videotaped performances of
the TMT on two separate days one week apart (Part 2). One of two physi-
cians administered the Unified Parkinson Disease Rating Scale Motor Exam
(Section III) and scores obtained were correlated with the TMT scores
(Part 3). A falls history was obtained for each subject and the discrimina-
tive power of the TMT to predict fallers was assessed using statistical tests
(Part 4). Data were analyzed using intraclass correlation coefficients (Parts
1&2), Spearman correlation coefficients (Part 3), and statistical tests of sen-
sitivity, specificity, positive and negative predictive values (Part 4). Results:
Interrater reliability of total TMT scores was good to excellent between all
raters (ICC=.87), physical therapist raters (ICC=.84), student raters
(ICC=.88), and between physical therapist and student raters (ICC
range=.82-.94). Preliminary results showed moderate to excellent
intrarater reliability of total scores for two raters (ICCs=.99 and .67). Mean
total TMT scores were moderately correlated with UPDRS motor exam
scores (Spearman correlation=-.45) and comfortable gait speed (Spearman
correlation =.53), but did not predict falls (sensitivity=13% and speci-
ficity=86% at cutoff score of 19).Conclusions: Our findings suggest that
the TMT is a reliable and valid measure of balance performance during
functional activities in individuals with PD.Analysis is in progress to deter-
mine if individual test items are predictive of falls. Clinical Relevance: To
identify individuals with PD at risk of falling, physical therapists need valid
and reliable examination tools that objectively measure functional mobil-
ity and balance in PD.
THEMATIC POSTERS: Imagery and Imaging
Friday 4:30-6:00
REPRESENTATION OF IMAGINED AND EXECUTED SEQUENTIAL
FINGER MOVEMENTS OF ADULTS POST STROKE AND HEALTHY
CONTROLS. J.E. Deutsch1, S. Fischer1,W. Liu2,A. Kalnin3, K. Mosier3, 1Physical
Therapy, UMDNJ-SHRP, Newark, NJ, 2Radiology, UMDNJ, Newark, NJ,
3
Radiology, Indiana University, IN.
Purpose/Hypothesis: The purpose of this study was to describe the
effects of brain injury on imagery ability and representation by examining
executed and imagined complex finger movement sequences with each
hand. We hypothesized that individuals post-stroke would exhibit similar
patterns of brain activation for executed and imagined movements to
healthy controls (HC) when using their ipsilesional hand but not their con-
tra-lesional hand. Number of Subjects: Five individuals post stroke (at least
one year post-stroke, right CVA with preserved motor function in the con-
tralesional hand) and five age matched HC. Materials/Methods: Subjects
were tested in two sessions with one week interval. In the first session
imagery ability was examined using the Motor Imagery Questionnaire
(MIQ) and chronometric break tests. Subjects practiced executed and imag-
ined paced sequential finger movement sequences with each hand. Audio
taped instructions were provided for practice of the tasks at home. During
the second session prior to brain scanning accuracy of finger movements
was confirmed. Data were acquired with a 3T Allegra MR scanner (Siemens)
using an echo-planar imaging (EPI) gradient system. Functional studies
(fMRI) were acquired using a 32 slice gradient echo EPI (TR=4000,TE=30,
64x64 matrix, FOV=22 cm); and a blocked paradigm, each consisting of 4
epochs of task performance alternating with visual attention.The four trials
194
of hand movements were: executed ipsi-lesional, imagined ipsi-lesional, exe-
cuted contra-lesional, imagined contra-lesional. MRI data were analyzed
using SPM 99, with a corrected height (p=.05) threshold. Group analyses
were performed to determine the volume of activation in pre-determined
regions of interest. Results: MIQ scores did not differ significantly between
groups. HC’s pattern of activation during executed tasks by either hand
included the contralateral primary sensory (1, 2, 3) motor (4) parietal (5, 7)
and premotor (PMC) and supplementary motor areas (SMA) (6). Individuals
post stroke pattern of brain activation when using their ipsilesional hand
was similar to that of HC. For the stroke affected hand executed movements
were bilaterally represented while imagined movements were lateralized to
the brains’ primary lesioned side. For all tasks performed by the individuals
post-stroke there was greater activation (50-500%) of area six on the con-
tralesional side of the brain. Conclusions: The pattern of activation
observed for tasks by the stroke affected hand suggest that it was easier for
individuals post-stroke to imagine rather than execute the movements.The
increased activity of the pre-motor and supplementary motor areas of the
contra-lesional side during all tasks for the stroke affected subjects suggests
that there may be a compensatory shift in the tasks of planning and
sequencing both imagined and executed sequential finger movements.
Clinical Relevance: Mental imagery by individuals post-stroke may serve
as a stimulus for plasticity of stroke affected side of the brain and possibly
be a good tool for rehabilitation of motor function.
RECOVERY FROM STROKE: WHAT IS THE ROLE OF THE UNDAM-
AGED, CONTRALESIONAL CORTEX? L. Boyd, E.D. Vidoni, Physical
Therapy & Rehabilitation Science, University of Kansas Medical Center,
Kansas City, KS.
Purpose/Hypothesis: The main goal of this study is to map the relation-
ships between the phenomenon of contralesional cortical activation after
stroke and motor learning. One explanation for contralesional cortical activ-
ity posits that it is a compensatory strategy, employed in response to task
difficulty. We hypothesize that contralesional cortical activity will be
reduced by motor skill learning indexed by a laterality index (LI) derived
from fMRI data (H1). Because skill learning is critical for neuroplastic
change, we also hypothesize that increased but non-specific use of the
hemiparetic upper extremity (UE) will not alter contralesional cortical acti-
vation (H2). Number of Subjects: For this report we mapped individual
changes in neural activation patterns across motor skill practice and at
retention in 6 people with chronic subcortical stroke.
Materials/Methods: The effect of 2 interventions on activation in the
undamaged cortex was assessed using fMRI.All participants used the hemi-
paretic UE to either to learn a joystick based targeting task (LEARN group;
n=4; mean motor UE Fugl-Meyer 37.0) or to completed a program of
increased but non-specific use of the hemiparetic UE (USE group; n=2; Fugl-
Meyer 40.5). Over 5 days all completed an initial fMRI testing session, 3 days
of practice or treatment and a day 5 fMRI retention test. The number of
movements and UE excursion was standardized across groups. Brain activ-
ity was quantified on an individual basis by calculating the LI using the
product of intensity and area of activation data for the primary motor cor-
tex (M1). Results: Demonstrating behavioral learning of the task,
response time (RT) decreased significantly (p<.05) for the LEARN group (-
278ms) while the percentage of correct target hits increased (+8%). This
was not true for USE group (RT slowed +62ms; % target hits reduced -5%).
Importantly, normalization of the pattern of brain activation was evident for
the LEARN group; LI improved significantly for M1 by retention (day 1 M1
LI -.125; retention M1 LI .735; 1=normal M1 activation). Again, the USE
group did not change (M1 LI day 1 -.16; retention -.09). Conclusions:
Despite the abnormal patterns of neural activation that occurred after brain
damage, clearly chronic stroke does not abolish motor learning ability. Our
data demonstrate that the functional organization of the motor system can
be modified by use even after stroke. Specifically, the magnitude of activa-
tion in undamaged, contralesional M1 was altered by task specific motor
learning but not by increasing non-specific hemiparetic UE use. Clinical
Relevance: These data support our hypothesis that post-stroke contrale-
sional M1 activation is in some part related to task difficulty and represents
a compensatory strategy (H1). It also appears that task specific practice and
learning are required to alter patterns of brain activation after stroke (H2).
Our findings have great clinical relevance for rehabilitation; it appears likely
195 J ournal of N eurological P hysical T herapy
that task specific learning is required to restore more normal patterns of
brain activity and improve functional outcomes after stroke.
BRAIN ACTIVATION DURING KINESTHETIC AND VISUAL IMAGERY
OF WALKING. CA Chatto1, JE Deutsch1, J. Pillai2, T. Lavin2, J. Allison2,
1
Program in Physical Therapy, UMDNJ, Newark, NJ, 2Department of
Radiology, Medical College of Georgia,Agusta, GA.
Purpose/Hypothesis: The purpose of this study was to contrast how
kinesthetic and visual imagery strategies, when used to mentally imagine
walking, would affect brain activation patterns. We hypothesized that
imagery strategy would modify cortical representation. Number of
Subjects: Six healthy, right handed adults (39-64 years old).
Materials/Methods: Subjects were tested in two sessions one week apart.
In the first session imagery ability was measured with the Vividness of
Movement Imagery Question-naire (VMIQ). Subjects practiced imaging
walking using visual and kinesthetic strategies, using a visual context (hall-
way) in which to practice imagined walking.A week after practicing sub-
jects returned for brain imaging.Actual and imagined walking speeds were
assessed to determine chronometric consistency. Functional Magnetic
Resonance Images were acquired on a 1.5T scanner (GE LX Horizon
Echospeed) using echo-planar technique. Images were acquired using a
blocked paradigm with 8 epochs of task performance alternating with
directed attention. Subjects viewed a video of hallway and then performed
the following tasks: 1) imagined walking down hallway using visual
imagery 2) imagined walking down hallway using kinesthetic imagery 3)
bilateral foot movements 4) imagined foot movements using visual
imagery and 5) imagined foot movement with kinesthetic imagery.
Subjects’ imagery vividness was recorded after each scan with the VMIQ.
Brain imaging data were analyzed using SPM99. For each subject, SPM
maps were computed by subtracting rest from task conditions to identify
voxels having increased intensity during tasks.A simple t-test was used to
determine significant activation in the following regions of interest (ROIs):
sensorimotor cortex (SMC), supplemental motor area (SMA), parietal cor-
tex (PC), dorsolateral prefrontal cortex (DLPFC). Data were analyzed at p
= .0001 with 20 voxel clustering and p = .05 corrected. Results:All ROIs
were activated bilaterally during both visual and kinesthetic imagery of
walking. The visual imagery task produced a right lateralized pattern for
SMC, DLPFC, and PC; while the kinesthetic imagery task produced a left lat-
eralized pattern for SMC, DLPFC, SMA and PC. Differences between right
and left sided activation within tasks were not significant due to subject
variability. The SMC exhibited 29% greater extent of activation for the
kinesthetic task than the visual task. Conclusions:These descriptive pre-
liminary findings suggest that similar brain regions are recruited with
visual and kinesthetic imagery of walking. The lateralization of the brain
activation and the different weighting of SMC may be related to the type
of imagery. Clinical Relevance: These findings provide a foundation for
further research with the use of mental practice of walking as an adjunct
to the rehabilitation. Selection of imagery strategy may be especially rele-
vant for persons following stroke.
EFFECT OF WALKING VS SHAM TREATMENT ON FINGER MOVE-
MENT CONTROL AND BRAIN REORGANIZATION IN WELL ELDERLY.
S. Anderson, H. Aldrich, S. Knight, C. Battles, J.R. Carey, University of
Minnesota, Minneapolis, MN.
Purpose/Hypothesis: Previous studies have shown that aerobic training,
including walking, can have beneficial cognitive effects.The possibility that
such cognitive effects might improve motor control is real.The purpose of
this study was to investigate whether a walking training program could
induce improvement in finger tracking performance accompanied by
changes in cortical activation within primary motor area (M1), as measured
by fMRI, in well elderly subjects.We hypothesized that subjects in the walk-
ing group would show greater improvement in finger tracking and signifi-
cant changes in brain reorganization compared to a sham group. Number
of Subjects: Fourteen well elderly subjects were assigned to either a walk-
ing group (N = 6, mean age = 81.7, SD = 1.9 years) or a sham group (N=8,
mean age 79.8, SD = 2.3 years). Materials/Methods: All subjects wore a
pedometer for one week prior to group assignment to record baseline
level of walking distance. Subjects assigned to walking group were
Vol. 29 • No. 4 • 2005
instructed to double their weekly walking distance within six weeks and
then maintain or further increase that distance for an additional six weeks.
Subjects assigned to the sham group received one 30-minute treatment per
week for 12 weeks of sham electrical stimulation to the finger and wrist
extensor muscles of their dominant hand. During this time, they were
instructed to maintain their regular walking distance. Before and after
training, subjects performed a six-minute finger movement tracking test
with functional magnetic resonance imaging of the brain inside a three-
Tesla magnet to measure finger movement control and the associated cor-
tical activation. Analysis of data was done with paired tests comparing
pretest to posttest change for both groups. Results: Results showed that
the walking group significantly increased their walking distance (p =
0.003), whereas the sham group showed no change. The finger tracking
accuracy increased significantly for the walking group (p = 0.01), whereas
for the sham group no change occurred. Despite the significant improve-
ment in tracking performance in the walking group, there were no signifi-
cant changes in measurements of brain reorganization (active voxel count
and signal intensity) in M1 of either group. Conclusions: We concluded
that walking training improved finger movement tracking control in well
elderly subjects but did not show a change in brain reorganization. The
absence of significant change in brain reorganization accompanying the
behavioral improvement may be due to the area (M1) studied or the time
at which the cortical activity was measured at posttest. Clinical
Relevance:These results suggest that an active walking training program
has beneficial effects on fine motor control of movements unrelated to the
walking exercise. The possibility exists that aerobic/walking training,
through molecular mechanisms not yet identified, may have similar bene-
ficial effects on motor control in patients with neurological problems.
INFLUENCE OF MOTOR-IMAGERY ABILITY ON SMA AND PSMA
CORTICAL ACTIVATION. T.J. Kimberley, G.S. Khandekar, Physical
Medicine and Rehabilitation, University of Minnesota, Minneapolis, MN.
Purpose/Hypothesis:The supplementary motor area (SMA) and pre-sup-
plementary motor area (PSMA) are considered to be vital in the planning,
initiation, and execution of motor tasks. Several studies have investigated
the role of SMA in mental imagery, but little is known about how the abil-
ity to imagine influences brain activation.The purpose of this study was to
investigate the role of SMA and PSMA during mental imagery in both
healthy subjects and subjects with stroke and how the ability to imagine
influences brain activation. Number of Subjects: Six subjects with severe
hemiparesis (Fugl Meyer UE score: 9-14, range: 8-113 months post stroke,
mean: 64.3 months) and six age and gender matched healthy subjects.
Materials/Methods:Whole-brain 3-Tesla fMRI was performed in subjects
with stroke during alternating phases of active wrist-tracking with the less
affected hand and imagined wrist-tracking with the hemiparetic side and
resting. Control subjects were assigned a side to imagine and a side to
track. At the end of the session, subjects were asked to rate the ability to
imagine the movements, on a scale of 0-5 with zero being inability to imag-
ine and five being perfect imagining of the task. Cortical activation inten-
sity within each region was determined and the percent change in signal
intensity from baseline was calculated. Subjects with stroke and healthy
subjects were divided into two groups: high imagery ability (self-rating: 3-
5) and low imagery ability (self-rating: 0-2). Statistical analysis of fMRI data
was done with two-tailed T-tests using percent signal intensity change.
Results: During the motor imagery task, subjects with stroke displayed sig-
nificantly greater percent increase in activation in contralateral SMA as
compared to healthy subjects [SMA: healthy: 0.88 ± 0.14, stroke: 1.39 ±
0.52, P = 0.03]. Pre SMA also showed a greater percent increase in the
stroke group, but this was not significant [PSMA: healthy: 0.48 ± 0.71,
stroke: 1.10 ± 1.24]. For the imagined wrist-tracking task, there was no sig-
nificant difference in the percent signal-intensity change between the high
and low imagining ability groups.This finding of no difference is supported
by adequate power [effect size: 1.1, N=12, power .80]. Conclusions:This
study provides evidence that mental imagery of a motor task in patients
with stroke promotes cortical activity, which is consistent with previous
research. Additionally, self-reported ability to imagine does not influence
the signal intensity of SMA and PSMA activation. Clinical Relevance:
Studies have shown that mental imagery may have beneficial effects when
combined with rehabilitation. Our findings show that motor imagery facil-
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
itates cortical activity that is functionally relevant. The data also support
that the strength of motor imagery ability does not influence the amount
of cortical activation.Thus, it is plausible that even patients that have diffi-
culty performing motor imagery will exhibit increases in cortical activa-
tion which may be an important adjunct to rehabilitation.
MOVEMENT CONTROL AND CORTICAL ACTIVATION IN FUNC-
TIONAL ANKLE INSTABILITY. K. Anderson, J.R. Carey, Program in
Physical Therapy, University of Minnesota, Minneapolis, MN.
Purpose/Hypothesis: One-third or greater of first time ankle sprain suf-
ferers report continuing instances of ankle instability, regardless of inter-
vention or severity of injury.This high prevalence of prolonged instability
requires exploration into contributing factors. Previous research has impli-
cated impaired sensorimotor control of the ankle. The purpose of this
study was to explore for differences in cortical activation, measured with
functional magnetic resonance imaging (fMRI), between people with a his-
tory of recurrent ankle sprains and those without such a history during an
ankle movement control task. Number of Subjects:Ten subjects (mean
age 29.9 ± 8.4 years) with complaint of unilateral (8 right, 2 left) functional
ankle instability (FI) and ten control subjects (age 26.9 ± 9.0) were
recruited from a sample of convenience.All subjects were right ankle dom-
inant. Materials/Methods: Functional MRI images using a 3 Tesla magnet
were obtained while the subjects performed an ankle tracking task with
each ankle separately (order randomized) using ankle inversion and ever-
sion to follow a 0.4 Hz sine wave. Movement control was calculated for
each ankle with an accuracy index. Using blood oxygenation level depen-
dent (BOLD) contrast method, cortical activation was assessed. We calcu-
lated the percent increase in signal intensity from baseline (% intensity)
during the task over all voxels in the anatomically defined regions of pri-
mary motor (M1), primary somatosensory (S1), and supplementary motor
(SMA) cortices using non-parametric tests. Results: Ankle pairwise %
intensity differences were found in FI subjects in S1 and M1. In M1, while
tracking with the sprained ankle, the FI subjects showed greater intensity
in the contralateral than ipsilateral hemisphere (p=0.005) while the con-
trols did not show a difference with either limb (p=0.333 right ankle,
0.208 left). In S1, while tracking with either ankle, the FI subjects demon-
strated greater intensity in the contralateral than ipsilateral regions
(p=0.021 sprained ankle, 0.047 unsprained ankle). Control subjects
demonstrated no difference between hemispheres for either ankle
(p=0.953 right, 0.374 left). Differences found in SMA were not significant.
No differences were observed between FI subjects and controls for either
ankle tracked in any of the three regions. Accuracy indices demonstrated
no between group or within subject differences. Conclusions: We con-
cluded that differences in patterns of cortical activation during a move-
ment accuracy task exist between those with recurring functional ankle
complaints and those without such complaints. Clinical Relevance:These
results invite further work into discovering a neurological mechanism for
functional ankle instability, which may lead to new interventions.
THEMATIC POSTER SESSION: Post-Stroke Hemiplegia
Saturday 8:00-11:00
SPLIT-BELT TREADMILL ADAPTATION AND GAIT SYMMETRY POST-
STROKE. DS Reisman1, AJ Bastian2, 1Department of Physical Therapy,
University of Delaware, Newark, DE, 2Kennedy Krieger Institute, Baltimore,
MD.
Purpose/Hypothesis: The purpose of this study is to understand the
capacity of persons with post-stroke hemiparesis to adapt locomotor inter-
limb coordination and the influence of this on gait symmetry. Number of
Subjects: 8 subjects with chronic post-stroke hemiparesis and age-matched
controls have been tested to date. Materials/Methods: Subjects walked on
a custom split-belt treadmill (Woodway) where the speed of each belt (leg)
could be controlled independently. Subjects walked in baseline conditions
(belts tied, slow=0.5 m/s and fast=1.0 m/s), split-belt conditions (impaired
leg moving fast (1.0 m/s) in one session, slow (0.5 m/s) in another) and
post-adaptation conditions (belts tied, slow=0.5 m/s). OPTOTRAK
(Northern Digital,Waterloo ON) sensors were used to record 3-dimensional
position data from both sides of the body. Infrared emitting diodes (IREDs)
196
were placed bilaterally on the 5th metatarsal head, lateral malleolus, lateral
knee joint space, greater trochanter, iliac crest and acromion process. Foot
contacts were determined using foot switches. Intra-limb (i.e. those mea-
sured from a single leg: stride length, stance/swing time) and inter-limb (i.e.
those where the measurement depended on both legs: time in double sup-
port, step length, limb orientation at weight transfer, limb phasing) kine-
matic variables were calculated. Results: Both controls and people with
chronic stroke could adapt inter-limb coordination and showed after-
effects following split-belt practice. Subjects with hemiparesis changed
limb phasing and step length from the baseline period to the early adapta-
tion period (p<0.05, p=0.10, respectively) and stored an after-effect (com-
paring baseline and early post-adaptation periods, p=0.09, p<0.05, respec-
tively). Similar results were found for double support and limb orientation
at weight transfer, though individual stroke subjects varied in their adaptive
abilities. Intra-limb parameters changed rapidly for controls and people
with hemiparesis, with no difference between the groups. For the 6 out of
8 subjects with hemiparesis that demonstrated a gait asymmetry, walking
on the split-belt treadmill temporarily reduced or eliminated the asymme-
try either during split-belt adaptation or due to after-effects in the post-
adaptation period. Conclusions: Since all subjects showed some adaptive
ability, we suggest that this form of locomotor adaptation may be less
dependent on cerebral structures. We speculate that the adaptation and
expression of the after-effect may be influenced by several factors includ-
ing: the degree of locomotor impairment, lesion location, and/or which leg
is driven faster during the adaptation. Clinical Relevance: The results of
this study preliminarily suggest that persons with post-stroke hemiparesis
retain the capability to adapt inter-limb coordination to produce a more
symmetric locomotor pattern. Split-belt treadmill training may therefore be
useful to improve gait symmetry of people with certain types of stroke.
PARETIC LOWER EXTREMITY LOADING AND WEIGHT TRANSFER
FOLLOWING STROKE. V.S. Mercer1, S. Chang1, J.L. Purser2, J.K. Freburger3,
1
Allied Health Sciences, UNC-CH, Chapel Hill, NC, 2Medicine, Duke
University Medical Center, Durham, NC, 3Cecil G. Sheps Center for Health,
University of North Carolina at Chapel Hill, Chapel Hill, NC.
Purpose/Hypothesis: Improved ability to bear weight on or load the
paretic lower extremity (LE) and to transfer weight from one LE to the
other is one of the main goals of stroke rehabilitation. Although this goal
appears theoretically sound, the functional significance of these abilities
has not been addressed empirically. The purpose of this project was to
determine how impairment-level measures of paretic LE loading and
weight transfer relate to clinical and/or self-report measures of physical
function and disability during early recovery from mild to moderate stroke.
Number of Subjects:Twenty-five subjects (12 men, 13 women; mean age
= 60.5 ± 17.2 years) with a diagnosis of a single, unilateral stroke partici-
pated in the study. Materials/Methods: Subjects were tested at 1, 2, and 3
months post stroke.The Step Test (ST) and the Repetitive Reach (RR) test
were used as measures of LE loading and weight transfer, respectively. A
third impairment-level measure, paretic hip abductor muscle torque, was
examined because of the important role of the hip abductors in both load-
ing and weight transfer. Self-selected gait speed (GS) and the MOS Short
Form-36 Physical Functioning Index (PFI) were used to assess physical
function. Three domains (mobility, ADL/IADL, participation) of the Stroke
Impact Scale (SIS) were used to assess self-reported disability. Regression
analyses were conducted to examine the bivariate associations between
each impairment and physical function measure and between each impair-
ment and disability measure for each time point (1, 2, 3 months). Results:
All of the impairment measures were positively associated with all of the
physical function measures.These associations generally got stronger over
time (i.e., from 1 to 3 months). The associations were stronger for self-
selected gait speeds (R2 values 0.30 - 0.79) than for the PFI scores (R2 val-
ues 0.15- 0.63). Both ST and RR scores were strongly associated with gait
speed at all 3 time points.At 3 months, each additional step on the ST cor-
responded to a 0.08 m/sec increase in gait speed (95% CI=0.06-0.10,
p<0.001), and each additional reach during RR was associated with a 0.03
m/sec gait speed increment (95% CI=0.02-0.04, p=<0.001). The impair-
ment-disability associations were weaker than the impairment-physical
function associations, with only some reaching statistical significance. ST
scores and RR scores were positively associated with SIS mobility (R2 val-
197 J ournal of N eurological P hysical T herapy
ues .32-.46) and SIS ADL/IADL (R2 values .16-.37), with RR scores having
the strongest associations. Hip abductor torque was positively associated
with SIS mobility (R2=.19).The impairment-disability associations also got
stronger over time. Conclusions: Impairment in paretic lower extremity
loading and weight transfer abilities relates to physical function and dis-
ability during the first 3 months following stroke. Clinical Relevance: By
use of interventions that promote symmetrical weight bearing and
smooth, rapid weight transfer between the lower extremities, physical
therapists may be able to help stroke survivors improve function and min-
imize disability.
SINGLE LIMB BODY WEIGHT SUPPORTED TREADMILL TRAINING.
J.H. Kahn1,T. Hornby2, 1Sensory Motor Performance Program, Rehabilitation
Institute of Chicago, Chicago, IL, 2Physical Therapy, University of Illinois at
Chicago, Chicago, IL.
Purpose/Hypothesis: Gait asymmetries, characterized by differences in
step length as well as timing, are common deviations seen in people who
have had a stroke. Body weight supported treadmill training (BWSTT) has
been shown to improve functional walking ability, including gait asymme-
try, in individuals post stroke. Despite these improvements, the labor inten-
sive demands of the task limit its use in the clinic. Multiple therapists are
often required and controlling gait kinematics is difficult with one thera-
pist. Previous evidence has shown that unilateral walking training may
have an effect on bilateral locomotor activity; specifically, altering condi-
tions on one leg may have an effect on bilateral activity. Unilateral training
may have the potential to affect gait symmetry following stroke, although
application of this training has not been reported. This study investigated
the effects of single limb BWSTT in people with chronic stroke who
stepped with their unimpaired limb. Stepping with the unimpaired limb
may encourage weight-bearing on the impaired extremity and promote
symmetrical walking. Hypothesis: Single limb BWSTT will improve step
length symmetry in individuals with chronic stroke. Number of Subjects:
Six subjects with chronic stroke who demonstrated a 20% step length
asymmetry completed the protocol. Materials/Methods: Subjects com-
pleted a 20 minute session of unilateral stepping with their unimpaired
limb on the treadmill, and the impaired limb held in a stationary position.
Subjects walked on the treadmill for 5 minutes at their normal, overground
gait velocity and speed was increased by 25% every 5 minutes. Body
weight support was determined by the least amount of support tolerated
without buckling. Subjects were evaluated using the Berg Balance Scale
and Gait Mat II Regis. Gait speed and symmetry during normal and fast
walking speeds were obtained at 1 week pre- and post-training.
Additionally, spatial-temporal data was collected immediately pre- and 10,
20, and 30 minutes post-training and 24 hours later. Step length asymmetry
was calculated as the ratio of impaired to unimpaired limb step length.
Results: Increased step length symmetry was observed at 10 minutes post-
single limb walking, with increases in gait speed observed up to 30 min-
utes. Symmetry changes returned to baseline by the following day while
improvements in speed lasted until 1 week post training. Changes in fast
walking speed were statistically significant (p<.05), and improvements in
symmetry were observed (p = 0.11) but not statistically significant.
Conclusions: Single limb BWSTT may improve step length symmetry in
the chronic stroke population, although more experimentation is required.
Clinical Relevance: The initial findings indicate that unilateral training
may improve bilateral walking performance in chronic stroke. Single limb
BWSTT may have the potential to be used in the clinic to assist in improv-
ing gait speed and symmetry. Such therapy may improve the feasibility of
performing BWSTT in the clinic while specifically targeting those who
demonstrate gait asymmetry.
THE EFFECTS OF SPEED AND LEVEL OF VOLUNTARY MUSCLE ACTI-
VATION ON REFLEX RESPONSES IN CHRONIC STROKE PATIENTS.
D. Nichols1, M. Pelliccio1, I. Black2, J. Hidler2, 1Inpatient PT, National
Rehabilitation Hospital,Washington, DC, 2Center for Applied Biomechanics
and Rehabilitation Research, National Rehabilitation Hospital,Washington,
DC.
Purpose/Hypothesis: PURPOSE: To determine if reflex responses are
exaggerated in chronic stroke subjects following multi-joint leg extension
movements, and the extent to which movement speed and muscle pre-acti-
Vol. 29 • No. 4 • 2005
vation modulates these reflex responses. BACKGROUND: Many factors con-
tribute to abnormal movement patterns in patients following unilateral
stroke including weakness, poor motor control and spasticity. Reflex
responses have been shown to be exaggerated following stroke which pre-
sents challenges while weight-bearing or stepping with the paretic leg.
While studies have quantified reflex behavior at a single joint (Knutsson,
1980) little has been done to look at reflexes during controlled multi-joint
movements. HYPOTHESIS:We hypothesize that stroke subjects will demon-
strate greater reflex activity following multi-joint leg movements and that
this activity becomes pronounced at higher movement velocities or when
muscles are voluntarily activated compared to controls. Number of
Subjects: 14 unilateral chronic (> 1 year) stroke survivors and 10 healthy
age-matched controls participated in this study. Materials/Methods: Each
subject was instrumented with surface electrodes over the gastrocnemius
(gastroc), hamstring (HS), rectus femoris (RF), vastus medialis (VM) and lat-
eralis (VL), adductor longus (AL), and gluteus medius (Gmed) and maximus
(Gmax). Subjects were seated in a BIODEX with their foot rigidly attached
to a 6 DOF load cell and footplate that could slide on a horizontal track to
produce passive leg extension. Using a visual feedback, subjects were
instructed to target match hip and knee torques at 10, 20 and 30% of their
maximum after which the leg was extended at one of three speeds (30, 60,
and 120º/s). EMGs were normalized by their maximum value, after which
the reflex response was identified as the integrated muscle activity for the
first 200 ms following the onset of movement. A single-factor ANOVA was
used to compare reflex response between groups (alpha = 0.05) across
speeds and pre-activation levels. Results: 1) The mean reflex activity in the
gastroc, HS and AL are larger in stroke survivors compared to controls (p <
0.05), while reflex responses in the rectus femoris were smaller in the
stroke subjects (p < 0.05). 2) Changes in speed affected stroke survivors
more than controls in the gastroc, HS and AL (p < 0.05). 3) Changes in mus-
cle pre-activation correlated with reductions in reflex activity, particularly
at slow speeds, however the correlation coefficient was not significant.
Conclusions: Stroke survivors have exaggerated reflex activity that is exac-
erbated with increases in movement speed, particularly in the biarticular
muscles. Clinical Relevance: Exaggerated reflex responses with increas-
ing speed may influence a stroke patient’s ability to perform tasks requir-
ing rapid leg extension movements such as sit-to-stand and postural adjust-
ments for balance. Stroke patients may self select slower movement
speeds to diminish the effect of speed on these muscles and enable patients
to maintain control of their movements.
DYNAMIC WALKING STABILITY IN HEMIPARETIC CHRONIC
STROKE SUBJECTS. K.P. Brady1, J.M. Hidler1, M.C. Sinopoli2, 1Center for
Applied Biomechanics and Rehabilitation Research, National
Rehabilitation Hospital, Washington, DC, 2Department of Biomedical
Engineering, Catholic University,Washington, DC.
Purpose/Hypothesis: The goal of this study was to identify key charac-
teristics of ground reaction forces exhibited during gait that could be used
to quantitatively evaluate stability during ambulation. The most common
way to measure stability during ambulation in stroke patients is through
force platform data analysis (Karlsson and Frykberg, 2000) and clinical tests
performed by health professionals such as the Berg Balance Test (Berg et al.,
1995).These tests give a numerical score based on an individual’s ability to
complete a set of tasks yet focus on static posture and limited dynamic sta-
bility that are limited by their subjectiveness. Number of Subjects: Eight
individuals with hemiparesis resulting from a CVA no less than one year
prior to the onset of the study and eight healthy age-matched control sub-
jects participated in the study. Materials/Methods: Each subject walked on
a split belt instrumented treadmill (ADAL3D-F/COP/Mz,TECMACHINE) out-
fitted with force sensors under each belt (Kistler,Winterthur, Switzerland),
which allows for the calculation of ground reaction forces and center of
pressure (COP) under each foot. Each subject walked on the treadmill at
five different speeds: their normal over-ground self-selected walking speed
(SS), ± 10% SS and ± 25% SS. Data was collected at each of the five speeds
for two periods of 30-seconds.The Fugl-Myer (Fugl-Meyer et al., 1975) lower
extremity scale was used to assess each stroke subject’s motor function
while the Berg Balance test was completed to give a known clinical mea-
sure of stability. Repeated measures ANOVA calculations were used to com-
pare ground reaction forces in each direction and variability in COP data
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
while Pearson correlation coefficients were used to determine whether
there are relationships between the gait metrics measured in this study and
Berg Balance and Fugl-Meyer clinical scales. Results: Both propulsion and
braking forces were significantly smaller in the stroke subjects than in the
control subjects in both the affected and unaffected legs (p < 0.05).
Interestingly, in the medial-lateral plane, there were no differences between
controls and the affected lower limb of stroke subjects yet there were sig-
nificant differences between controls and the unaffected leg at all speeds
(p < 0.05). A similar trend emerged for variability measures of COP where
there were no differences between control subjects and the affected stroke
lower limb yet there were significant differences for the unaffected leg, par-
ticularly at heel strike and mid-stance. There were no correlations with
these measure and commonly used clinical scales of postural stability (Berg
Balance) and motor function (Fugl-Meyer). Conclusions: Results from this
study indicate that stroke subjects exhibit a wider variety of spatial patterns
in both their ground reaction force and COP trajectories than do healthy
individuals. Clinical Relevance:These results suggest that kinetic analysis
of hemiparetic gait may be useful to incorporate into future assessments of
dynamic stability.
LOWER LIMB STRENGTH AND COORDINATION PATTERNS OF
CHRONIC STROKE SUBJECTS IN A FUNCTIONAL POSTURE. MM
Pelliccio, N Neckel, D Nichols, J Hidler, National Rehabilitation Hospital,
Washington, DC.
Purpose/Hypothesis:The goal of this study was to quantify the strength
and coordination patterns of the paretic leg in individuals with chronic
stroke while in a functional position. Following cerebrovascular accident
(CVA) patients often lose independent control over synergistic muscle
groups, resulting in joint movements that are often inappropriate for the
desired task (Twitchell, 1951; Brunnstrom, 1970). In the upper limb, these
inappropriate movements have been attributed to abnormal torque gener-
ation about joints secondary to the intended, or primary, joint axis
(DeWald et al, 2001). No such abnormal secondary joint torque patterns
were found in the lower limb of acute (<6 months post injury) CVA
patients (Hidler et al, 2005).We hypothesize that compensatory strategies
adopted by acute stroke subjects necessary to overcome excessive lower
limb weakness (Hidler et al, 2005) may lead to abnormal secondary joint
patterns in the chronic (>1 year post injury) stages of their injury.
Number of Subjects: Fourteen chronic CVA survivors with unilateral
lesions and ten age-matched, non-neurologically involved control subjects
participated in the study. Materials/Methods:With their trunks stabilized
with large foam bumpers, stroke subjects stood on their affected lower
extremity while their affected foot was attached to a 6-degree of freedom
load cell (JR3,Woodland CA) which recorded forces and torques. Subjects
were asked to generate a maximum torque along eight different directions
(hip abduction/ adduction, hip and knee flexion/extension, and ankle dor-
siflexion/ plantarflexion) during which a visual display provided bio-feed-
back of the torque they generated about that primary joint axis.
Simultaneous secondary torques generated about the other joints, as well
as EMG data from eight leg muscle groups, were recorded during each
maximum exertion. Results: Across all conditions tested, stroke group
generated significantly less primary torque in their affected leg than the
control group (p<0.05). Furthermore, with maximum exertions, they pro-
duced significantly different secondary joint torque patterns during ankle
plantarflexion, knee extension, and hip abduction (p<0.05), demonstrating
changes in coordination. Analysis of muscle activity revealed significant
differences in muscle activation patterns which were consistent with the
observed abnormal secondary torques. Conclusions : Our findings
demonstrate that chronic stroke subjects experience changes in coordina-
tion that were not found in acute stroke subjects, suggesting that com-
pensatory strategies utilized early after CVA may develop into chronic
motor impairments. Clinical Relevance: At the onset of stroke, through
years after, rehabilitation techniques should continue to be adapted to
account for the detrimental contributions of abnormal muscle synergies.
Not only should therapists and their patients re-educate the muscles about
a particular joint, but they should be mindful of coordination of other
musculature to prevent development of abnormal secondary joint patterns
limiting inefficiency with functional tasks.
198
GAIT PARAMETERS ASSOCIATED WITH RESPONSIVENESS TO A
TASK-SPECIFIC AND/OR STRENGTH TRAINING PROGRAM POST-
STROKE. T. Klassen1, S.J. Mulroy2, K.J. Sullivan3, 1Vancouver Coastal Health,
Vancouver, British Columbia, CANADA, 2Pathokinesiology Laboratory,
Rancho Los Amigos National Rehabilitation Center, Downey, CA,
3
Biokinesiology and Physical Therapy, University of Southern California, Los
Angeles, CA.
Purpose/Hypothesis: After stroke, patients exhibit weakness that con-
tributes to decreased walking velocity and increased disability. While evi-
dence exists that patient’s post-stroke respond to task-specific and
strength training programs, it is not clear which biomechanical parameters
of gait are most influential in improved walking outcome.The purpose of
this study was to identify the gait parameters associated with responsive-
ness to a task-specific and/or strength training program designed to
improve locomotor recovery. Number of Subjects: 20 subjects, ranging
from 4 to 60 months post-stroke. Materials/Methods: Subjects com-
pleted one of four training regimens consisting of a combination of two of
the following: body weight supported treadmill training; lower extremity
(LE) resisted cycling, progressive resistive LE strengthening, or a sham con-
dition (arm ergometry). Each subject received 24 treatment sessions (1
hour/day; 4x/week; 6 weeks), and the exercises were alternated each day.
Subjects ambulated at a self-selected velocity across a 10-meter walkway
using customary assistive devices, but no lower extremity orthoses, both at
baseline and post intervention. Kinematics and kinetics of the hemiparetic
LE were recorded with a VICON motion system and a Kistler force plate.
Electromyographic activity was recording using indwelling, fine wire elec-
trodes in soleus, anterior tibialis, vastus intermedius, rectus femoris, semi-
membranosus, adductor longus, gluteus maximus and gluteus medius.
Changes in LE kinematics, kinetics, and muscle activation intensities for the
10 subjects with the greatest increase in velocity (HI group) were com-
pared with those of subjects with less improvement (LO group) using an
independent T-test with a p value of < .05. Results:Velocity increased after
intervention by 0.144 m/sec with the HI group vs. 0.016 m/sec with the
LO group. Subjects in the HI group displayed greater increases of preswing
ankle plantarflexion angle [+3.8 deg vs -0.2 deg], ankle plantarflexion
power [+0.248 W/kgm vs +0.031 W/kgm], terminal stance hip extension
angle [+5.8 deg vs -0.7deg], hip flexor moment [+0.154 Nm/kgm vs -.031
Nm/kgm], and hip flexor power [+0.188 W/kgm vs 0.006 W/kgm].
Furthermore, intensity of soleus activation was also significantly greater in
the HI group subjects after the intervention [15%max vs 0.3%max].
Conclusions: Increased activation of soleus, promoting an improvement
of the trailing limb posture, combined with changes in hip and ankle bio-
mechanics during terminal stance and pre-swing, were associated with the
greatest increase in gait velocity in individuals post-stroke that completed
a task-specific and/or strength training program designed to improve loco-
motor recovery. Clinical Relevance: Biomechanical analyses can be an
effective tool for understanding the mechanisms that underlie responsive-
ness to physical therapy interventions, therefore allowing a more targeted
approach to ameliorating impairments to function.
Supported by The Foundation for Physical Therapy as part of
PTClinResNet.
HIP JOINT POSITION AFFECTS VOLITIONAL KNEE EXTENSOR
ACTIVITY POST-STROKE. M. Lewek1, T. Hornby1, Y. Dhaher1, B. Schmit2,
1
Sensory Motor Performance Program, Rehabilitation Institute of Chicago,
Chicago, IL, 2Marquette University, Milwaukee,WI.
Purpose/Hypothesis: Individuals post-stroke often exhibit significant
functional limitations due to either inadequate or inappropriate volitional
muscle activation. In the lower extremity this is particularly apparent dur-
ing ‘spastic paretic stiff-legged gait’, which has been attributed to excessive
quadriceps activity during the stance to swing transition.The mechanism
underlying the altered volitional activation of the knee extensors has yet to
be elucidated; however, evidence from animal and human models has
demonstrated the importance of hip angle sensors in modulating lower
extremity muscle activity.Although the hip’s position has become a focus
for retraining ‘normal’ walking patterns following stroke, there are as of
yet, no quantitative studies which examined the influence of hip angle
afferent information during isolated volitional muscle activation after
199 J ournal of N eurological P hysical T herapy
stroke.The purpose of this study was therefore to quantify the role of hip
joint positioning on the volitional activation of the uniarticular knee exten-
sor muscles after stroke. It was hypothesized that greater hip flexion
would yield greater quadriceps activity. Number of Subjects: Fourteen
subjects with chronic (> 1 yr) stroke were recruited for testing.
Materials/ Methods: Subjects were positioned on a Biodex dynamometer
to record the electromyographic (EMG) activity from the uniarticular knee
extensor muscles [vastus lateralis (VL) and vastus medialis (VM)] during
maximum voluntary isometric knee extension contractions.The knee was
fixed at 60º, while hip position was fixed by altering the subject’s posture
in random order to include: sitting upright (90º), semi-reclined (45º), and
supine (0º). EMG data was full wave rectified and low pass filtered to pro-
duce a linear envelope.The outcome variable of interest was the integrated
EMG activity around peak torque production. A two-way (muscle and hip
position) repeated-measures ANOVA (repeated for hip position) was used
to determine the effect of varying hip posture on knee extensor activity.
Results: Hip position had a substantial effect on the amount of volitional
VL and VM muscle activity produced (p=0.07).With the hip positioned in
full extension, both muscles were volitionally activated significantly less
than when the hip was positioned in flexion (p=0.03). Conclusions:The
angle of the hip joint appears to play a significant role in the volitional acti-
vation of the uniarticular knee extensors, although more data is required.
Patients with stroke tend to walk with the hips in greater flexion, which
may facilitate activation of the knee extensors contributing to ‘stiff knee
gait’ pattern. Clinical Relevance: Hip joint angle contributes to the mod-
ulation of volitional quadriceps activation and likely influences reflex-
ive/spastic activation contributing to inappropriate muscle activity during
functional activities.A strong emphasis should therefore be placed on hip
joint posturing during gait retraining to assist with appropriate muscle
activation patterns.
DEVELOPMENT AND VALIDATION OF CIRCUMDUCTION ASSESS-
MENT SCALE FOR INDIVIDUALS WITH HEMIPLEGIA. JL Moore1, HR
Roth1, M. Lewek1,YY. Dhaher1,TG. Hornby2, 1Sensory Motor Performance ,
Rehabilitation Institute of Chicago, Chicago, IL, 2Department of Physical
Therapy, University of Illinois of Chicago, Chicago, IL.
Purpose/Hypothesis: Circumduction is a compensatory technique com-
monly observed in individuals with hemiparesis following unilateral
stroke.This maladaptive strategy is a combination of hip abduction and hip
hiking to produce a hemi-circular movement of the leg during the swing
phase of gait. Such movements increase energy expenditure and may result
in unstable walking patterns. Despite subjective clinical evidence suggest-
ing that circumduction movements are common in individuals following
stroke there is no standardized definition or clinical rating tool to quantify
circumduction. Our purpose is therefore to develop a reliable and valid rat-
ing scale to quantify circumduction based on observational gait analysis.
Number of Subjects:Ten subjects were recruited for this study. All sub-
jects had chronic (>1 year) stroke with resulting hemiplegia and presented
with hip circumduction during ambulation. Materials/Methods: The
Circumduction Assessment Scale (CAS) is an 11 point rating scale of cir-
cumduction, which we define as a lower extremity movement performed
during the swing phase of gait in which the heel of the hemiparetic limb
moves lateral to the foot’s position during stance. Subjects underwent
videotaped optoelectronic gait analysis for the purposes of collecting 3D
trajectories of limb segments. Physical therapists scored circumduction on
the CAS while viewing the videotaped sessions. Spearman rank correlation
coefficients were used to assess the validity of the CAS by comparing the
objective gait measures during the computerized gait analysis to the ther-
apist’s ratings on the CAS.The precision of the rating scale was investigated
by calculating the standard error of estimating the peak circumduction
length during swing. The inter- and intra-rater reliability of the CAS was
assessed by ICCs. Results:We developed the CAS to serve as an objective
measure of circumduction in patients with hemiplegia. The results to
date indicate that physical therapists can reliably measure circumduction
using clinical gait analysis using the CAS, with an ICC of 0.896.
Conclusions:The CAS was designed to be a reliable and valid measure of
limb circumduction in individuals with hemiplegia using only clinical gait
assessment. The CAS has the potential to be a reliable measure of limb cir-
cumduction during gait in the chronic stroke population. Clinical
Vol. 29 • No. 4 • 2005
Relevance: The CAS may be used to assess the effect of a specific treat-
ment intervention, or changes in an individuals gait over time. Objective
documentation of gait impairments has the potential to improve insurance
coverage and demonstrate the need for further therapy.This scale can be
integrated into therapists’ and researchers’ evaluations, treatment plans/
protocols, goal setting, and may aid in development of improved rehabili-
tation techniques for gait recovery in patients with stroke.
SENSORIMOTOR IMPAIRMENTS AND REACHING PERFORMANCE IN
PERSONS WITH HEMIPARESIS: RELATIONSHIPS DURING THE
ACUTE AND SUBACUTE PHASE AFTER STROKE. JM. Wagner1, CE.
Lang1, SA. Sahrmann1, D.F. Edwards2, AW. Dromerick3, 1Program in Physical
Therapy,Washington University School of Medicine, St. Louis, MO, 2Program
in Occupational Therapy, Washington University School of Medicine, St.
Louis, MO, 3Department of Neurology, Washington University School of
Medicine, St. Louis, MO.
Purpose/Hypothesis: The purpose of this study was evaluate the rela-
tionships between measures of upper extremity (UE) sensorimotor impair-
ment and reaching performance in patients with hemiparesis during early
recovery after stroke, and to evaluate how measures collected shortly after
stroke are related to future performance. Number of Subjects: 33 patients
(age = 64.1) with mild-moderate hemiparesis resulting from a stroke were
tested twice: acutely (average = 9.8 days) and subacutely (average = 108.6
days). Materials/Methods: UE isometric strength of the shoulder, elbow,
and wrist flexors/extensors was assessed using a hand held dynamometer.
Shoulder pain, tactile sensation, joint position sense, and spasticity were
assessed using standard clinical tests. UE active range of motion (AROM),
isolated joint movement, and reaching performance were assessed using a
3-D motion capture system.The strength of each muscle group was repre-
sented as a ratio of involved to non-involved force.A composite UE strength
score was calculated by taking the mean of the ratio values.A composite UE
tactile sensation score was calculated by averaging the monofilament
scores.The ability to perform isolated movement at each joint was quanti-
fied by calculating an individuation index (II) for the shoulder, elbow, and
wrist joints. AROM was calculated during the isolated movement task.
Reaching performance was assessed during the initial phase of reaching.
Reaching performance variables were movement speed (peak wrist veloc-
ity), accuracy (endpoint error) and efficiency (reach path ratio). Pearson
product moment correlations were used to describe the relationships
between impairment and reaching performance. Results: Acutely, AROM
and strength were moderately correlated with all reach variables. These
relationships were maintained in the subacute phase. Isolated movement
control was moderately correlated with all reach variables during the acute
phase but was poorly correlated to reaching during the subacute phase.
Somatosensory impairments were poorly correlated to reaching perfor-
mance during both phases. AROM was the only impairment measured in
the acute phase that was moderately correlated with subacute reaching
performance.All other acute impairment measures were poorly correlated
with subacute reaching performance. Conclusions: UE AROM had the
strongest and most consistent relationship with reaching performance dur-
ing the acute and subacute phases after stroke. Clinical Relevance: The
ultimate goal of UE rehabilitation is to promote use of the UE. These data
illustrate the importance of objectively quantifying UE AROM during the
acute phase after stroke since it was the only clinical impairment measure
that demonstrated a moderate relationship with future performance.
NEUROMUSCULAR STIMULATION IMPROVES GRASPING FUNCTION
IN INDIVIDUALS WITH CHRONIC STROKE. B. Quaney1, LH. Zahner1,
MJ. Santos2, Z. Kadivar2, B. McKiernan3, 1Landon Center on Aging, University
of Kansas, Kansas City, KS, 2Physical Therapy and Rehabilitation Sciences,
Kansas University Medical Center, Kansas City, KS, 3Physical Therapy
Education, Rockhurst University, Kansas City, MO.
Purpose/Hypothesis: Despite rehabilitation efforts, 60% of individuals
continue to have significant upper extremity (UE) disability one year post-
stroke. It is unclear if manual dexterity can be further improved after this
time.The purpose of this pilot study was twofold: 1) To determine if neu-
romuscular stimulation (NMES) improves grasping function in individuals
with chronic stroke, and 2) To determine if grasping function is enhanced
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
when NMES is used during functional task training. Number of Subjects:
Six subjects (4 FE, 2 M, 58 ± 2.9 y/o) with chronic ischemic stroke (3 - 10
yrs. post-stroke) and severe hand dysfunction participated in this study.
Inclusion criteria: a) 10 deg. passive wrist extension, c) 90% passive exten-
sion of the fingers and thumb with the wrist in a neutral position, and d)
no evidence of other neurological disorders. Subjects did not participate in
other UE exercise programs during the study. Materials/Methods: Each
subject received two applications of NMES (passive or functional) in a
counterbalanced order (30 min x 5x/wk x 2 wks). Passive NMES was per-
formed by placing the impaired forearm in a mid-position and stimulating
the wrist flexors and extensors to produce two contractions/minute (30
contractions: 300usec pulse width @ 40 Hz; 2s ramp up/down with a 6s
hold). Functional NMES when grasping and releasing a tennis ball was per-
formed using single channels from two separate stimulators with manual
switches (30 grasp-releases: 300usec pulse width @ 40 Hz; 0.1 on/off
ramp). UE motor performance speed, function and strength was measured
at baseline, following treatment and 2 weeks after treatment using con-
ventional clinical tests: a) UE Fugl-Meyer (FM) (66 total points possible), b)
Box to Block (BB), i.e., the number of 1-inch blocks transported per
minute, c) Jebsens Dexterity Test (JDT) (7 tasks), d) Grip Strength (GS) and
e) Pinch Strength (PS). Results: While subjects generally improved their
motor performance speed, function and strength with both applications of
NMES, significant gains in fine motor skills were specific to the functional
NMES. Compared to baseline, functional NMES increased movement
speeds in the JDT by 17% (p< 0.02) and increased FM scores by 19% (p<
0.05). In contrast, passive NMES only demonstrated significant gains in FM
(18%; p< 0.04). JDT improvements using functional NMES continued to be
significant two weeks after treatment. Conclusions:These results are con-
trary to the prevailing clinical view that UE motor recovery is limited to 1
year post-stroke. NMES appears to be a viable method in which to facilitate
motor performance gains in chronic stroke. The increased grasping func-
tion observed with this brief therapeutic intervention is most likely due to
mechanisms other than muscle hypertrophy. Clinical Relevance: The
increased movement speeds (JDT) suggest that fine motor control can be
improved by applying NMES during a grasping task. Further study is war-
ranted to determine if specific types of NMES applications are appropriate
across UE disability levels.
BILATERAL MOTOR OUTPUTS FROM THE RETICULOSPINAL SYS-
TEM TO THE UPPER LIMBS DURING REACHING IN THE MONKEY.
JA. Buford1, AG. Davidson2, 1Physical Therapy, The Ohio State University,
Columbus, OH, 2Neurobiology and Anatomy, University of Rochester
Medical Center, Rochester, NY.
Purpose/Hypothesis:This study describes the motor outputs and neural
activity of the reticulospinal system in the monkey during reaching. The
hypotheses are 1) that single sites in the reticular formation will produce
bilateral motor outputs to the upper limbs and 2) that neural activity in the
reticulospinal system will code for the preparation as well as the execution
of upper limb movement during voluntary reaching. Number of Subjects:
2 young adult male <Macaca fascicularis> monkeys were the subjects.
Materials/Methods: Subjects were trained to reach with the R or L arm to
a target on the R or L side, depending on instructions given during a wait-
ing period before each trial.An electrode positioning system was then sur-
gically implanted, allowing daily access to the brainstem with tungsten
microelectrodes in the awake, behaving animal. Single-pulse microstimula-
tion at 10 Hz was applied to areas throughout the reticulospinal system in
the brainstem as EMG was recorded throughout the shoulder girdle and
upper limbs (24 muscles). Extracellular action potentials were also
recorded from cells in this region. Neural activity patterns in relation to
preparatory and movement-related periods of the task were analyzed as
were averaged muscle responses to microstimulation. Results:
Microstimulation of the reticulospinal system tended to inhibit extensors
and facilitate flexors ipsilateral to the stimulus and produce the opposite
effects contralaterally. Effects were strongest and most frequently elicited in
the extensors and in the proximal muscles, especially the upper trapezius.
Bilateral effects were the norm, though some sites did produce strictly ipsi
or contralateral effects in the muscles studied. About 25% of the 196 neu-
rons analyzed had activity related to preparation, 25% had activity related to
preparation and to movement, and 50% had only movement-related activity.
200
About 30% of the neurons had activity that was related to the arm used for
reaching, and 30% (non-exclusive) had activity related to the target con-
tacted. Only about 10% had activity that was unique to a certain hand-tar-
get combination. Conclusions: Reticulospinal neurons have motor output
effects and neural activity patterns during movement that demonstrate a
role in the control of voluntary reaching. Effects were observed in the
shoulder girdle, shoulder, elbow, and even at the wrist. Characterization of
the reticulospinal system as strictly for postural control or for control of
locomotion may be oversimplified.This major descending system also con-
tributes to the execution of discrete, skilled reaching movements. Clinical
Relevance: The motor patterns emanating from the reticulospinal system
are reminiscent of the limb movements associated with the ATNR and with
synergies associated with recovery from stroke. The present findings lend
strength to the long-held concept that the reticulospinal system may be an
alternative pathway for voluntary motor control after stroke.
THEMATIC POSTER SESSION: Motor Learning
Saturday 1:30-3:30
TELEREHABILITATION FOR MOTOR RETRAINING IN PATIENTS
WITH STROKE. MK. Holden, T.. Dyar1, E. Bizzi1, L. Schwamm2, L. Dayan-
Cimadoro3, 1Dept. of Brain & Cognitive Sciences and Mc Govern Institute
for Brain Research, Massachusetts Institute of Technology, Cambridge, MA,
2
Clinical Research Center, Massachusetts Institute of Technology,
Cambridge, MA, 3Dept. of Physical Therapy, Spaulding Rehabilitation
Hospital, Boston, MA.
Purpose/Hypothesis:To assess the clinical feasibility and effectiveness of
providing home-based virtual environment (VE) training using a remotely
controlled telerehabilitation system. Number of Subjects: 12 patients
with chronic stroke were admitted; 1 patient dropped out prior to start of
training. Mean age for subjects who completed training was 56.7 ± 15.6yr.;
duration post-injury was 5.8 ± 4.4yr.; gender, 6 male, 5 female; involved
side, 5 Right, 6 Left. Mean upper extremity (UE) Fugl-Meyer (FM) motor
score (max=66) at entry was 38.3 ±13.8. Materials/Methods:Treatment
intervention consisted of 30 one-hr sessions of real-time interactive VE
motor training for the involved UE, delivered remotely by a therapist via
the internet, 5x/wk for 6 wk. During training, patients practiced move-
ments within virtual ‘scenes’ designed to elicit goal oriented movements.
Outcome measures FM, Wolf Motor test (WMT) and Strength (grip, shoul-
der flexion) were given Pre-training, Post 15 and 30 sessions, and at 4 mo.
follow-up. Stability of motor recovery prior to training was assessed with
FM (2 tests, 1-12wk apart). Paired t-tests were used to assess significance.
Results: Mean values for the 2 baseline FM-UE tests showed no significant
difference (-0.3 +/- 1.6, p=0.56), indicating stable motor recovery prior to
VE training via telerehabilitation. Following training, mean FM-UE Motor
scores improved significantly after 15rx (+2.5, p=0.003), after 30rx (+6.7,
p=<0.0001), and at 4 mo. follow-up (+7.6, p=0.001). Mean WMT scores
improved significantly after 15rx (-6 sec, p=0.0235), after 30rx (-15.5sec.,
p=0.0097), and at 4 mo. follow-up (-18.4 sec., p=0.0032). Shoulder Strength
improved after 15rx (40%, p=0.0027), 30rx (69%, p=0.0010) and at follow-
up (66%, p=<0.0001). Grip Strength improved significantly after 30rx
(44%, p=0.0253) but was only partially maintained at followup (26%,
p=0.0897). Conclusions: Subjects’ improvements indicate that VE training
conducted remotely over the internet is feasible and may be a viable new
method for neurorehabilitation. Subjects gains on all 3 clinical measures
(FM,WMT, Strength) show that they were able to generalize motor training
received in VE to real world performance, even to tasks not specifically
trained in VE, and to retain gains for 4 mos. Our results concur with those
of others, that subjects with chronic stroke are capable of significant
motor improvements even many years s/p stroke. Clinical Relevance:The
novel home-based treatment method used in this study may provide advan-
tages and a viable treatment alternative for patients with stroke. For exam-
ple, the difficulty of obtaining transportation to/from therapy clinic is
avoided; no commute also allows patients to have more energy to devote
to motor practice during sessions, and facilitates more intense frequency
of treatment. VE motor retraining via telerehabilitation appears effective
in improving UE motor control and functional performance in subjects
with chronic stroke; in addition it provides a fun and motivating treatment
alternative to standard therapy exercises.
201 J ournal of N eurological P hysical T herapy
Supported by NIH Grants No. HD40959, HD40959-02S1 and 3MO1RR
01066-25S.
EFFECTS OF RANDOM AND BLOCKED ORDER PRACTICE ON
MOTOR LEARNING IN INDIVIDUALS WITH PARKINSON DISEASE. C.
Lin1, CJ Winstein1, KJ Sullivan1, AD Wu2, 1Biokinesiology and Physical
Therapy, University of Southern California, Los Angeles, CA, 2Neorology,
University of Southern California, Los Angeles, CA.
Purpose/Hypothesis: In general, random order practice has been shown
to be superior for motor learning in young adults compared to blocked
order task practice. Random practice is thought to be beneficial to learn-
ing since the learner’s task-switching capability is strengthened. Since indi-
viduals with Parkinson disease (PD) have a task-switching deficit, the pur-
pose of this study is to investigate the effects of practice order on learning
goal-directed arm movements in individuals with PD compared to age-
matched controls (CN). We hypothesize that blocked order practice is
superior for motor learning for those with mild PD. Number of Subjects:
Ten adults with mild PD (mean age= 68.7 yrs; Hoehn & Yahr I or II; ran-
domly assigned to either blocked practice, PDB, n=5, or random practice,
PDR, n=5) and 8 age-matched controls (mean age= 57.1, assigned to
blocked practice, CNB, n=4, or random practice, CNR, n=4) participated.
Materials/Methods:All participants practiced 3 lever arm movement pat-
terns, each with specific spatial and temporal requirements. Performance
accuracy was quantified across acquisition and delayed (day 2) retention
test using root mean square error (RMSE) and timing error (TF). Results:
Both groups (PD and CN) decreased error (RMSE) across practice (p<
.01).At the end of acquisition, the control groups showed more accurate
performance than the PD groups. In delayed retention, the control subjects
who practiced in the random condition had lower RMSE than those that
practiced in the block condition (effect size, ES=0.7). Interestingly, this was
not the case for the PD groups. Consistent with our hypothesis, the PD sub-
jects who practiced with a blocked schedule were more accurate in
delayed retention than the PD subjects who practiced in the random con-
dition (ES= 0.8 for group RMSE difference). In addition, the temporal accu-
racy was better for the PD group that practiced in the block condition (ES=
0.8 for group TE difference). Conclusions: Consistent with our hypothe-
sis, adults with PD learned motor skills better in blocked order practice
than in random order practice. Clinical Relevance: This pilot data sug-
gests that conditions of practice that may be beneficial for motor learning
in healthy adults may not be as effective for individuals with PD in which
task-switching deficits are commonly present.
LEARNING EFFECT ASSESSMENT ON SUBSEQUENT SUBJECT PER-
FORMANCE ON THE EQUITEST. BALANCE SYSTEM. B. Gilliam, D.
Charles, S. Kathmann, J. Smith, N.S. Darr, D. Greathouse, Belmont University,
Nashville,TN.
Purpose/Hypothesis: The sensory organization test (SOT) assesses the
ability to maintain equilibrium as somatosensory, vestibular, and visual
input is altered in a systematic manner. Previous studies have suggested
the possibility of a learning effect with repeated SOTs.The purpose of our
study was to determine if a learning effect occurred with repeated admin-
istration of the SOT over two test days performed one week apart.
Number of Subjects: Thirty-five healthy subjects (20 female, 15 male)
between 22 and 57 years old participated in this study.
Materials/Methods: Subjects signed an informed consent approved by
Belmont University Institutional Review Board and underwent a short
physical examination to determine eligibility. Exclusion criteria included
previous experience with the EquiTest |*regis*| System or other sensory
organization testing equipment, vision outside the range of 20/20 to 20/60,
positive Rhomberg test, lower extremity strength or ROM deficits, or lower
extremity injury within last 6 months. Data were collected using the
NeuroCom EquiTest Regis System. Testing occurred during two separate
sessions seven days apart. During the first testing session subjects com-
pleted a baseline SOT, performing three trials of each of the six conditions
for a total of 18 trials. Two additional SOTs (post test 1 and post test 2)
were performed on the first day of testing. One week later subjects
returned and completed three additional SOTs (post tests 3, 4, and 5) using
the identical protocol to the first day of testing. Mean equilibrium scores
Vol. 29 • No. 4 • 2005
were calculated from subject performance during the 6 conditions.
Composite equilibrium scores were calculated using the weighted average
of the 6 equilibrium scores Composite equilibrium scores and mean equi-
librium scores for each SOT were analyzed using one-way repeated mea-
sures ANOVA. Significant differences from baseline scores (p≤0.05) were
examined further using paired t-test comparisons with a Bonferroni cor-
rection. Results:There was a significant increase in mean equilibrium SOT
scores from baseline across post-tests 3 and 4, and there was a significant
increase in composite equilibrium SOT scores from baseline across post-
test 3.When each testing condition was analyzed separately, only condition
3 showed statistically significant improvements from baseline across all six
SOTs; however, the SOT score patterns across the six testing conditions are
consistent with those found in previous research throughout all six SOTs.
Conclusions:The increase in performance during post-test 3 and post-test
4, which were performed one week after baseline testing, is indicative of a
learning effect which is most likely due to the subject learning how to
anticipate and cope with impaired visual feedback or altered propriocep-
tive input. Clinical Relevance: Clinicians and researchers should be
aware that mean equilibrium scores and composite equilibrium scores
may increase with practice even when subjects are tested a week later.
UPPER LIMB FUNCTIONAL RESPONSE TO MOTOR LEARNING
ALONE AND MOTOR LEARNING WITH FUNCTIONAL NEUROMUS-
CULAR STIMULATION FOR STROKE SURVIVORS. JJ Daly1, J. Rogers2, I.
Brenner2, E. Perepezko2, M. Dohring2, E. Fredrickson2, J. Gansen2, 1Neurology,
Case Western Reserve University School of Medicine, Cleveland, OH,
2
Research Service, LS Cleveland VA Medical Center, Cleveland, OH.
Purpose/Hypothesis:The purpose of the study was to test two interven-
tions in chronic stroke survivors (>12 months) with moderate to severe
upper limb functional deficits.The two interventions were: 1) motor learn-
ing (ML-alone); and 2) functional neuromuscular stimulation along with
motor learning (FNSML). Number of Subjects: Eighteen. Materials/
Methods: Eighteen subjects were stratified according to the Fugl-Meyer
Upper Limb Coordination Scale and randomized to: FNSML or ML-alone.
Subjects had a Trace wrist extensor grade. Many had 0 grade finger flex-
ors/extensors. Treatment was: 5 times/wk for 12 weeks. The therapist
patient ratio was 1:3. Subjects practiced task components and full task per-
formance (60-tasks array). For 1.5 hrs of each daily session, FNS was pro-
vided for the subjects in the FNSML group.A two-channel, surface stimula-
tor, the EMS+2 (Staodyne, Inc., Longmont, Colorado) was used for
finger/wrist flexors/extensors and lower/middle trapezius. The waveform
was biphasic, symmetric, and rectangular. Stimulus parameters were:
300microsecs phase duration; 30Hz; amplitude, 1mA to the highest com-
fortable stimulus; and 10secs on/10secs off duty cycle (1sec ramp up,
10secs on, 1 sec ramp down, 10secs off). Subjects practiced single and mul-
tiple joint movements using FNS, including the following movements: alter-
nating wrist flexion/extension; and simultaneous wrist extension and finger
flexion. FNS was used in conjunction with task component movements like
preparation before grasping an object. Outcome measures were: 1) the Arm
Motor Ability Test (AMAT); 2) the AMAT wrist/hand components
(AMATW/H); and 3) the Functional Independence Measure. The AMAT is
comprised of 13 functional tasks (using knife/fork; grasping mug handle
and drinking from cup). Pre-treatment baseline comparisons between the
two groups were made using t-test.Within-group, pre-/post-treatment com-
parisons were made using t-test. Group comparisons in response to treat-
ment were made using an ordinal regression model (PLUM Ordinal Model,
SPSS) for the FIM. Post-treatment FIM score was the dependent variable,
pre-treatment was a co-variate, and group assignment was the independent
variable. Results: At baseline, there was no significant difference between
the two groups for the outcome measures (p>.05). In response to treat-
ment, there were significantly greater gains for FNSML group versus ML-
alone, according to the FIM (p=.003). In response to treatment, FNSML had
significant improvement in the AMAT, AMATW/H, and FIM (p= .042, .036,
and .007, respectively); whereas the ML-alone group did not (p=.167; .242;
.068, respectively). Conclusions: Results suggested that FNSML could be
functionally beneficial for moderately to severely involved stroke survivors
with chronic deficits. Clinical Relevance:The treatment was successfully
offered with a therapist: patient ratio of 1:3. Moderately to severely involved
stroke survivors with chronic deficits can benefit from intervention.
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
PROCEDURAL LEARNING OF FUNCTIONAL MOBILITY TASKS IN
THE PRESENCE OF SEVERE MEMORY DEFICITS FROM INTRAVEN-
TRICULAR HEMORRHAGE. K.A.Volk, R.O. Myers, E. Fitzpatrick-DeSalme,
MossRehab, Philadelphia, PA.
Background & Purpose: Memory deficits frequently occur in patients
with both acquired and traumatic brain injuries. Declarative memory, or
learning of facts and events, is often impaired in these patients. However,
procedural memory, or learning of motor skills, is often preserved. This
case report describes how a severely amnestic patient was able to learn
functional mobility tasks in physical therapy through the use of procedural
learning techniques. Case Description:A 52-year old woman suffered an
intraventricular hemorrhage in all 4 ventricles. She was oriented to person
only, and presented with significant anterograde and retrograde amnesia.
She demonstrated severe declarative memory deficits with no awareness
of the tasks that she was practicing in therapy. Her working memory was
also devastated. Within minutes she would be unable to recall what she
was doing while she was performing a specific skill. Upon admission she
was dependent in all areas of functional mobility. Physical therapy inter-
vention consisted of repetitive procedural learning techniques. Functional
mobility training included regimented routines with consistent, brief cues
provided on a minute-to-minute basis to re-orient the patient to the current
task. Novel tasks consisted of wheelchair propulsion and ambulation with
a rolling walker. Outcomes:The patient remained disoriented to place, rea-
son for hospitalization, date, and time. She remained unable to actively
recall or describe the functional tasks that she performed in therapy on a
daily basis. Despite the severity of her deficits, she progressed from a
dependent to a minimal assist level of overall function with the provision
of frequent and discrete verbal cues. Discussion:The literature supports
the use of procedural learning for those lacking declarative and working
memories. However, the majority of this research utilized small samples
that significantly limit the ability to generalize their findings to this partic-
ular population as a whole.The literature also does not involve the use of
real-world tasks or functional mobility skills. Physical therapists often con-
front the challenge of treating patients who suffer severe memory impair-
ments resulting from neurologic insult or disease processes. Despite the
difficulties that these patients present, therapists can successfully use tech-
niques involving procedural learning when training functional mobility
tasks in order to facilitate the acquisition of such skills and to increase
functional outcomes overall.
POSTERS
VASOMOTOR INNERVATION PATTERNS OF PERIPHERAL NERVES
SUPPLYING THE DISTAL LOWER EXTREMITY. RJ Allen1, EM Jefferson2,
VK Bhangu3, 1Physical Therapy, University of Puget Sound, Tacoma, WA,
2
UCI, Irvine, CA, 3Royal Medical Institute, New Delhi, INDIA.
Purpose/Hypothesis: Investigate innervation patterns to the arterial sys-
tem of the leg and foot from eight major peripheral nerves and compare
these vasomotor innervation patterns with somatosensory distribution
fields. Number of Subjects: Seven adult volunteers (5 females, 2 males), age
ranging from 31 to 64 yrs (x = 39), reporting no history of vascular pathol-
ogy or insufficiency, peripheral neuropathy, chronic lower limb pain, hyper-
tension, or hypersensitive responses to amine-type anesthetics.
Materials/Methods: Peripheral nerves studied included superficial and
deep fibular, sural, saphenous, and tibial nerves, along with the tibial nerves
medial and lateral plantar and medial calcaneal branches. On eight days, with
at least 24 hour separation, each subject received a neural blockade to one
nerve following thermal stabilization in a 16o C climate controlled chamber.
Neural blockade temporarily interrupted local sympathetic innervation to
arteries supplied by the nerve resulting in vasodilation and superficial
hyperemia. Fields of hyperemia represented the vascular innervation field of
the nerve and was imaged using digital thermography.The anesthetic agent
was 1.8 ml of 3% Carbocaine hydrochloride solution injected at each nerves
most proximal selective location using tissue infiltration. Success and selec-
tivity of each block was established via somatosensory testing using Semmes
Weinstein monofilaments. Results: All subjects showed consistency in
hyperemia fields for each of the nerves blocked. In most cases, vasomotor
innervation fields corresponded with expected sensory patterns. Notably
202
different from sensory distributions were the vasomotor fields for superfi-
cial and deep fibular nerves. Deep fibular nerve blockade produced hyper-
emia of the entire lateral leg and proximal aspect of the foots dorsum, then
into the webspace between digits 1 and 2. Blocking the superficial fibular
nerve produced vascular change only in the middle aspect foots dorsum
extending through digits 2 through 5. Hyperemia was not observed during
single distal branch blockades for the plantar surface between digits 3 and
4, suggesting dual innervation. Conclusions: Vasomotor innervation fields
of the leg and foot from peripheral nerves show patterns similar to sensory
innervation, with the exception of vascular fields supplied by superficial and
deep fibular nerves.These patterns are consistent with the hypothesis that
peripheral nerves innervate principle adjacent blood vessels, thus produc-
ing potential neurovascular symptoms that may deviate from expected sen-
sory patterns. Clinical Relevance: Prior studies established that upper
limb vasomotor innervation varies from well known sensory patterns.
Upper extremity vasomotor innervation charts are proving useful in estab-
lishing neurovascular etiologies for atypical symptom patterns due to
peripheral neuropathies. The present study represents the initial phase of
investigating vasomotor innervation to the lower extremity in an effort to
arrive at a complete mapping of arterial innervation of the limbs.
LASER MICRODISSECTION OF BRAIN STEM NEURONS TO EXAMINE
CHANGES IN GENE EXPRESSION AFTER SPINAL CORD INJURY. SR
Allen1, JD Houle2, 1University of Central Arkansas, Conway,AR, 2Department
of Neurobiological and Developmental Sciences, University of Arkansas for
Medical Sciences, Little Rock,AR.
Purpose/Hypothesis: Previous studies have used in situ hybridization
indicating changes in regeneration-associated genes (RAGs) expression to
measure the effects of neurotrophic factors administered to damaged neu-
rons after spinal cord injury (SCI). In-situ hybridization is a lengthy process
for recording gene expression.The goal of this preliminary study was to use
a more time efficient method of laser microdissection and quantitative poly-
merase chain reaction (Q-PCR) to determine the effects of glial cell-line
derived neurotrophic factor (GDNF) on the expression levels of (RAGs) in
red nucleus neurons affected by a cervical level SCI. Number of Subjects:
Six female Sprague-Dawley rats. GDNF treated rats, experimental group
(N=3) Saline treated rats, control group (N=3). Materials/Methods: Six
adult female Sprague-Dawley rats underwent surgery for the complete
removal of a 2mm hemi-section on the right side of their spinal cord.
During the surgery, one group of rats was treated with GDNF at the site of
the hemi-section for one hour.The second group of rats was administered
saline to serve as a control. Two days after the surgery, animals in both
groups were sacrificed and red nucleus neurons in the midbrain were iso-
lated via laser micro dissection techniques. Neuronal mRNA was prepared
for Q-PCR.The RAGs measured were BII-tubulin and growth associated pro-
tein-43 (GAP-43). Actin was used as the housekeeping gene for controlled
gene expression. Results:The results of the Q-PCR showed no significant
difference in the RAGs expression levels between injured and uninjured
neurons of the red nucleus two days after SCI. However, there was a trend
for increased expression of BII-tubulin mRNA in the injured red nucleus
neurons during this time frame. For spinal cord injuries treated with GDNF
at their lesion site, no significant increases were found in the expression of
the RAGs. However, a trend towards the increase of a growth-associated
protein (GAP-43) mRNA for the GDNF treated group was indicated during
this time frame. Conclusions:These results demonstrate the ability to mea-
sure changes in gene expression in specific neurons after a traumatic injury.
It is possible that significant effects of acute treatment with GDNF may be
detected after longer periods post injury and treatment. Follow-up studies
are planned for using larger sample groups and looking at the effects of
GDNF on RAGs gene expression at various time periods after injury and
treatment. Clinical Relevance: By observing the effects of neurotrophic
factors on changing the gene expression of RAGs and genes important to
the survival of damaged neurons after SCI, it may be beneficial to treat
patients with neurotrophic factors following SCI.
MOVEMENT CONTROL AND CORTICAL ACTIVATION IN FUNC-
TIONAL ANKLE INSTABILITY. K. Anderson, J.R. Carey, Program in
Physical Therapy, University of Minnesota, Minneapolis, MN. (See Imagery
and Imaging Thematic poster session for abstract)
203 J ournal of N eurological P hysical T herapy
EFFECT OF WALKING VS SHAM TREATMENT ON FINGER MOVE-
MENT CONTROL AND BRAIN REORGANIZATION IN WELL ELDERLY.
S. Anderson, H. Aldrich, S. Knight, C. Battles, J.R. Carey, University of
Minnesota, Minneapolis, MN. (See Imagery and Imaging Thematic poster
session for Abstract)
ASSESSING FACTORS IMPACTING COMMUNITY MOBILITY AFTER
STROKE: A PILOT STUDY. J. Beaverson, L. Beaudreau, J. Filkowski, C.A.
Robinson, P. Noritake Matsuda, A. Shumway-Cook, Dept of Rehabilitation,
University of Washington, Seattle,WA.
Purpose/Hypothesis: Limited community mobility is a common occur-
rence following stroke and is associated with disability in both basic and
instrumental activities of daily living. The skills and factors affecting com-
munity mobility following stroke are largely unknown.This pilot study mea-
sured participation in community mobility among survivors of stroke and
examined the relationship between clinical measures of sensation, strength,
balance, and gait and participation in community mobility in order to iden-
tify factors constraining community mobility following stroke. Number of
Subjects: Thirteen adults diagnosed with stroke (mean age 64 ± 7; mean
time since stroke 66 mos, independent ambulators) and 19 older adults
(mean age 78 ± 6) without stroke participated. Materials/Methods:
Measures included self-reported trips/activities into community, perfor-
mance on Berg Balance Test (BBT), 10m-gait velocity, Rivermead Mobility
Index (RMI) and Dynamic Mobility Evaluation (DYME). Impairment testing
included dynamometer measures of lower extremity (LE) strength, gonio-
metric measures of LE range of motion (ROM), ankle spasticity, and LE sen-
sation. Results: Participation in community mobility following stroke was
characterized by equivalent number of trips into the community, but fewer
walking related activities per trip, as compared to adults without stroke.
Gait velocity and BBT were significantly (p<.001) worse in the subjects
with stroke, and correlated with walking related activities (r =.508, p<.01)
but not trips into the community. Gait velocity was slower on all complex-
walking tasks in the DYME; however there was considerable variability
among subjects with stroke. Some tasks (stairs and obstacles) consistently
affected gait velocity in all subjects with stroke, while others (load and talk)
did not. Impairments in plantar- flexion and hip abduction strength in the
paretic limb correlated with community mobility (activities per trip), and
with other clinical measures of balance and gait. Conclusions: This pilot
study suggests the impact of stroke on community mobility is variable.
Clinical measures of balance, strength (plantarflexor and hip abduction)
and gait velocity are related to level of participation in community mobil-
ity, specifically the number of walking activities performed per trip.
Performance of complex walking tasks was globally impacted by stroke, but
the degree of impact varied by individual and task. Further studies are
needed to confirm results and explore the relationship between locomotor
adaptation and participation in community mobility following stroke.
Clinical Relevance: Community mobility is a highly valued outcome to
patients following stroke and is complex and difficult to measure, with
many factors influencing outcome. Specifically, strength, balance, velocity
and ability to adapt gait appear to be important to ambulation outcomes,
while ROM, sensation, and spasticity may be less important.
DIAZEPAM TOLERANCE EFFECTS ON VESTIBULAR FUNCTION
TESTS FOLLOWING REPEATED ORAL DOSES. PA Blau1, N. Schwade2, P.
Roland2, 1Physical Therapy, UT Southwestern Medical School, Dallas, TX,
2
Otorhinolaryngology, University of Texas Southwestern Medical Center,
Dallas,TX.
Purpose/Hypothesis: Benzodiazepines are used in clinical practice to
suppress acute vestibular symptoms.There have been limited studies look-
ing at the effects of tolerance on parameters designed to measure the
integrity of the vestibular system and its interaction with the oculomotor
and balance systems.The goals of this study were two-fold: 1) to determine
if clinical doses of diazepam (10 mg/day) administered for 14 days impair
performance measures that assess the integrity of the vestibular ocular
reflex and the ocular motor system and 2) to examine if tolerance devel-
ops over time. Number of Subjects: Thirty normal male subjects who
ranged in age from 20-36 years were randomly assigned to placebo or
diazepam group. Materials/Methods:The effects of divided doses of 10
Vol. 29 • No. 4 • 2005
mg diazepam given daily over a 2-week period were recorded using ran-
dom saccadic eye movements (SEM), sinusoidal harmonic acceleration
stimulus for the vestibular ocular reflex (VOR), and subjective ratings of
sedation. Measures were collected at baseline, 90 min after each dose on
days 3, 7, 10, and 14, and 48 hours after drug cessation on day 16. Urine
samples were collected one time per week. Both subjects and investigator
were blinded to treatment condition. Results:The present study indicates
that vestibular function tests are sensitive indicators for drug effects
related to low doses of diazepam between treatment groups. There were
significant effects for the parameters of saccadic latency, self-ratings for
perceived sedation,VOR gain and phase at 0.01, 0.02, 0.04, and 0.08 Hz, but
no effect on saccadic peak velocity or accuracy measures and gain and
phase frequency at 0.16 Hz., indicating selective effects on different CNS
mechanisms. No significant effects for time were seen in any of the vari-
ables measured, but trends were observed, indicating greater impairment
on day 3 of drug administration followed by gradual return toward base-
line by day 16. Conclusions:The results of this investigation demonstrate
that low divided doses of diazepam selectively impair behavioral tests mea-
suring the integrity of the VOR and SEM.These findings confirm previous
literature in man showing an effect for diazepam on both phase and gain
parameters during rotational tests. Studies using vestibular function tests
to evaluate the development of tolerance over time will need to minimize
error variance within and between the treatment groups. Clinical
Relevance: It is still not known if clinical patients need to be drug-free for
48 hours prior to undergoing vestibular function testing. It does appear
that low divided doses of diazepam do not affect the overall interpretation
of VOR results as subjects still remained in the normal ranges. Saccadic
latency and sedation measures appear to be more sensitive to changes over
time and less affected by subject variability than VOR parameters.
THE EFFECTS OF BODY WEIGHT SUPPORTED GAIT TRAINING AND
FUNCTIONAL ELECTRICAL STIMULATION ON GAIT SPEED AND
CONTROL IN AN INDIVIDUAL WITH A TRAUMATIC BRAIN INJURY.
J. Bogle, D. Dennison, K. Gorgos, V. Stivala, M. Pascal, Physical Therapy,
College Misericordia, Dallas, PA.
Purpose/Hypothesis:The purpose of this study was to determine if body
weight supported treadmill training (BWS-TT) and functional electrical
stimulation (FES) would improve gait speed and endurance in an individ-
ual with a traumatic brain injury. Number of Subjects: One. Materials/
Methods:This study had an ABA design. In condition A, the subject partic-
ipated in BWS-TT for 10 sessions. In condition B, he participated in BWS-
TT with the addition of FES for 8 sessions. FES was controlled by a switch
placed in the subject’s left shoe. Unweighting his leg in pre-swing trig-
gered electrical stimulation to the left peroneal nerve to help increase left
swing. In the last phase of the study, the subject again participated in
BWS-TT without FES for 5 sessions. During each session, the subject had
30 percent of his weight supported by the BWS system.Treadmill speed,
distance, and time walked were recorded for each trial of walking.The sub-
ject performed 3 to 4 trials per session. Data Analysis: Distance walked
and walking speed per trial were graphed and visually analyzed using cel-
eration lines drawn using the split-middle technique. Results:The subject
demonstrated improvements in both distance and speed throughout the
course of the study. Examination of the celeration lines revealed he was
able to sustain a higher level of consistent improvement while using FES.
His walking speed on the treadmill improved from 1.1 mph at the start of
the study to 1.7 mph at the end of the first set of BWS-TT sessions. Speed
increased to 2.2 mph at the end of sessions with BWS-TT and FES. When
he resumed BWS-TT only, speed decreased to 2.0 mph; it increased to 2.2
mph at the end of the study. Distance walked per trial improved from 195
feet in the beginning of the study to 369 feet at the end. Conclusions:The
use of BWS-TT can be a useful intervention to increase gait speed and
walking distance in an individual with a traumatic brain injury.Adding FES
during this intervention increased the improvement in this subject.
Clinical Relevance: Decreased independence in gait is a frequent func-
tional limitation in individuals with TBI. Using BWS-TT and FES together
as interventions may help improve gait speed and endurance. The FES
used in this study was relatively inexpensive and easy to apply, making it
feasible for clinical use.
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
RECOVERY FROM STROKE: WHAT IS THE ROLE OF THE UNDAM-
AGED, CONTRALESIONAL CORTEX? L. Boyd, E.D. Vidoni, Physical
Therapy & Rehabilitation Science, University of Kansas Medical Center,
Kansas City, KS. (See: Imagery and Imaging Thematic Poster Session for
Abstract)
DYNAMIC WALKING STABILITY IN HEMIPARETIC CHRONIC
STROKE SUBJECTS. K.P. Brady1, J.M. Hidler1, M.C. Sinopoli2, 1Center for
Applied Biomechanics and Rehabilitation Research, National
Rehabilitation Hospital, Washington, DC, 2Department of Biomedical
Engineering, Catholic University, Washington, DC. (See: Post-Stroke
Hemiplegia Thematic Poster Session for Abstract)
RISK AND PROTECTIVE FACTORS FOR FALLS AMONG INDIVIDUALS
WITH INCOMPLETE SPINAL CORD INJURY. SS Brotherton1, J.S.
Krause1, P.J. Nietert2, 1Rehabilitation Sciences, Medical University of South
Carolina, Charleston, SC, 2Biostatistics, Bioinformation, and Epidemiology,
Medical University of South Carolina, Charleston, SC.
Purpose/Hypothesis: The purpose of this study was to determine the
risk and protective factors for falls among ambulatory individuals with
incomplete spinal cord injury (SCI). Number of Subjects: Participants
were recruited from a group of individuals with incomplete SCI who took
part in a previous study on subsequent injuries following SCI. One hun-
dred and twenty individuals from a potential subject pool of 221 persons
consented to participate. Materials/Methods: A survey instrument was
designed to collect data on the incidence of falls, demographic and SCI
characteristics, health, and physical activity and was completed by study
participants.These data were compared among fallers and non-fallers using
t tests and chi square statistics. Unadjusted bivariate analyses were then
used to determine factors that were moderately associated with having a
fall.These variables were entered into a forward stepwise regression model
to identify which ones were associated with increased risk for falling. A
logistic regression that included only participant characteristics that could
have been present before the fall was also used to identify subject factors
associated with increased risk for having a fall. Results: Seventy-five per-
cent of respondents sustained a fall over the previous year. Stepwise regres-
sion revealed that the odds of having a fall were significantly lower for indi-
viduals who exercised more frequently (OR=0.65, p=0.013) and for those
who used a walker (OR=0.18, p=0.009).The odds of having a fall were sig-
nificantly higher for individuals who restricted community activities due
to fear of falling (OR=1.56, p=0.034), had a higher level of education (OR=
4.17, p=0.001), and reported more days of poor physical health (OR=1.12,
p=0.015). When the analysis was limited to subject characteristics that
could have been present before the fall, stepwise analysis revealed that the
odds of having a fall were higher for individuals who reported dizziness
(OR=7.72, p=0.013) and had a higher level of education (OR=2.26,
p=0.002). Conclusions: Increased exercise frequency and walker use
were associated with decreased risk of falls (protective factors), whereas
more days of poor physical health, limited participation in community
activities due to fear of falling, and a higher level of education were asso-
ciated with increased risk of falls.When only subject characteristics were
considered, dizziness and higher levels of education were independent
predictors of experiencing a fall in the SCI population. Clinical
Relevance: The findings provide a better understanding of the risk and
protective factors for falls and may assist rehabilitation professionals in
developing strategies for health promotion and injury prevention for
ambulatory individuals with incomplete SCI.
BILATERAL MOTOR OUTPUTS FROM THE RETICULOSPINAL SYS-
TEM TO THE UPPER LIMBS DURING REACHING IN THE MONKEY.
J.A. Buford1, A.G. Davidson2, 1Physical Therapy, The Ohio State University,
Columbus, OH, 2Neurobiology and Anatomy, University of Rochester
Medical Center, Rochester, NY. (See: Post- Stroke Hemiplegia Thematic
Poster Session for Abstract)
EFFECT OF TYPE 2 DIABETES MELLITUS ON DECISION-MAKING
AND SELECTIVE ATTENTION. S.D. Burns, Dept. of Rehabilitation
Science, University of Oklahoma Health Sciences Center, Oklahoma City,
OK, L. Riolo, Dept. of Physical Therapy, Indiana University, Indianapolis, IN.
204
Purpose/Hypothesis:The purpose of this study was to examine the inter-
action between type 2 diabetes, depression, and cognitive function.
Number of Subjects: 65 male veterans, 33 having DM, were recruited
from the Veterans Administration Medical Center in Oklahoma City.
Veterans included in the study were aged 50 to 69 years old and had no
current or past (within 20 years) history of drug or alcohol abuse, demen-
tia, psychiatric disorder, stroke or head trauma with loss of consciousness
> 10 minutes, or any sensory or motor disorder that would preclude neu-
ropsychological testing.Veterans with type 1 diabetes were also excluded.
Materials/Methods: The presence of depression was assessed with the
Beck Depression Inventory (BDI).The Stroop Color Word Test (SCWT) was
used to measure selective attention and the Iowa Gambling Test (IGT) to
evaluate decision-making. Most recent glycosylated hemoglobin (HbA1c)
values were obtained through chart review and used as indicators of meta-
bolic control. Results: After removing one outlier, group differences in
mean values of BDI scores, SCWT interference scores, and ratio of bad
cards to good cards chosen in the IGT were compared with independent
t-tests. Pearson or Spearman correlation coefficients were determined for
all variables. Partial correlation coefficients and r2 values were computed.
There were significant group differences in BDI scores (t (62) = 2.58,
p=.01) and SCWT interference scores (t (62) = .03, p=.04) but not IGT
ratios. BDI scores were significantly correlated with diabetic status (r =.35,
p=.004) and IGT ratios (r = .39, p=.001) and inversely correlated with
interference scores (r = -.25, p=.04). HbA1c values were strongly inversely
correlated to interference scores (r=-.60, p=.0003). Diabetic status
accounted for 12% of variation in BDI scores, 5% of variance in interfer-
ence scores, and 3% of variance in IGT ratios. Variation in BDI scores
accounted for 15.7% of the variation in IGT ratios and 6% of the variation
in interference scores. Variance in HbA1c values explained 37% of the
variation in interference scores. The partial correlation between BDI and
IGT ratio scores was r =.51 (p=.004) and r =-.62 (p=.0003) for HbA1c and
interference scores. Conclusions: Male veterans with type 2 DM demon-
strated more depression and poorer selective attention compared to vet-
erans without DM. The correlations point to a relationship between DM
and depression and support the generally accepted premise that depres-
sion affects cognitive performance. Depression explained more of the vari-
ation in cognitive test scores than did diabetic status particularly for the
IGT.The strong relationship between metabolic control of DM and a mea-
sure of selective attention suggests directions for research into causality.
Clinical Relevance:Adequate cognitive functioning is necessary for self-
care, a key component in management of DM. Factors affecting cognition
in this population have not yet been fully delineated.
BRAIN ACTIVATION DURING KINESTHETIC AND VISUAL IMAGERY
OF WALKING. C.A. Chatto1, J.E. Deutsch1, J. Pillai2, T. Lavin2, J. Allison2,
1
Program in Physical Therapy, UMDNJ, Newark, NJ, 2Department of
Radiology, Medical College of Georgia, Agusta, GA. (See Imagery and
Imaging Thematic Poster session for Abstract)
THE PATIENT-REPORTED IMPACT OF SPASTICITY MEASURE
(PRISM): A NEW MEASURE ASSESSING THE IMPACT OF SPACTICITY
ON PERSONS WITH SPINAL CORD INJURY. K. Cook1, A. Williams2, C.
Teal2, S. Robinson-Wheelen2, J. Mahoney3, J.C. Engebretson3, K. Hart4, A.M.
Sherwood5, 1METRIC, Veterans Affairs, Houston, TX, 2Veterans Affairs,
Research, Houston, TX, 3Nursing, University of Texas Health Science
Center, Houston, TX, 4The Institute for Rehabilitation Research, Houston,
TX, 5National Institute on Disability and Rehabilitation Research (NIDRR),
Washington, DC.
Purpose/Hypothesis: Clinicians have long known that spasticity has a
substantial impact on the quality of life of persons who have spinal cord
injury (SCI).To date, however, there has been no self-report instrument to
assess the range of its impact. The study purpose was to understand the
experiences of spasticity in the everyday lives of persons with SCI and
develop a measure to standardize evaluation of these experiences.
Number of Subjects: Open-ended semi-structured interviews lasting
approximately 45 to 90 minutes were conducted with 24 persons with SCI
and spasticity. Patients reported a wide range of ways in which their spas-
ticity impacted their lives; including some positive ones (help with trans-
fers). We developed pilot items based on patients’ natural language state-
205 J ournal of N eurological P hysical T herapy
ments and administered these to 181 participants. Materials/Methods:
Data were factor analyzed and items were clustered into 7 subscales assess-
ing: (1) impact on ADLs, (2) social avoidance, (3) psychological impact, (4)
impact on health service utilization, (5) impact on independence, (6)
embarrassment, and (7) positive impact of spasticity. Results:The 7 PRISM
subscales exhibited excellent internal consistency and test/retest reliabili-
ties. Conclusions: Content validity was supported in the factor analytic
results; discriminant validity was supported by the only moderate correla-
tions among subscales; and construct validity was supported by the psy-
chometric design (items developed based on participant interviews).
Clinical Relevance:To date, there have not been effective tools for evalu-
ating the impact of spasticity on persons with SCI.The PRISM fills this gap.
Of particular importance is the inclusion of a subscale to measure what
persons with SCI view as positive aspects of spasticity.
UPPER LIMB FUNCTIONAL RESPONSE TO MOTOR LEARNING
ALONE AND MOTOR LEARNING WITH FUNCTIONAL NEUROMUS-
CULAR STIMULATION FOR STROKE SURVIVORS. J.J. Daly1, J. Rogers2, I.
Brenner2, E. Perepezko2, M. Dohring2, E. Fredrickson2, J. Gansen2, 1Neurology,
Case Western Reserve University School of Medicine, Cleveland, OH,
2
Research Service, LS Cleveland VA Medical Center, Cleveland, OH. (See
Motor Learning Thematic poster session for Abstract)
CONSTRAINT INDUCED MOVEMENT THERAPY FOR AN INDIVID-
UAL EXHIBITING HEMIAKINESIA POST STROKE. S.B. Davis1, L.G.
Richards1,A.L. Behrman2, 1Brain Rehab Research Ctr, Malcom Randall VAMC,
Gainesville, FL, 2Physical Therapy, University of Florida, Gainesville, FL.
Background & Purpose: Patients with hemiakinesia exhibit the inability
to carryout purposeful movements in the absence of paresis.They may not
spontaneously use their upper extremity contralateral to the lesion.When
asked to move they may have the ability to coordinate movements. During
manual muscle testing they demonstrate good to normal strength.This has
been a clinically challenging scenario and few interventions have been
advocated to remediate hemiakinesia.The purpose of this case study was
to examine the effect of Constraint Induced Movement Therapy (CIMT) on
upper extremity (UE) performance. Case Description:The individual was
a 39 year old right handed white female seen 11 months after a major left
putamenal hemorrhage during her fifth month of pregnancy. She exhibited
aphasia, anomia, pronounced hemiakinesia with right UE strength 4+ to 5,
mild right shoulder subluxation, mild increased tone, normal propriocep-
tion, stereognosis, impaired 2-point discrimination and minimal sponta-
neous use of her right UE. She initially scored 1.00 on the Amount of Use
of the Motor Activity Log (MAL) indicating very rare use.The initial Actual
Amount of Use Test (AAUT) was 0.53 in Amount and 1.12 in Quality. She
was an independent ambulator at 1.16 meters per second (mps) self-
selected speed and 1.69 mps fast walking. She did not exhibit any right
arm swing. Prior to the stroke she was a dental hygienist, homemaker and
active in her community. She lived at home with her husband, two children
requiring help from caregivers. Her goals were to become more indepen-
dent in cooking, child care and driving. She participated in CIMT for 6
hours/day for 10 days and was mitt compliant at least 90% of waking
hours. Outcomes: Outcome measures were collected pre, post, 6 and 12
months.At post-test, amount and quality of arm use (MAL) increased almost
to the pre-stroke levels (4.8 and 4.6, respectively).This was maintained at
3.98 and 4.05 at 12 months.The AAUT continued improving at 6 months,
in both maximum amount 1.71 and maximum quality 3.19.Times on the
Wolf Motor Function Test improved from 2.69 seconds to 1.7 post CIMT,
approaching the less involved side (1.35), however, increased to 2.21 at 6
months and 5.63 at 12 months. Fugl Meyer improved across all testing
from baseline 56 to 61 at 12 months. Box and Blocks Test initially increased
from 31 to 37 post CIMT and maintained an average of 56% of the left UE
extremity at 12 months. MOS-36 increased from 22 to 28 post and 29 at
12 months. Geriatric Depression Scale decreased from 7 to 4 after CIMT.
The personal goals for childcare and resuming driving were attained.
Discussion: Outcomes demonstrated the potential value and efficacy of
CIMT as an intervention for the challenging problem of hemiakinesia.
Measures of function and quality of life substantiate the participant’s per-
ception of improvement and gains. This case study illustrates a potential
application of CIMT for hemiakinesia post-stroke.
Vol. 29 • No. 4 • 2005
REPRESENTATION OF IMAGINED AND EXECUTED SEQUENTIAL
FINGER MOVEMENTS OF ADULTS POST STROKE AND HEALTHY
CONTROLS. JE Deutsch1, S. Fischer1,W. Liu2,A. Kalnin3, K. Mosier3, 1Physical
Therapy, UMDNJ, Newark, NJ, 2Radiology, UMDNJ, Newark, NJ, 3Radiology,
Indiana University, Newark, IN. (See Imagery and Imaging Thematic Poster
Session for Abstract)
VELOCITY OF VERTICAL AND HORIZONTAL EYE MOVEMENTS IN
PROGRESSIVE SUPRANUCLEAR PALSY. K.E. Donley, M.J. Johnson, C.
Zampieri, R.P. Di Fabio, Physical Therapy, University of Minnesota,
Minneapolis, MN.
Purpose/Hypothesis: Purpose.The objectives of this study were to inves-
tigate the velocity of vertical and horizontal saccades in people with PSP
in the early stages of their disease and to compare the velocity of voluntary
vertical eye movements with concurrent unintended horizontal eye move-
ments associated with vergence. Number of Subjects: Subjects. Nine sub-
jects (70.3 /- 5.36 years, 4 women and 5 men) participated in a within
group cross-sectional study. Six subjects were diagnosed with probable
PSP and 3 with possible PSP. Materials/Methods: Methods. Vertical and
horizontal saccades were practiced prior to data collection. Infrared ocu-
lography was used to measure the eye velocities in raw voltage per second
during the saccade attempts. Orthogonal eye velocities were compared
using one-way ANOVA and paired t-tests. Results: Results. Left horizontal
eye velocity due to vergence was significantly faster than intended down-
ward saccade velocity during a vertical saccade attempt (z-value = 3.6827,
p =0.000). Similarly, right horizontal velocity due to vergence was faster
compared to intended upward vertical saccade velocity (z = 2.118,
p=0.034).When comparing eye movement in a pure plane without regard
to vergence, voluntary horizontal right saccades were significantly faster
than vertical up saccades (z =6.38, p=0.000) and voluntary left horizontal
saccades were significantly faster than vertical downward saccades (z =
6.98, p= 0.000). Conclusions: Discussion and Conclusion. The results of
this preliminary work suggest that early in the course of PSP, the vertical
burst neurons in the rostral interstitial nucleus of the medial longitudinal
fasciculus are selectively degenerated. The velocities recorded also imply
that the horizontal burst neurons in the paramedian pontine reticular for-
mation are not markedly affected. During a volitional vertical saccade, the
accompanying horizontal eye movements due to vergence are compara-
tively faster.This illustrates that although the vertical saccade is slowed, the
omnipause neurons are not limiting the speed of horizontal vergence eye
movements Clinical Relevance: Background. Progressive Supranuclear
Palsy (PSP) is a Parkinsonian syndrome characterized by oculomotor
deficits (slow and limited voluntary eye movement) and recurrent falls.
The mechanism responsible for the loss of rapid eye movements or sac-
cades in PSP is not clear.
Funded by grant #H133G 030159 to Dr. Di Fabio from the National
Institute on Disability & Rehabilitation Research.
ORTHOPEDIC CONSIDERATIONS IN THE MANAGEMENT OF A
PATIENT WITH NEUROLOGICALLY INDUCED IMPAIRMENTS OF
THE FOOT AND ANKLE: A CASE REPORT. A. Driscoll1, R. Joshi2, M.
Johnson3, 1Mercy Rehab Associates, Darby, PA, 2Mercy Rehab Associates,
Darby, PA, 3Mercy Rehab Associates, Darby, PA.
Background & Purpose: Joint range of motion (ROM) limitations are a
significant issue in patients with neurological disabilities, particularly
when considering lower extremity orthotic management, transfers and
ambulation. Joint mobilization techniques have been successful in increas-
ing joint ROM of the foot and ankle in the orthopedic population though
little literature exists supporting the use of manual therapy in restoring
ROM deficits in patients with neurological impairments. This case report
describes the use of joint mobilization techniques in a patient with multi-
ple sclerosis (MS). Case Description:A 24 year old female with a history
of chronic progressive MS was referred for outpatient physical therapy
(PT) with increased difficulty with transfers and ambulation and patient
report of her feet turning inside her present MAFOs. During ambulation
with PLS MAFOs supination was noted during mid stance with plantar
flexion out of the orthoses bilaterally in terminal stance. Patient goals
include return to previous independent (I) transfers and ambulation with
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
a rolling walker and wear of MAFOs with increased comfort. PT interven-
tions initially included manual stretching to the gastroc/soleus muscles
though no significant improvement was noted in 7 sessions. Upon further
examination by a neurologic clinical specialist, similar ROM limitations
were noted in ankle dorsiflexion in both knee flexion and extension. In
addition, decreased articular motions were noted at the talus and the mid
foot, indicating restrictions in joint mobility at the talocrural joint. Joint
mobilization techniques to the foot and ankle were then incorporated into
the treatment program. Outcomes: The patient responded well to joint
mobilization gaining 15/22 degrees of ankle dorsiflexion at the right and
left respectively following 4 sessions of PT.The increase in ROM allowed
for casting for articulating MAFOs with the foot aligned in sub-talar neutral
and ankle dorsiflexion at 0.Ambulation was improved and the patient was
able to resume (I) transfers and household ambulation using new orthoses
with a full foot plate, ankle strap and a rolling walker. Discussion: This
case demonstrates the significant role of PT in the restoration of joint ROM
and correction of underlying biomechanical dysfunctions in a patient with
primary neurological dysfunction. Thorough examination of the foot and
ankle allowed for appropriate treatment strategies to correct underlying
joint mechanics. Through the combination of stretching and joint mobi-
lization, ROM was restored within a minimal number of sessions allowing
progression to alternate orthoses and functional mobility training. Of sig-
nificance is the need to incorporate principles of manual therapy, specifi-
cally joint mobilization techniques, into the care of clients with neurologi-
cal disabilities to achieve optimal functional mobility.
PREDICTING OUTCOME OF A PHYSICAL THERAPY PROGRAM IN
PATIENTS WITH PARKINSON’S DISEASE. T. Ellis1, R. Wagenaar1, C.J. de
Goede2, G. Kwakkel2, W.C. Eric2, 1Physical Therapy & Athletic Training,
Boston University, Boston, MA, 2Boston University, Boston, MA.
Purpose/Hypothesis: The ability to identify those patients with
Parkinson’s Disease (PD) who are most likely to benefit from rehabilitation
would help physical therapists target patients more appropriately. The
purpose of this study was to determine the value of patient characteristics
in predicting rehabilitation outcome. Number of Subjects:This study was
part of a randomized controlled trial in which the efficacy of a physical
therapy (PT) program was investigated. Sixty-eight subjects with PD within
Hoehn and Yahr stage II or III participated in group treatment conducted
twice per week for 1.5 hours in duration over a six-week period.
Materials/ Methods: Outcome measures consisted of the Sickness Impact
Profile (SIP-68), mobility portion of the SIP-68 (SIPM), the Unified
Parkinson’s Disease Rating Scale (UPDRS) and comfortable walking speed
(CWS). Regression analyses were conducted to identify which determi-
nants predicted rehabilitation outcome. Results: Baseline CWS, SIPM,
UPDRS II and UPDRS total scores best predicted outcomes in CWS, SIPM,
UPDRS II and UPDRS total scores, respectively. Age, gender and disease
severity were not predictive of outcome. Slow pretreatment CWS, higher
scores (greater disability) on the SIPM, UPDRS II and total UPDRS were
related to greater improvements after intervention. Conclusions: Those
individuals with the greatest level of disability and functional limitations in
this sample were more likely to improve after participating in a group
physical therapy program. Clinical Relevance: This data highlights the
potential usefulness of classifying individuals with PD according to their
baseline functional status to determine rehabilitation outcome.
AEROBIC CONDITIONING OF OLDER ADULTS USING AN INDEPEN-
DENT HOME EXERCISE PROGRAM IN THE CHRONIC PHASE OF
RECOVERY FROM STROKE. ML English,A. Ruble,T.Thompson, Physical
Therapy, University of Kentucky, Lexington, KY.
Purpose/Hypothesis:To determine if an intervention program consisting
of independent, self-monitored aerobic exercise designed specifically for
the individual older adult recovering from stroke will result in improved
aerobic exercise tolerance, endurance and improved functional mobility.
Number of Subjects:Three, using a Single Subject Design, multiple probes
across subjects. Materials/Methods: A sample of convenience of three
older adults who were recovering from stroke > one year prior to initia-
tion of the study served as subjects. Subjects were tested in a staggered
fashion, with Subject A beginning first, Subject B beginning after Subject A
206
began to improve in performance, and Subject C beginning as Subject B
demonstrated improvement. Subjects initially completed the Folstein Mini
Mental Status Examination (MMSE) and the SF-36 Item Health Survey.
Functional tests/measures included in baseline testing were the Timed Up
and Go Test (TUG),Three-Minute Walk Test, and the Physical Performance
and Mobility Exam (PPME). Each subject was instructed in an individually
prescribed aerobic exercise program and instructed to exercise 3 times
per week for 12 weeks, using exercise equipment of his/her choice, eval-
uated and approved by the investigators. Researchers provided a heart
monitor and blood pressure cuff to each subject for self-monitoring, and
subjects recorded results from each exercise session.The functional tests
listed above were reassessed weekly throughout the exercise program and
three months following completion of the program. Subjects also
repeated the SF 36-Item Health Survey at the end of the twelve weeks of
exercise. Results: All three subjects successfully completed 12 weeks of
independent, self-monitored exercise, though one was unable to return for
three month follow-up tests due to medical complications. Over the twelve
week period, all three subjects improved in time of performance of the
TUG.Two subjects demonstrated increased distance covered in the Three-
Minute Walk Test. Two subjects showed improvement in the Physical
Performance and Mobility Exam. Two subjects demonstrated increased
endurance in exercise sessions by gradually increasing duration from 15
minutes to 45 and 20 minutes to 45, respectively. No significant changes
were noted in the Quality of Life Health Survey. Results at the three month
follow-up: two subjects were approaching baseline levels in all tests.
Conclusions: Older adults recovering from stroke who perform an inde-
pendent aerobic exercise program using a location and equipment of their
choice demonstrate the ability to self-monitor and improve exercise toler-
ance and endurance. Further study is required to determine if improved
exercise tolerance contributes to improved functional mobility and quality
of life. Clinical Relevance: Diminished exercise tolerance and endurance
are closely associated with stroke. Older adults recovering from stroke may
benefit from a specifically prescribed and designed, self-monitored exer-
cise program as part of a total rehabilitation program.
KINEMATICS OF REACH-TO-GRASP MOVEMENTS IN SUBJECTS
WITH CEREBELLAR DEFICITS. K.M. Erickson, P.L. van Kan, Kinesiology,
University of Wisconsin-Madison, Madison,WI.
Purpose/Hypothesis: We examined the kinematics of reaching to grasp
in humans to determine the role of the cerebellum in the timing of finger
opening with proximal joint movement. The cerebellum is important for
the control of multijoint, coordinated movements, such as reaching to
grasp.An unresolved question is whether the cerebellum specifically con-
trols temporal relations between reach, hand preshaping, and grasp com-
ponents or whether the cerebellum integrates reach, hand preshaping, and
grasp components into a single central program. Number of Subjects: 5
subjects with cerebellar damage and 6 healthy, age-matched controls were
studied. Materials/Methods:We measured kinematics of reach, hand pre-
shaping, and grasp while subjects with cerebellar damage (n=5) and
matched controls (n=6) performed reaches with a precision grip that
required opposition of the index finger and thumb. The task was per-
formed under two conditions: as fast and accurately as possible, and slowly
and accurately.Transport of the hand was characterized by angular veloc-
ity of elbow and shoulder joints, wrist trajectory, and amplitude and timing
of tangential wrist velocity. Hand preshaping was characterized by ampli-
tude and variability of peak grip aperture and its timing relative to the
reach. Grasp was characterized by relative timing of contact of the index
finger and thumb with the target. Results: Results showed that PGA is
tightly coupled to both peak shoulder velocity (PSV) and peak elbow
velocity (PEV) in healthy controls. Cerebellar subjects showed disruptions
in timing of PGA with PSV and PEV, with both joints contributing to an
overall disruption in timing of PGA with peak wrist deceleration (PWD).
These disruptions were more profound in the fast and accurate condition.
In addition, cerebellar subjects were much more variable in the timing of
multiple aspects of reaching to grasp including time of PGA relative to
total movement time, timing of peak wrist velocity (PWV), time of PSV,
time of PEV, as well as relative timing of PGA with PWD, PSV, and PEV.
Conclusions: Kinematics of reaching to grasp in subjects with cerebellar
damage are characterized by increased variability. The increased variabil-
207 J ournal of N eurological P hysical T herapy
ity uncouples reach, hand preshaping, and grasp components in both spa-
tial and temporal domains. Clinical Relevance: Current recommendations
to patients with cerebellar lesions include learning to slow their move-
ment down and to decompose movement into a series of single joint
movements (Bastian 1997).This study supports the usefulness of slowing
movements, as timing of proximal joints with finger opening is less dis-
rupted in slower movements. If patients can be trained to move more
slowly, disruptions to the proximal joint coordination are minimized and
the overall movement of reaching to grasp is more normalized. However,
at slower speeds, increased variability in magnitude and timing of PGA
should still be expected based on the current results.
UPPER EXTREMITY PHASE MANIPULATION AND WALKING IN PER-
SONS WITH A CVA. M.P. Ford1, R.C. Wagenaar2, K.M. Newell3, 1Physical
Therapy, The University of Alabama at Birmingham, Birmingham, AL,
2
Physical Therapy, Boston University, Boston, MA, 3Kinesiology, The
Pennsylvania State University, University Park, PA.
Purpose/Hypothesis: To investigate the effects of walking velocity and
upper extremity phase manipulation on inter-segmental coordination dur-
ing treadmill walking in persons with a CVA. Number of Subjects: 8 indi-
viduals (12 - 72 yrs; mean 49; standard deviation: 17.4) who have suffered
a CVA participated. Materials/Methods: There were 3 separate condi-
tions while walking at 0.22, 0.40, 0.63, 0.85, 1.10, 1.30, and 1.52 m/s: 1) no
upper extremity phase manipulation; 2) instructions to move the arms in
phase at each velocity level; 3) instructions to move the arms out of phase
at each velocity level. 3D kinematic data were collected using a Skill
Technologies 6D Research System. The total range of movement ampli-
tudes for arms (τA) and legs (τL), and transverse rotation of thorax (τT),
pelvis (τP) was calculated. The amplitude of transverse trunk rotation
(τPT) was calculated by determining the maximum differences between
(τT) and (τP). The shoulder and hip angle time-series data were used to
compute the point estimates of relative phase between the arms.We deter-
mined if the power (power spectrum) in arm movement frequency was
higher at stride or step frequency during walking. For statistical analysis a
within-group analysis of variance with repeated measures, including two
within-factors, 1) velocity manipulation and 2) instruction was used with a
.05 significance level. Results: Across all walking velocities the arms
moved more out of phase during no upper extremity phase manipulation
and instruction to move the arms out of phase, as compared to instruction
to move the arms in phase. Instructions to move both in or out of phase,
led to larger involved arm movement amplitude (τAi) and non-involved
arm movement amplitude (τAni) as compared to the condition with no
upper extremity phase manipulation. When participants were instructed
to move the arms in phase the τAi was larger at both 0.43 and 0.66 m/s, as
compared to instructions to move out of phase.The larger τAni coincided
with the power in the non-involved arm movement frequency being
higher at stride frequency when participants were instructed to move
their arms in phase as compared to out of phase. Finally, τT, τP, and τPT
were greater when participants were instructed to move their arms out of
phase, as compared to in phase. Conclusions:The results from the present
study demonstrate flexibility of the coordination patterns of walking to
meet constraints imposed on the movements of body segments.
Additionally, these results suggest that the ability to modify arm movement
amplitude, along with frequency, is necessary for synchronization with the
stride frequency. Clinical Relevance: Slower walking velocity in patients
with severe upper extremity dysfunction (e.g., CVA) may be due to inabil-
ity to alter coordination patterns. Future studies should investigate the
underlying dynamics of arm dysfunction and adaptations during treadmill
and over-ground walking.This will provide a foundation for interventions
which address motor impairments of the upper and lower extremity
related to walking in persons with a CVA.
PROTECTIVE STEP TRAINING IN PEOPLE WITH PROGRESSIVE
SUPRANUCLEAR PALSY. C.E. Franzen, S.L. Gubka, L. Hamilton, C.
Zampieri, R.P. Di Fabio, Physical Medicine & Rehabilitation, University of
Minnesota, Minneapolis, MN.
Purpose/Hypothesis: Progressive Supranuclear Palsy (PSP) is an atypical
parkinsonian disorder affecting the basal ganglia and the brainstem.
Vol. 29 • No. 4 • 2005
Clinical features include oculomotor deficits, dysphagia, and postural insta-
bility.The fall rate for people with PSP is reported to be 100% in the first
year of diagnosis.The purpose of this pilot study was to compare the effect
of traditional balance training to a program augmented by saccade exer-
cises and a cognitive challenge during gait on protective step reaction time
(RT) in people with PSP. Number of Subjects: 187 perturbations induced
protective step trials were collected from four subjects with PSP.
Materials/Methods: Each subject participated in two phases of the study.
During the control phase, subjects underwent four weeks of perturbation
and balance training followed by an eight-week rest phase. Subsequently,
subjects were entered into the experimental phase, consisting of four
weeks of perturbation and balance training along with saccade exercises
and a cognitive challenge during gait. Following each session of training,
electromagnetic sensors placed on the trunk and feet were utilized to mea-
sure body segment position during perturbation trials. Data were collec-
tively analyzed for expected and unexpected backward perturbations
administered at the hips or shoulders.The dependent variables were lead
and lag foot step RT. Results:A within group control vs. treatment analy-
sis of lead foot step RT showed a significant decrease in median step RT
from 0.50 seconds in the control phase to 0.31 following the experimen-
tal phase (H = 9.40, df = 2, p = 0.0022). Similar results were found for the
lag foot. Conclusions: Four weeks of perturbation training combined with
saccade exercises and a cognitive challenge during gait resulted in signifi-
cantly faster step RT in people with PSP when compared to step RT fol-
lowing perturbation training alone. Clinical Relevance: Protective step-
ping for people with PSP can be improved with rehabilitation training.
However, our study did not address the relationship between step RT and
the incidence of falls.At this time, it is not known if a faster protective step
reaction time results in decreased falls risk.
FUNCTIONAL PREDICTORS OF OUTCOMES FOLLOWING CON-
STRAINT-INDUCED MOVEMENT THERAPY FOR INDIVIDUALS WITH
POST-STROKE HEMIPARESIS. S.L. Fritz, Exercise Science/ Physical
Therapy, University of South Carolina, Columbia, SC.
Purpose/Hypothesis: Constraint Induced Movement Therapy (CIMT) is a
rehabilitative strategy used primarily with the post-stroke population to
increase the functional use of the neurologically-weaker upper-extremity
through massed practice while restraining the lesser-involved upper-
extremity. While solid research evidence supports CIMT, limited evidence
exists regarding the specific characteristics of individuals who benefit
most from this intervention. The goal of this study was to determine the
descriptive predictors for CIMT outcomes. Number of Subjects:A conve-
nience sample of 55 individuals post-stroke was recruited that met specific
inclusion and exclusion criteria. Materials/Methods: These individuals
participated in CIMT 6-hours per day, for two-weeks with restraint of their
less-affected upper extremity. Pre-test, post-test and follow-up assessments
were performed to assess the outcomes for the Wolf Motor Function Test
(WMFT) and the amount section of the Motor Activity Log (MALa). The
potential functional predictors were: minimal motor criteria, finger exten-
sion, grip strength, Fugl-Meyer upper-extremity motor score, and the
Frenchay score. A step-wise regression analysis was used in which the
group of potential predictors was entered in a linear regression model
with simultaneous entry of the dependent variables’ pre-test score as the
covariate. Two regressions models were determined for each dependent
variable per experiment, one for the post-test, and one for the follow-up
test. Results: Finger extension was the only significant predictor of WMFT
outcomes. Minimal motor criteria and upper-extremity Fugl-Meyer motor
score were predictive of the MALa immediately following therapy, but only
the Fugl-Meyer score was predictive of outcomes at the follow-up.
Conclusions:This experiment provides the most comprehensive investi-
gation of predictors of CIMT outcomes to date. Further substantiation of
these findings in more diverse samples is warranted in order to meet the
urgent need of determining the appropriate candidates for CIMT. Clinical
Relevance:The identification of clinical predictors for outcomes of CIMT
is of value to both research and clinical settings. Who benefits most from
CIMT needs to be understood, in order to target the correct population.
LEARNING EFFECT ASSESSMENT ON SUBSEQUENT SUBJECT PER-
FORMANCE ON THE EQUITEST. BALANCE SYSTEM. B. Gilliam, D.
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
Charles, S. Kathmann, J. Smith, N.S. Darr, D. Greathouse, Belmont University,
Nashville,TN. (See Motor Learning Thematic Poster Session for abstract)
SELF-REPORTED EARLIEST SYMPTOMS OF PARKINSON DISEASE. D.
Glendinning, V. Patel, D. Maldonado, G. Siozon, P. Trivedi, Physical Therapy
and Sport Sciences, Seton Hall University, South Orange, NJ.
Purpose/Hypothesis: Parkinson disease (PD) is caused by cell death in
the substantia nigra pars compacta of the midbrain. Although the classic
diagnostic signs of PD are muscle rigidity, tremor, and bradykinesia, these
signs only appear after approximately 90% of the neurons within the pars
compacta have degenerated. Currently, research is focused on developing
neuroprotective treatments to halt the progression of cell death in PD.
Neuroprotective treatments will only be effective if the cell death can be
recognized by signs that precede the cardinal signs of PD. Physical thera-
pists, trained to observe movement, are well-suited to develop early detec-
tion tests for PD. The purpose of this study was to ask persons with PD
directly about their earliest symptoms, to obtain clues for early detection.
To date, no one has methodically queried persons with the disease about
pre-diagnostic symptoms. Number of Subjects: 45. Materials/Methods:
Surveys were distributed at support groups, physician offices, and on an
internet website, and were completed anonymously by persons with idio-
pathic PD. The survey included basic demographic data, multiple-choice
questions, and open-ended questions related to pre-diagnostic physical and
emotional symptoms. Subjects were required to order the onset of symp-
toms in each section. Results: Forty-five people (16 females, 29 males, aged
73.2 ± 8.9) responded to the survey.The average number of years with PD
was 8 ± 6.53.Thirty-five percent of respondents reported tremor as the first
sign of PD. The remaining subjects reported diminished olfaction, depres-
sion, voice changes, and bradykinesia.An analysis of all early signs revealed
that 1) as a cluster of early symptoms, sleep disorders, fatigue, depression
and tiredness occurred in 50% of subjects, and 2) males and females had dif-
ferent early signs: males more often reported classic signs of the disease,
and females more often reported fatigue, tiredness, depression and voice-
weakening. Ten-percent of all subjects also reported that symptoms first
appeared after major medical events, such as surgery or trauma.
Conclusions:This study had 2 major findings. First, most people with PD
reported a classic symptom as the first symptom of PD, suggesting that they
were unable to detect any subtle earlier symptoms of impending PD.
Second, females especially, reported fatigue, depression, tiredness and sleep
disturbances as early signs of PD.This cluster of symptoms should be added
to previously reported micrographia and diminished olfaction, as early indi-
cators of PD. Clinical Relevance: Because individuals may not be able to
detect the early symptoms of PD, physical therapists should be aware that
pre-diagnostic signs of PD may include fatigue, depression, tiredness, and
sleep disturbances, in addition to the previously reported micrographia and
diminished olfaction. In addition, physical therapists need to conduct more
research to develop clinical test batteries for early detection.The ultimate
goal would be to halt disease progression with new neuroprotective treat-
ments, such as drug, gene, or physical therapy.
CASE REPORT: A MODIFIED CONSTRAINT INDUCED MOVEMENT
THERAPY (MCIMT) PROGRAM FOR THE UPPER EXTREMITY OF A
COMMUNITY-DWELLING MALE WITH SEVERE CHRONIC HEMIPLE-
GIA. R.M. Hakim, E. Driscoll, J. Ricci,T. Szasz, Physical Therapy, University of
Scranton, Scranton, PA.
Background & Purpose: Traditional Constraint-Induced Movement
Therapy (CIMT) protocol may be difficult to implement because of the
time commitment and use of a restrictive device (Page et al., 2002). Recent
studies of modified Constraint-Induced Movement Therapy (mCIMT) pro-
tocol using a combination of outpatient therapy and unsupervised practice
were effective in improving function of the more affected upper extrem-
ity (UE) for patients with mild hemiparesis and learned nonuse (Page et al.,
2001; Page, Sisto & Levine, 2002). The purpose of this case report was to
determine if a modified, reduced intensity version of the traditional CIMT
protocol would elicit functional improvements in the UE of a community-
dwelling individual with severe, chronic hemiplegia. Case Description:
The case was a 68 year old male, eight years after a right stroke, who dis-
played severe UE hemiplegia that did not meet the traditional minimum
208
motor criteria for CIMT (i.e., active wrist extension of at least 20 degrees
and finger extension of at least 10 degrees), but had the ability to grasp a
washcloth on a table top, lift it, and release it (Taub & Morris, 2001; Bonifer
& Anderson, 2003). He participated in a two-hour mCIMT program for ten
weekdays over a two week period using a mitt and/or verbal cueing as the
constraint. During the program, the patient agreed to engage his more
affected UE in activities for 90% of waking hours. Testing was conducted
before and after intervention, and again at a one-month follow up visit.The
outcome measures used were: the Wolf Motor Function Test (WMFT),
Action Research Arm Test (ARAT), and Motor Activity Log (MAL).
Outcomes: The WMFT scores displayed improvements in performance
time (PT) for 13 of 15 timed items and 16 of 17 functional ability (FA)/qual-
ity of movement items at post testing. At follow up, all items of WMFT
either remained the same or improved in FA (except item 17) and 10 of 15
items further improved for PT. Grip strength doubled from pretest to
posttest. However, only 27% of grip strength gain was maintained at one-
month follow up. For the ARAT, the subject demonstrated improvement
with an average increase of 2.3, 1.7, and 0.3 on grasp, grip and pinch sub-
tests respectively, and had an increase of 3.3 on his overall score.At follow-
up testing, he demonstrated further improvements on grasp and overall
score showing gains of 2.7 and 0.7 respectively, and the time it took to
complete tasks in both grasp and grip decreased/improved from pretest
and posttest to follow-up. For the MAL, the patient showed minimal
improvement in affected arm usage for the tasks specified, despite subjec-
tive reports that he was using his affected arm more often and with less
effort during activities of daily living. Discussion: This program shows
promise as an effective and practical application of mCIMT for persons
with severe, chronic hemiplegia. Further research is warranted on a larger
group of individuals following stroke who demonstrate learned nonuse.
RELIABILITY OF CLINICAL MEASURES TO ASSESS PATIENTS WITH
VESTIBULAR HYPOFUNCTION. C.D. Hall1, S.J. Herdman2, 1Rehab R&D
Center, Atlanta VAMC, Decatur, GA, 2Rehabilitation Medicine, Emory
University,Atlanta, GA.
Purpose/Hypothesis: Evaluation of patients with vestibular hypofunc-
tion includes measures of subjective complaints, balance, gait and quality
of life.A variety of tools can be used to identify patient problems and assess
change with intervention or time. It is important that a measure be reliable
in order to be assured that any changes in score over time are due to real
changes in the individual’s performance rather than to errors in scoring.
Many of the measures and tools have established interrater reliability, yet
test-retest reliability has not been determined, has been determined with a
very small sample size or has not been determined in individuals with
vestibular hypofunction. The purposes of this research were to 1) deter-
mine test-retest reliability of clinical measures of subjective complaints,
balance, gait and quality of life in patients with vestibular hypofunction
and 2) establish criteria for significant change in each of these measures.
Number of Subjects: Sixteen volunteers were recruited from patients
referred to the Emory University Dizziness & Balance Center with a diag-
nosis of either unilateral or bilateral vestibular hypofunction. Diagnosis
was confirmed with a positive head thrust test and rotary chair or caloric
testing. Materials/Methods: Participants performed two trials of each of
the measures within the initial physical therapy session. The measures
included rating of disability, percent of day affected by dizziness, head
movement induced dizziness, SF-36, preferred gait speed, gait deviations
and dynamic gait index. In order to assess test-retest reliability of the mea-
sures Pearson product moment correlations (r) were calculated using SPSS
11.0. Correlation values greater than .75 are generally considered to indi-
cate good reliability. Significant change in each measure was based on the
mean change in score plus 2 SD of the test-retest variability. Results:The
average age of the group was 51.8 years (range: 29-78 years) with 18.8% of
the patients at least 65 years old and 38% male.Three of the subjects had
bilateral vestibular loss.The average time from onset of symptoms was 12.8
months (range = .75 - 43 months). All measurement tools demonstrated
excellent reliability (r = .82 - 1.00) except for head movement induced
dizziness (r = .59). For each measure we report what constitutes significant
change. For example based on our definition, a change of 3 points or more
in the total dynamic gait index score constitutes significant change.
Conclusions:A variety of tools are available for the assessment of patients
209 J ournal of N eurological P hysical T herapy
with vestibular hypofunction.We found that all of the scales examined in
this study, with the exception of head movement induced dizziness,
demonstrate excellent test-retest reliability in the vestibular patient popu-
lation. Clinical Relevance: Incorporation of valid and reliable assessments
in clinical practice is critical in order to demonstrate the effectiveness of
therapeutic intervention.The variability in test-retest reliability can be used
as criterion for significant change but criteria based on functional signifi-
cance need to be developed.
VESTIBULAR EVALUATION IN INDIVIDUALS WITH MILD BRAIN
INJURY. S.L. Hammond1, C. Harro2, 1Mary Free Bed Rehabilitation Hospital,
Grand Rapids, MI, 2Grand Valley State University, Grand Rapids, MI.
Purpose/Hypothesis: Clients with mild brain injuries (MBI) are suscepti-
ble to vestibular dysfunction. The Dizziness Handicap Inventory (DHI),
Sensory Organization Testing (SOT), Dynamic Gait Index (DGI), Dix-
Hallpike Maneuver (DHM), and Head-Impulse Test (HIT) are objective
vestibular examination measures that have been validated in subjects with
vestibular pathologies. Research utilizing these tests to examine the preva-
lence of vestibular dysfunction post-MBI and assessing the validity of these
measures in clients with MBI is lacking. The primary purpose of this
descriptive study was to investigate the application of objective measures
to examine the incidence of vestibular dysfunction in clients with MBI and
secondly, to examine the concurrent validity of the DGI with SOT and DHI
scores in clients with MBI. Number of Subjects: Fifteen subjects with
diagnosis of MBI with onset < 6 months were recruited from MBI outpa-
tient clinic. Mean age was 40 years (range 19-78) and mean time post-injury
was 69 days (range 12-167). Subjects were excluded if they had spinal or
extremity injuries that contraindicated test administration or previous neu-
rologic diagnoses. Materials/Methods:The DHI, SOT, DGI, DHM, and HIT
were administered in controlled order to subjects over two sessions. The
DHI was used to quantify subjects’ self report of dizziness. SOT was used
to assess the use of sensory inputs for balance, specifically vestibular input.
The DGI was used to evaluate subjects’ functional balance during gait
tasks.The DHM and HIT were administered to detect BPPV and vestibulo-
ocular function, respectively. Descriptive statistics were used to examine
the sample’s score distribution for each test and Pearson correlation was
used to examine the relationship between tests. Results:The mean score
on the DHI was 50 (IQR 35-72), with 60% of scores being 50 or higher.The
mean SOT composite balance score was 61.1 (IQR 54.5-71.0), with 73.3%
of subjects falling below their normative age group scores. Forty-six per-
cent of subjects were determined to have difficulty using vestibular input
to maintain balance.The mean score on the DGI was 19 (IQR 16.5-22.0),
with 53.3% of subjects in a fall risk category. Two subjects had positive
DHM results and 3 subjects had positive HIT results.A significant good cor-
relation (r = -0.795) was found between DHI and DGI scores, indicating
that subjective vestibular symptoms were related to subjects’ functional
balance deficits. Conclusions:These findings demonstrate that vestibular
dysfunction is prevalent in clients with MBI.The DHI, DGI, and SOT find-
ings detected a large percentage of subjects with vestibular impairment,
demonstrating the validity of vestibular testing in MBI. Clinical
Relevance: Individuals who experience MBI should be screened for
vestibular dysfunction. In this study the DHI demonstrated sensitivity in
measuring self-reported vestibular symptoms, which correlated with sub-
jects’ functional balance scores.The DGI and SOT were valid measures for
detecting balance dysfunction in MBI.
BOTULINUM TOXIN A AND SERIAL CASTING AS ADJUNCT TREAT-
MENTS FOR REHABILITATING UPPER EXTREMITY SPASTICITY FOL-
LOWING BRAIN INJURY IN A PEDIATRIC PATIENT. N.J. Hellyer, S.L.
Eischen, Program in Physical Therapy, Mayo Clinic College of Medicine,
Rochester, MN.
Background & Purpose: Disabling subdural hemorrhage can occur in
children secondary to arteriovenous malformations (AVM).AVMs occur at
a frequency of one in every 100,000 children and can cause movement
dysfunction following hemorrhagic brain injury. Like other types of upper
motor neuron injury, the recovery of functional movement following
injury is often impeded by the development of spasticity. Therefore, the
management of spasticity is a critical concern for the patient and health
Vol. 29 • No. 4 • 2005
care providers. Casting, soft tissue mobilization, motor re-education,
surgery, and anti-spasticity medications are traditionally used to manage
spasticity, increase ROM, and improve functional mobility. Botulinum toxin
type A (BTA) is one anti-spasticity medicine that is used as an adjunct agent
to facilitate traditional physical therapy interventions. However, there is
very little evidence that documents the effectiveness of BTA and/or serial
casting for improving functional movement, especially in the upper
extremities of pediatric patients. Case Description: The patient was a
nine year old male referred for rehabilitation three months post hydro-
cephalus secondary to sudden hemorrhage of a previously asymptomatic
AVM. Initially the patient demonstrated a marked reduction in upper
extremity PROM of all joints. Notably for this case, left elbow extension
was restricted to 90º- 60º PROM. Gross voluntary muscle activity within the
available ROM was absent to poor. Upper extremity spasticity was rated 3
(modified Ashworth) bilaterally at the shoulder, elbow, and wrist. FIM
scores were 0 for transfers, self-care, and mobility. Upper extremity inter-
ventions included a single BTA injection and ROM, neuromuscular re-edu-
cation, casting (left elbow only), and functional training over a 4 week
period. Outcomes:At discharge the patient demonstrated improved ROM
(left elbow extension 115º - 60º PROM), decreased spasticity (+2 wrist, +1
elbow, -1 shoulder), left extremity anti-gravity control through available
ROM, and improved FIM scores (3 for bed mobility, 1 for gait, and 4 for
wheel chair mobility). At one year follow-up, FIM scores were further
improved with no additional serial casting or BTA administration.
Discussion: Despite the limited clinical evidence, it is reasonable to pre-
dict that an agent, such as BTA, is capable of creating a therapeutic window
during which time spasticity is attenuated and ROM can be improved. In
this particular case, we observed a persistent functional change in the
upper extremity of a pediatric patient treated with traditional physical
therapy, casting and BTA injection. This outcome suggests that BTX and
casting are appropriate adjunct treatments for upper extremity spasticity.
However, systematic studies are needed to more clearly demonstrate the
effectiveness of BTA and casting interventions on improving upper
extremity function in pediatric patients with brain injury.
TELEREHABILITATION FOR MOTOR RETRAINING IN PATIENTS WITH
STROKE. M.K. Holden,T.A. Dyar1, E. Bizzi1, L. Schwamm2, L. Dayan-Cimadoro3,
1
Dept. of Brain & Cognitive Sciences and Mc Govern Institute for Brain
Research, Massachusetts Institute of Technology, Cambridge, MA, 2Clinical
Research Center, Massachusetts Institute of Technology, Cambridge, MA,
3
Dept. of Physical Therapy, Spaulding Rehabilitation Hospital, Boston, MA.
(See Motor Learning Thematic poster session for abstract)
DECREASED ARM SWING AT FAST WALKING SPEED IN MILD
PARKINSON DISEASE (PD). M. Hong1, G. Earhart1, D. Damiano2, J.
Perlmutter2, 1Physical Therapy,Washington University in St. Louis, St. Louis,
MO, 2Neurology,Washington University in St. Louis, St. Louis, MO.
Purpose/Hypothesis: Clinicians commonly note that people with mild
PD have reduced arm swing but the relationship to walking speed remains
unknown.The purpose of this study was to determine whether arm swing
was reduced at various walking speeds compared to controls.We hypoth-
esized that PD subjects would 1) have a narrower range of gait speeds
compared to controls and 2) demonstrate less arm swing than controls.
Number of Subjects:We tested 10 subjects with mild PD (stages 1-3) and
10 healthy age and gender matched control subjects. Materials/Methods:
Subjects walked across a 10 m room at three different speeds: slow, natural,
and fast. For the slow and fast conditions, the subjects were instructed to
walk as slow or as fast as they could. For the natural walking condition, the
subjects were told to walk at their normal and comfortable walking speed.
Three trials in each condition were recorded using a Vicon system. The
order of the conditions was randomized for each subject. Gait speeds and
shoulder angles in the sagittal plane, as a measure of arm swing, were cal-
culated for two strides per trial. For the PD group, we looked at the more
impaired arm and for the control group, we analyzed their dominant side.
At matched speeds, Mann-Whitney Rank Sum Tests were used to compare
peak-to-peak shoulder angles per stride between the two groups.A Pearson
Product Moment r was calculated between gait speeds and peak-to-peak
shoulder angles for both groups. Results:There was no difference in the
mean speeds for the three different conditions between the two groups.
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
Both groups increased arm swing with an increase in gait velocity (r =.71
for PD group, r =.79 for control group). The PD group demonstrated sig-
nificantly smaller amplitudes of arm swing in the fast walking condition
(p=.045) compared to the control group.There were no differences in arm
swing between the two groups in the slow or the natural walking condi-
tions (p=.212, p=.089). Conclusions:The PD group was able to regulate
gait speed across the same range as the control group. However, decreased
arm swing was noted in patients with mild PD only in the fast condition,
when they were walking at a faster than normal speed. Clinical
Relevance: Clinicians should be cautious to take gait speed into account
when assessing arm swing. Previous work has shown that with verbal
instructions to increase arm swing, patients with PD not only increased
arm swing but also walked faster than natural walking speed. Instructing
more advanced PD patients, whose fast walking speeds are below the level
of functional ambulation, to increase arm swing while walking fast may
increase walking speed and improve function, but this remains to be
proven.
SINGLE LIMB BODY WEIGHT SUPPORTED TREADMILL TRAINING.
J.H. Kahn1,T. Hornby2, 1Sensory Motor Performance Program, Rehabilitation
Institute of Chicago, Chicago, IL, 2Physical Therapy, University of Illinois at
Chicago, Chicago, IL. (See Post-Stroke Hemiplegia Thematic poster session
for abstract)
PHYSIOLOGICAL RESPONSES OF INDIVIDUALS WITH SPINAL CORD
INJURY DURING ROBOTIC-ASSISTED TREADMILL WALKING. J.F.
Israel,T. Hornby, Physical Therapy, University of Illinois at Chicago, Chicago,
IL.
Purpose/Hypothesis: Body weight supported treadmill training (BWSTT)
has been shown to be effective in retraining walking following incomplete
spinal cord injury (SCI), although its performance in the clinic is limited.
Development of robotic devices which provide passive guidance during
walking may increase performance of BWSTT, but may minimize voluntary
effort by the subject.The purpose of this study was to investigate whether
robotic-assisted treadmill walking provides a sufficient stimulus to generate
appropriate muscle activity and metabolic responses compared to thera-
pist-assisted walking. We hypothesized that therapist-assisted treadmill
walking would generate increased Vo2 responses and more appropriate
lower extremity muscle activity vs., robotic-assisted treadmill walking.
Number of Subjects: Twelve individuals with motor incomplete SCI par-
ticipated in the study. Materials/Methods: Cardiopulmonary, metabolic,
and electromyographic (EMG) responses during therapist-assisted treadmill
walking were compared to robotic-assisted ambulation with and without
visual biofeedback. Robotic training was provided by the Lokomat and
visual feedback of bilateral hip and knee torques during swing and stance
phases were displayed on a computer screen. Subjects were asked to walk
on the treadmill with <40% BWS for 10 minutes with either robotic- or ther-
apist-assistance followed by 10 minutes of the other testing method.
Standardized metabolic testing equipment was used to obtain cardiopul-
monary measurements for 5 minutes in sitting and 2 minutes in standing
prior to treadmill walking and throughout the testing period including 10
minutes of recovery. Electromyographic (EMG) activity was collected from
key lower extremity muscles during each minute of treadmill walking.
Results: Therapist-assisted treadmill walking demonstrated significantly
higher (p<0.01) Vo2, heart rate (HR), and minute ventilation (VE) during all
10 minutes compared with robotic-assisted walking without biofeedback.
Providing visual biofeedback during the walking tasks minimized the dif-
ferences between conditions, although Vo2 responses during therapist-
assisted walking were greater (p<0.05) during the last 3 minutes of walk-
ing. EMG activity was significantly higher only for the rectus femoris in
pre-swing during therapist- vs. robotic-assisted walking without feedback.
This difference was minimized with feedback. Conclusions: Therapist-
assisted treadmill walking elicits increased aerobic responses and more
appropriate muscle activity compared to robotic-assisted treadmill walking,
although provision of biofeedback of joint torques may increase patient
effort. Clinical Relevance: Understanding the physiological responses to
robotic- or therapist-assisted BWSTT is important the relative contribution
of passive guidance during walking tasks.
210
SINGLE LIMB BODY WEIGHT SUPPORTED TREADMILL TRAINING.
J.H. Kahn1,T. Hornby2, 1Sensory Motor Performance Program, Rehabilitation
Institute of Chicago, Chicago, IL, 2Physical Therapy, University of Illinois at
Chicago, Chicago, IL. (See Post-Stroke Hemiplegia Thematic Poster Session
for Abstract).
INFLUENCE OF MOTOR-IMAGERY ABILITY ON SMA AND PSMA
CORTICAL ACTIVATION. T.J. Kimberley, G.S. Khandekar, Physical
Medicine and Rehabilitation, University of Minnesota, Minneapolis, MN.
(See Imagery and Imaging Thematic poster session for abstract)
NEUROMOTOR CONTROL IN FOCAL HAND DYSTONIA. T.J.
Kimberley1, K.J. Simura2, M. Flanders2, 1Physical Medicine and
Rehabilitation, University of Minnesota, Minneapolis, MN, 2Neuroscience,
University of Minnesota, Minneapolis, MN.
Purpose/Hypothesis: Focal hand dystonia is an under-diagnosed disorder
associated with repetitive hand movements that require fine motor control
and sensory-motor integration, such as typing or playing a musical instru-
ment.The disorder involves excessive co-contraction of muscles and abnor-
mal postures that prevent normal motor function when performing the spe-
cific hand movements.The cause of the disorder is widely debated, and no
objective diagnostic criteria or fully successful treatment exists. Current lit-
erature focuses on spinal cord reflexes and a cortical change associated with
focal hand dystonia, and does not include a comprehensive analysis of mus-
cle activation.Thus, the purpose of this study is to analyze neuromotor con-
trol in focal hand dystonia compared to healthy motor control in the same
task.We hypothesize that patient’s abnormal muscle synergies can be iden-
tified and characterized by the time course of muscular activation.This may
contribute towards the development of specific diagnostic categories and
suggest successful treatment options. Number of Subjects:Three subjects
with focal hand dystonia and three healthy subjects. Materials/Methods:
Surface electrodes were used to record electromyographic (EMG) activity of
proximal and distal muscles of each hand and arm (abductor pollicis brevis,
first dorsal interosseus, flexor digitorum superficialis in two positions: cen-
tral portion, and ulnar portion, abductor digiti minimi, extensor digitorum,
and the deltoid) while an instrumented glove and 3D motion monitoring
was used to record kinematic activity of fingers, arms, and trunk.All subjects
performed a task involving repetitive typing of a sequence of letters on an
instrumented keyboard, at increasing speeds. Principal components analysis
was used to quantitatively describe the main EMG bursting patterns and the
patterns of co-variation across synergistic and antagonistic hand muscles dis-
tinguishing the fundamental difference between groups. Results:
Preliminary results show that the onset of dystonic symptoms is gradual, and
involves a steady decrease in activation of the muscle controlling the dys-
tonic digit and progressive compensatory increase in synergistic muscle
activity as well as proximal arm muscles and trunk compensations normally
not involved in the movement. Subjects with dystonia avoided making force-
ful contraction of the dystonic finger muscles by substituting early activity
in a muscle synergistic to the affected finger. Conclusions: Identifying this
synergistic activity and the method of co-activation in a subject may suggest
diagnostic criteria for dystonia types and lead to identifying possible treat-
ment interventions. Clinical Relevance: The results of this study will serve
as the basis for subsequent studies aiming to develop (1) categorizations of
dystonia types, (2) effective diagnostic tools and (3) treatment options spe-
cific to each individual’s disorder.
GAIT PARAMETERS ASSOCIATED WITH RESPONSIVENESS TO A
TASK-SPECIFIC AND/OR STRENGTH TRAINING PROGRAM POST-
STROKE. T. Klassen1, S.J. Mulroy2, K.J. Sullivan3, 1Vancouver Coastal Health,
Vancouver, British Columbia, CANADA, 2Pathokinesiology Laboratory,
Rancho Los Amigos National Rehabilitation Center, Downey, CA,
3
Biokinesiology and Physical Therapy, University of Southern California, Los
Angeles, CA. (See Post-Stroke Hemiplegia Thematic poster session for
abstract)
CHANGES IN SIT-TO-STAND FOLLOWING ANKLE JOINT MOBILIZA-
TIONS IN SUBJECTS WITH HEMIPLEGIA. P. Kluding, M. Santos, Physical
Therapy and Rehabilitation Sciences, University of Kansas Medical Center,
Kansas City, KS.
211 J ournal of N eurological P hysical T herapy
Purpose/Hypothesis:The purpose of this research project was to deter-
mine if manual mobilization of the ankle joint can increase ankle range of
motion (ROM) and improve sit-to-stand (STS) function for patients with
hemiplegia following stroke. Stroke is one of the leading causes of adult
disability and often results in hemiparesis, or weakness on one side of the
body.This weakness together with spasticity, muscle and joint stiffness can
make it very difficult for patients to move their limbs and perform basic
functional tasks.The research hypotheses were that joint mobilizations will
be effective in increasing ankle ROM, and that increased ankle ROM with
structured practice of functional skills will result in greater improvement
on functional performance than practice alone. Number of Subjects:
Sixteen subjects with hemiplegia following stroke were randomly assigned
to either an experimental group (mean age 55.5 ± 10.7 years, 18.3 ± 11.8
months post-CVA) or a control group (age 56.1 ± 13.7 years, 24.6 ± 15.7
months post-CVA). Materials/Methods: All subjects participated in 30
minutes of functional task practice, twice each week for 4 weeks. The
experimental subjects also received joint mobilizations to the proximal
and distal tibia-fibula, and talocrural articulations of the hemiplegic lower
leg during each treatment session. Dependent variables, including ankle
ROM and biomechanical analysis during STS, were measured at baseline
and following the intervention with a motion analysis system and force-
plate. Changes in these variables were compared between the 2 groups
using an independent t-test (0.05 level of significance). Results: The
experimental subjects had a significantly greater increase in passive dorsi-
flexion (5.7º ±3.1 compared to an increase of 0.19|*omicron*| ± 2.6 in the
control), and total active ROM (10.8º ± 7.5 compared to 2.3º ± 7.5 in the
control).The experimental group also performed the STS task significantly
faster (-0.82 seconds ± 0.91 compared to -0.016 seconds ± 0.45 for the
control), and there was a significant correlation (r =-0.79) between gain in
ROM and time from start of STS to peak dorsiflexion. However, the control
group significantly decreased the difference in average vertical force
between the two lower extremities during STS (-9.56% body weight) com-
pared to the experimental group (1.86% body weight). Conclusions:This
preliminary work demonstrates that joint mobilizations may be effective at
increasing ankle ROM and improving time for STS when combined with
functional task practice in subjects with hemiplegia after stroke. However,
the control group appeared to receive greater benefit from the functional
task practice in achieving more equal weight bearing between the lower
extremities. Clinical Relevance: This study raises questions about the
relationship between ankle mobility and weight bearing during STS. The
subjects who received the ankle stretching intervention may not have had
enough practice opportunity with their newly available motion to fully
improve on the task. Further investigation may be indicated.
RELATIONSHIPS BETWEEN MOVEMENT CONTROL AT 9 UPPER
EXTREMITY SEGMENTS AND LOSS OF HAND FUNCTION IN PEOPLE
WITH CHRONIC HEMIPARESIS. C.E. Lang, Physical Therapy,Washington
University, St. Louis, MO.
Purpose/Hypothesis:The hand is a tool that people use to interact with
their environment, and consequently, loss of hand function in people with
hemiparesis is a major contributor to disability post stroke.To use the hand
for functional activities, a person may need adequate control of the more
proximal upper extremity segments, to appropriately position and orient
the hand with respect to the environment, and may need adequate control
of the fingers, to manipulate objects within the environment.The purpose
of this study was to investigate how movement control at 9 segments of the
upper extremity (shoulder, elbow, forearm, wrist, and 5 fingers) contributed
to loss of hand function in people with chronic hemiparesis. Number of
Subjects: 20 subjects with chronic hemiparesis, age range 43-85.
Materials/Methods:To measure movement control at the 9 segments, sub-
jects were studied making isolated movements at the shoulder, elbow, fore-
arm, wrist, and five fingers using 3-D kinematic techniques. Extracted vari-
ables for each segment included the: active range of motion (AROM),
individuation index, and stationarity index.To measure hand function, sub-
jects performed a battery of standardized clinical tests. Principal compo-
nent analysis was used to create a single hand function score for each sub-
ject from the clinical test battery. Correlation analyses were used to
examine relationships between movement control at the 9 segments and
hand function. Multiple regression was used to determine how proximal,
Vol. 29 • No. 4 • 2005
middle, and distal segments contributed to the variance in hand function.
Results: The ability to move each segment against gravity (AROM) was
strongly correlated with hand function, such that the greater the AROM, the
greater the hand function. The ability to move segments in isolation (indi-
viduation index), and the ability to hold segments still (stationarity index)
were also correlated to hand function, with more proximal segments hav-
ing similar correlation coefficients to the more distal segments. Proximal,
middle, and distal AROM values accounted for > 80% of the variance in hand
function, with the largest contribution coming from the distal segments. In
separate analyses, proximal, middle, and distal individuation and stationarity
indices accounted for > 65% of the variance in hand function, with the
largest contribution coming from the proximal segments. Conclusions:
Movement control at proximal, middle, and distal upper extremity seg-
ments was important for functional use of the hand in people with chronic
hemiparesis. Clinical Relevance: An understanding of how movement
control at each upper extremity segment contributes to hand function in
people with hemiparesis will provide insight into how future therapeutic
interventions may be better structured to optimize recovery of function.
GAIT INITIATION IN HEALTHY YOUNG AND HEALTHY OLDER
ADULTS AND IN ADULTS WITH PARKINSON’S DISEASE. C.A. Larson,
B. Amman, V. Lopez, M. Syjud, J. Wolf, N. Yip, School of Health
Sciences/Program in Physical Therapy, Oakland University, Rochester, MI.
Purpose/Hypothesis: Gait initiation refers to the transition from standing
motionless to taking a step forward and reaching a constant walking
speed. Gait initiation is often problematic in persons with Parkinson’s dis-
ease due to akinesia and bradykinesia.The purposes of this study were to
describe gait initiation kinetics, specifically center of pressure (COP)
excursion patterns, and to determine if COP varies when gait is initiated
with the right or left foot, slow or fast speeds and between healthy young
(HY) and healthy older (HO) adults and adults with Parkinson’s Disease
(PD). Number of Subjects: Fourteen subjects, five HY (ages 21-27), five
HO (ages 50-60) and four persons with PD (ages 75-85 with Hoehn and
Yahr scores of I-III) initiated gait upon seeing a light-emitting diode signal
and walked forward approximately four meters. Materials/Methods: Six
trials were performed for each condition (step with right or left foot first,
self-determined slow or fast speed) for a total of 24 trials. COP was
obtained using a Kistler force plate and spatial and temporal parameters
were determined by a Labview data analysis program designed by the first
author. Initially, a 3 (HY, HO, PD) x 2 (right or left step foot) x 2 (slow or
fast speed) ANOVA with repeated measures was used to analyze individual
trial data. No differences (p=0.08-0.97) were found when comparing the
right and left step foot trials, therefore, right and left trials were pooled for
analysis. Then slow and fast speed data were analyzed separately using a
one-way ANOVA and Bonferroni post hoc tests using mean data. Results:
Subjects with PD tended to be slower than the HY and HO adults as mea-
sured by the following temporal variables: reaction time, onset to farthest
swing time, farthest swing to forward progression time, and forward pro-
gression to end time and were significantly slower for total movement time
at slow speeds (p=0.01) and fast speeds (p=0.04). Subjects with PD also
had smaller COP excursions than HY and HO adults with respect to the
farthest lateral and posterior distance toward the swing limb from the ini-
tial COP position and the farthest swing to forward progression distance.
There were no differences between the groups in the COP angles for slow
(p=0.24) and fast (p=0.16) speeds. Conclusions: Individuals with
Parkinson’s disease tend to or significantly move slower and have reduced
COP spatial excursion patterns as compared to HY and HO adults which
may indicate a safety strategy or an unwillingness to produce forces which
would move them toward the edges of their base of support and challenge
balance during gait initiation. Clinical Relevance:A better understanding
of the kinetics during gait initiation in persons with PD will eventually lead
to development of more appropriate intervention strategies and hopefully
reduce risk of fall.
HIP JOINT POSITION AFFECTS VOLITIONAL KNEE EXTENSOR
ACTIVITY POST-STROKE. M. Lewek1, T. Hornby1, Y. Dhaher1, B. Schmit2,
1
Sensory Motor Performance Program, Rehabilitation Institute of Chicago,
Chicago, IL, 2Marquette University, Milwaukee, WI. (See Post-Stroke
Hemiplegia Thematic poster session for abstract)
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
INVESTIGATION OF LATERAL FORCES WHILE PERFORMING
VOLUN-TARY FORWARD STEPPING WITH AND WITHOUT USING A
CANE IN HEALTHY ADULTS AND HEMIPLEGIC PATIENTS WITH
STROKE. Y. Lin1, P.Tang1, W. Chang1, L. Lu2, 1School and Graduate Institute
of Physical Therapy, National Taiwan University, Taipei, TAIWAN, 2Physical
Therapy, Chung Shan Medical University Rehabilitation Hospital,Taichung,
TAIWAN.
Hypothesis:This study investigated differences in the lateral forces while
performing voluntary forward stepping with and without a cane in healthy
adults and hemiplegic patients with stroke. Number of Subjects: Five
hemiplegic patients with stroke (mean age=55.9 ± 11.5yrs) and five age-
matched healthy adults (mean age=56.0 ± 7.0yrs) participated in this
study. Materials/Methods: Four conditions, stepping forward with the
left and right leg, and with and without using a cane, were tested. Ground
reaction forces underneath the lower extremities and the cane were col-
lected by two force plates and an instrumented cane, respectively. The
loading duration (from onset of the increase in lateral force toward the
stepping leg to the first zero crossing of the lateral force), unloading dura-
tion (onset of the increase in lateral force toward the stance leg to the sec-
ond zero crossing of the lateral force), force impulses during the loading
and unloading durations, and the rate of lateral force transfer prior to foot
liftoff were analyzed. Results: Compared with healthy adults, patients
with stroke showed longer loading duration (P = 0.003), smaller force
impulse in the loading phase (P = 0.024), and slower rate of lateral force
transfer (P = 0.001) when stepping with the unaffected leg without a cane;
and showed longer loading (P = 0.003) and unloading durations (P = 0.01),
and smaller force impulses in the unloading phase (P = 0.001) while step-
ping with the affected leg without a cane. Without using a cane, patients
with stroke also showed longer unloading duration (P = 0.017), faster rate
of lateral force transfer (P = 0.009), greater force impulse in the loading
phase (P = 0.021), and smaller force impulse in the unloading phase (P =
0.017) while stepping forward with the affected leg than with the unaf-
fected leg. While using a cane to perform the stepping, most of these
patients decreased the generation of force impulses in the loading and
unloading phase although the amount of the decreases did not reach a sig-
nificant level (loading phase P = 0.059; unloading phase P = 0.071). No sig-
nificant change was observed for the rate of lateral force transfer between
the no cane and cane use conditions for the patient group either.
Conclusions : To achieve a safe lateral weight transfer required prior to
and during a forward stepping movement, patients with stroke appeared
to lengthen the loading and unloading durations in order to compensate
for their decreased ability to generate lateral impulses in the loading and
unloading phases, respectively. Using a cane might partially contribute to
the lateral impulse generation required for performing the stepping move-
ment such that the impulses generated by the lower extremities decreased
slightly. Clinical Relevance : For patients with stroke to step forward, the
use of a cane might potentially decrease the difficulty of the lower extrem-
ities to perform the lateral weight shifting required prior to and during this
movement.
EFFECTS OF RANDOM AND BLOCKED ORDER PRACTICE ON
MOTOR LEARNING IN INDIVIDUALS WITH PARKINSON DISEASE.
C. Lin1, C.J. Winstein1, K.J. Sullivan1, A.D. Wu2, 1Biokinesiology and Physical
Therapy, University of Southern California, Los Angeles, CA, 2Neorology,
University of Southern California, Los Angeles, CA. (See Motor Learning
Thematic poster session for abstract)
USE OF ‘TIME SPENT IN BALANCE CORRECTION’ AS A MEASURE OF
BALANCE. P.V. Loubert1, L. Swan2, H. Otani3, 1Physical Therapy, Central
Michigan University, Mt. Pleasant, MI, 2Physical Therapy, University of the
Pacific, Stockton, CA, 3Psychology, Central Michigan University, Mt. Pleasant,
MI.
Purpose/Hypothesis: Conventional measurement of postural sway from
force plate technology has been derived from the standard deviation of the
individual center of pressure locations relative to the average center of
pressure location.When measuring static balance activities such as tandem
stance, some data was occasionally lost if subjects took a step (i.e. used a
step strategy) or otherwise changed body position during testing.The pur-
212
poses of this study were to: 1) develop a measure of postural sway that
incorporated these normal balance strategies and 2) examine the relation-
ship of this new measure with conventional measurement. Number of
Subjects: Fourteen women with a mean age of 26 years. Materials/
Methods: The subjects completed two trials each of two different static
standing balance tasks while standing on a force plate with their eyes
closed: 1) standing with feet together and 2) standing with feet together
with a vibratory stimulus applied to the bilateral gastrocnemius muscles.A
sliding, 10 ms time window was used to examine each 60 second trial. If the
subject had more than a pre-specified change in any of the three dimen-
sions of movement, “corrective activity”was recorded. The final measure
was the percentage of time spent in balance correction (TSBC). Results:
ANOVAs demonstrated that the new measure,TSBC, and conventional mea-
surement both showed a significant difference between the vibration con-
dition and the normal condition (p<0.05).When the effect size of the bal-
ance tasks on each measure were examined, the strength of association
between the balance tasks and the measure was greater for the TSBC mea-
sure (R2 =0.79) than for the conventional measure (R2 = 0.68).
Conclusions:The TSBC measure demonstrated more sensitivity than con-
ventional measurements in detecting the balance difference between two
static standing balance tasks. Clinical Relevance:Therapists working clin-
ically view balance strategies, such as stepping, as appropriate responses in
a given environmental context. Researchers have seldom incorporated the
appropriate use of balance strategies into their measurement of postural
sway.The TSBC measure offers the advantage of incorporating a clinical per-
spective to bridge the gap between research and clinical views of balance.
THE FIVE-ITEM DYNAMIC GAIT INDEX: DEVELOPMENT AND
TESTING. G.F. Marchetti1, S.L. Whitney2, 1Physical Therapy, Duquesne
University, Pittsburgh , PA, 2Physical Therapy, University of Pittsburgh,
Pittsburgh, PA.
Purpose/Hypothesis: The Dynamic Gait Index (DGI) was developed to
examine patient ability to modify gait responses during 8 walking tasks.
The DGI has been reported to help clinicians identify patients at increase
risk of falls.The purpose of this study was to examine the scaling and rat-
ings of the DGI and to evaluate the properties of a 5-item version in patients
with balance and vestibular dysfunction. Number of Subjects: Ninety
three patients (mean age 61 years, SD 16, range 14 -90) with balance and
vestibular disorders seen in a tertiary-care clinic for balance disorders were
included. Materials/Methods:All subjects were examined while perform-
ing 8 items of the DGI by a licensed physical therapist. Scaling of the ordi-
nal DGI measure was examined using Rasch analysis modeling to determine
the range of item difficulty and subject ability. Items showing similar prop-
erties were considered for elimination. Coefficient Alpha was used to deter-
mine the internal consistency of the reduced item DGI. Factor analysis was
used to determine the construct structure of the new 5-item DGI.The abil-
ity of the 5-item DGI to identify subjects with a self-reported history of falls
was determined using analysis of discriminative function and a receiver
operating characteristic (ROC) curve. Results: The 8-item DGI demon-
strated excellent inter-item reliability (0.96). Rasch model scaling and fit sta-
tistics identified three items for elimination: walking-horizontal head turns,
gait with pivot turn, and stair climbing. The 5-item test (level gait, change
gait speed, walking-vertical head turns, step over obstacle, step around
obstacle) showed good internal consistency (Crohnbachs alpha=0.89).
Factor analysis demonstrated a single construct explained 71% of test vari-
ance with a minimum item loading of 0.76.The 5-item DGI demonstrated
good ability to discriminate fallers (p < 0.01, 61% correctly identified). ROC
curve analysis showed optimal screening for fallers at a score of 12/15 (sen-
sitivity 70%, specificity 53%) and was superior to the full 8 item test.
Conclusions:The 5-item DGI appears sufficient to identify gait responses
to changing task demands in patients with balance and vestibular disorders.
Clinical Relevance:The 5-item DGI can reduce examination time without
compromising information gained about dynamic gait.
EFFICACY OF SPLIT ANTERIOR TENDON TRANSFER SURGERY AND
BODY WEIGHT SUPPORTED TREADMILL TRAINING POST-STROKE:
A CASE STUDY. N.D. Matthews1, K.J. Sullivan1, V. Eberly2, S. Mulroy2,
1
Biokinesiology & Physical Therapy, USC, Los Angeles, CA, 2Pathokinesiol-
ogy Laboratory, Rancho Los Amigos Medical Center, Downey, CA.
213 J ournal of N eurological P hysical T herapy
Background & Purpose: To investigate the efficacy of body weight sup-
ported treadmill training (BWSTT) following split anterior tendon transfer
(SPLATT) surgery to improve walking ability in an individual post-stroke.
Case Description:The patient is a 53 year old male, 5 years post left inter-
nal capsule hemorrhage resulting in right hemiplegia who had severe walk-
ing disability due to inadequate right hip and knee flexion during swing
and excessive inversion/plantarflexion throughout the gait cycle. The
patient’s functional walking ability improved with outpatient therapy; how-
ever, his gait continued to be severely limited by the equinovarus deformity.
A SPLATT procedure was recommended. Surgery was performed four years
post-stroke and included the SPLATT, toe flexor release, tendo-Achilles
lengthening, and rectus femoris release. Two months after surgery the
patient returned to physical therapy for treatment. Intervention: Physical
therapy intervention consisted of BWSTT 1-3x/week x 25 weeks (52 ses-
sions) for a total of 20 minutes of treadmill walking each session.Treadmill
speed varied between 1.7 and 2.2 mph, with the body weight support
decreased across training from 40% to 10%. Concurrently, the patient per-
formed a home exercise program on non-treatment days which focused on
lower extremity stretching and strengthening. Outcomes: LE Fugl-Meyer
Motor Score (LEFM), gait velocity, six minute walk and other musculoskele-
tal measures were taken pre-treatment, every 4-5 weeks across sessions, at
completion of therapy, and at 1- and 3-month follow-up. Instrumented gait
and motion analysis with fine-wire EMG recording of LE muscle activity was
performed before surgery and 1-wk post treatment. Across post-surgical
treatment, there was minimal change in the LEFM (pre 26/34, post 27/34);
however, self-selected gait velocity with AFO and cane increased 62% (pre
0.59, post 0.95m/s) and 6-minute walk increased 75% (pre 169.2, post
296m). Gait and motion analysis revealed a decrease in ankle inversion dur-
ing stance from 30 degrees to 10 degrees. Pre-operatively, tibialis anterior
fired continuously throughout the gait cycle, post-treatment EMG revealed
normal onset and cessation of tibialis anterior at 53.3% and 14.0% of the
gait cycle, respectively.The patient reported increased confidence in walk-
ing with and without his brace and increased daily community walking. He
also resumed an active role in his community. Discussion: This case
demonstrates the beneficial use of SPLATT surgery combined with BWSTT
to improve walking ability in an individual with chronic stroke. The
improved structural alignment gained from surgery combined with task-
specific training resulted in significant changes in muscle phasing and
velocity during gait and improved functional ambulation in our patient.
CLINICAL TESTS OF WALKING DUAL-TASK PERFORMANCE AFTER
ACQUIRED BRAIN INJURY (ABI): FEASIBILITY AND DUAL-TASK
COST COMPARISONS TO A YOUNG ADULT GROUP. K. McCulloch, K.
Blakley, L. Freeman, Division of PT,Allied Health Sciences, UNC-Chapel Hill,
Chapel Hill, NC.
Purpose/Hypothesis: 1) To describe feasibility of three tests of dual-task
performance during walking for individuals with ABI. 2) To compare dual-
task performance on the most feasible measure between subjects with ABI
and a group of young adults. umber of Subjects: 18 ambulatory adults
(5 women) with ABI (age range 24-58); independently ambulatory for a dis-
tance of at least 40 feet (3 subjects used a cane or walker). Two subjects
undergoing day treatment with recent onset were limited household
ambulators. 16 subjects with chronic cognitive impairments required sup-
port for independent living; 14 were community ambulators. Comparison
group subjects were 25 young adults (7 male) without brain injury (age
range 22-35). Materials/Methods:ABI subjects performed 1- ‘Stops walk-
ing while talking test’(SWWT); 2- Walking While Talking Test (WWTT) that
requires walking while repeating the alphabet and alternate letters of the
alphabet; and 3- Walking and Remembering Test (WART)that tests speeded
walking on a 12 inch narrow path while performing a working memory
task. Dual-task costs on the WART were compared for the ABI and young
adult sample. Results: Task feasibility and difficulty for ABI subjects: The
SWWT test was negative for all subjects.The alphabet WWTT task was easy
for 89%, but the alternate alphabet task was too difficult for the majority
(66%).The WART cognitive task was completed by all subjects, even those
with severe declarative memory deficits.The WART walking task was not
feasible for one subject who was legallyABI and young adult dual-task cost
comparisons:WART median relative dual-task costs for walking speed were
greater for ABI subjects [.18, 95% C.I. (.01, .24)] than young adults [.002,
Vol. 29 • No. 4 • 2005
95% C.I. -.02, .05)]. Mean reductions in digit span accuracy were similar
[ABI subjects .87, 95% C.I. (.79, 95); young adults .92, 95% C.I.88, .95)].
Subjects with ABI had more difficulty with step accuracy on average, but
the median dual-task steps off the path was zero for both groups.
Conclusions:Task difficulty is important when assessing dual-task perfor-
mance.The SWWT and WWTT have limitations for ambulatory individuals
with ABI, as the cognitive tasks are either too simple (SWWT) or too diffi-
cult (WWTT alternate alphabet cognitive task). Measures that allow for
adjustment of task difficulty (WART) are feasible for individuals with cog-
nitive impairment.The use of a working memory task revealed similar dual-
task costs for cognitive task performance between the ABI and young.
Clinical Relevance:The diverse nature of deficits following ABI necessi-
tates flexibility in outcome measures. Dual-task measures that record per-
formance of both tasks and allow some adjustment of task difficulty may
provide better insight into the effects of dual-task conditions and inform
plans for intervention.
PARETIC LOWER EXTREMITY LOADING AND WEIGHT TRANSFER
FOLLOWING STROKE. V.S. Mercer1, S. Chang1, J.L. Purser2, J.K. Freburger3,
1
Allied Health Sciences, UNC-CH, Chapel Hill, NC, 2Medicine, Duke
University Medical Center, Durham, NC, 3Cecil G. Sheps Center for Health,
University of North Carolina at Chapel Hill, Chapel Hill, NC. (See Post-
Stroke Hemiplegia Thematic poster session for abstract)
EFFECTS OF BODY WEIGHT SUPPORTED TREADMILL TRAINING ON
RUNNING IN A PATIENT POST-STROKE: A PROSPECTIVE CASE
REPORT. E.W. Miller, S. Combs, C. Fish, B. Lakin,A. Schlotterbeck,A. Sieber,
Krannert School of Physical Therapy, University of Indianapolis,
Indianapolis, IN.
Purpose/Hypothesis: Many benefits of body weight supported treadmill
training (BWSTT) have been documented, including increased cadence,
symmetry, gait velocity and confidence of ambulation. However, there are
no studies that have focused on BWSTT and running. Further, there is lim-
ited literature regarding rehabilitation of running in individuals who have
neurological conditions such as stroke. The purpose of this report was to
investigate the feasibility and effectiveness of using BWSTT to improve the
running ability of a patient post stroke. We hypothesized that the inter-
vention would be feasible and effective. Number of Subjects:The partic-
ipant was a 38-year-old man, 2.5 years post-stroke. Materials/Methods:A
prospective case report design was selected in which baseline was estab-
lished and followed by an 8-week treatment phase. Immediate and delayed
post testing was performed. Dependent variables used for single system
analysis included: single leg balance, running step length, step length ratio,
step width, and 25-meter sprint speed. Pre/post dependent variables
included: lower extremity strength, 6-minute walk, and the Stroke Impact
Scale.The 2 standard deviation band method was used to analyze the data
with alpha set a 0.05. The variables measured during pre-and post-test
phases were subjectively analyzed based on a 10% difference defined as a
functional change in ability. Results: Left single leg balance, right step, step
width, and sprint speed changed significantly from baseline to delayed
post-test. All pre-post measures showed greater than 10% improvement.
Conclusions: Our data supported current literature that suggests that
patients with chronic deficits due to stroke can make functional gains with
continued rehabilitation and also that BWSTT is a useful and effective tool
in the clinical setting. Our data also added to current literature by demon-
strating the feasibility and effectiveness of using BWSTT to improve run-
ning ability. Clinical Relevance: BWSTT was a feasible and effective inter-
vention for improving running ability in this high functioning patient
post-stroke. It may be an option for other patients with neurological con-
ditions with a goal of regaining running ability.
DEVELOPMENT AND VALIDATION OF CIRCUMDUCTION ASSESSMENT
SCALE FOR INDIVIDUALS WITH HEMIPLEGIA. J.L. Moore1, H.R. Roth1, M.
Lewek1, Y.Y. Dhaher1, T.G. Hornby2, 1Sensory Motor Performance ,
Rehabilitation Institute of Chicago, Chicago, IL, 2Department of Physical
Therapy, University of Illinois of Chicago, Chicago, IL. (See Post-Stroke
Hemiplegia Thematic poster session for abstract)
THE EFFECTS OF SPEED AND LEVEL OF VOLUNTARY MUSCLE
ACTIVATION ON REFLEX RESPONSES IN CHRONIC STROKE
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
PATIENTS. D. Nichols1, M. Pelliccio1, I. Black2, J. Hidler2, 1Inpatient PT,
National Rehabilitation Hospital, Washington, DC, 2Center for Applied
Biomechanics and Rehabilitation Research, National Rehabilitation
Hospital,Washington, DC. (See Post-Stroke Hemiplegia Thematic poster ses-
sion for abstract)
TETRAPLEGIA DUE TO CRITICAL ILLNESS POLYNEUROPATHY FOL-
LOWING SEVERE TBI, ACCOMPANIED BY MULTIPLE COMPLICA-
TIONS. A CASE REPORT OF PROLONGED INPATIENT ACUTE REHA-
BILITATION COURSE AND FUNCTIONAL OUTCOMES. A. Packel,
Physical Therapy, MossRehab Hospital, Cheltenham, PA.
Purpose/Hypothesis: Descriptions of severe critical illness polyneuropa-
thy (CIP) and functional recovery are sparse in the literature.This case illus-
trates the potential for recovery from concomitant TBI and CIP, and rein-
forces the need for intensive, comprehensive services. Number of
Subjects: Case report of a 54-year-old man who sustained a severe TBI due
to a mechanical explosion in close proximity to his face. Patient was admit-
ted to rehab 8 weeks after injury, with no active movement or muscle con-
tractions in his trunk, neck, and three extremities. He was able to open and
close his right hand spontaneously. He was unable to communicate, and
inconsistently able to perform actions with his right hand upon command.
Initial FIM scores were all either 1 or 0 and initial Disability Rating Score
(DRS) = 21T, indicating extremely severe disability. Materials/Methods:
Patient’s acute inpatient rehabilitation course lasted 37 weeks. On the
tenth day of his rehab stay, Pt. had EMG/NCV tests with finding of severe
peripheral polyneuropathy affecting lower extremities more than upper
extremities, diagnosed as critical illness polyneuropathy. This provided an
explanation for his minimal movement throughout and also led to the belief
that considerable motor recovery might occur, but might require months to
years.A strong social situation allowed planning for discharge to his home,
despite the expectation of prolonged severe deficits in movement through-
out. Heavy focus was placed on family training for all aspects of care, and
optimizing return of strength as the polyneuropathy resolved. Results: At
time of discharge, the patient was able to communicate basic needs mostly
consistently, drive a power wheelchair indoors with frequent verbal cues
and minimal assistance, and feed himself with minimal assistance. Strength
remained 1/5 to 2/5 throughout except his right upper extremity, which
achieved up to 4/5 strength. FIM scores ranged from 1 to 4, and DRS score
at discharge = 13, indicating severe disability. His wife and hired caregiver
were able to assist him with all care, including prescribed exercises, posi-
tioning, and standing program. Continued recovery of motor function and
strength were anticipated, over a prolonged period. Further results will be
presented at 3 month and 6-month follow-up after discharge. Conclusions:
Early detection of critical illness polyneuropathy in this patient helped to
guide his course of treatment.An extended inpatient rehabilitation course
was required due to his severe TBI, severe CIP, and multiple medical com-
plications.This allowed him to be successfully discharged to home and be
cared for by his family, while his polyneuropathy continued to resolve.
Clinical Relevance: Limited information is available in the literature
regarding recovery from severe critical illness polyneuropathy. More infor-
mation is needed in order to aid in prognosis and help to guide treatment
in patients with severe critical illness polyneuropathy.
LOWER LIMB STRENGTH AND COORDINATION PATTERNS OF
CHRONIC STROKE SUBJECTS IN A FUNCTIONAL POSTURE. M.M.
Pelliccio, N. Neckel, D. Nichols, J. Hidler, National Rehabilitation Hospital,
Washington, DC. (See Post-Stroke Hemiplegia Thematic poster session for
abstract)
NEUROMUSCULAR STIMULATION IMPROVES GRASPING FUNCTION
IN INDIVIDUALS WITH CHRONIC STROKE. B. Quaney1, L.H. Zahner1,
M.J. Santos2, Z. Kadivar2, B. McKiernan3, 1Landon Center on Aging, University
of Kansas, Kansas City, KS, 2Physical Therapy and Rehabilitation Sciences,
Kansas University Medical Center, Kansas City, KS, 3Physical Therapy
Education, Rockhurst University, Kansas City, MO. (See Post-Stroke
Hemiplegia Thematic poster session for abstract)
EFFECT OF PLANTAR SOMATOSENSORY INPUT ON VERTIGO:
COMPARISON BETWEEN DIRECT PRESSURE AND TRANSCUTAN-
EOUS ELECTRICAL NERVE STIMULATION. N.L. Nicolai, L.N. Cartwright,
214
S.T. Quenga, L.P. Frasier, R.J. Allen, Physical Therapy, University of Puget
Sound,Tacoma,WA.
Purpose/Hypothesis:To compare the effects on vertigo of two methods of
somatosensory input to the plantar surfaces of the feet; direct plantar sur-
face pressure versus TENS. Number of Subjects: Twenty-one normal vol-
unteers (5 male, 16 female; age range 22-44 yrs) screened for history of
vestibular or oculomotor pathology, episodic dizziness, lower extremity pain
or somatosensory loss, and use of oculomotor altering or ototoxic sub-
stances. Materials/Methods: Subjects were assessed for intact plantar sen-
sation via 4.56 (metatarsal heads) and 5.07 (calcaneus) Semmes Weinstein
monofilaments. Subjects reclined 60o from vertical were exposed to vertigo
induction via 90 sec irrigation of the right external auditory meatus with 90
ml of 5o C water. Using a within-subjects design, vertigo was induced in each
subject three times; each induction was followed by one of three treatment
conditions. Condition A was no-treatment control. Condition B involved
bilateral plantar stimulation via sensory level TENS applied to the calcaneal
region and second metatarsal heads, using random intensity and rate modu-
lation with subjects self-selecting the amplitude limit prior to vertigo induc-
tion. In condition C the plantar aspects of both feet pressed against a solid
surface with peak pressures ranging from 12 to 53 kg. To eliminate order-
effects or habituation bias the order of treatment conditions was varied
according to a preset schedule. Efficacy of each treatment condition was
assessed via subjective reports of vertigo intensity (visual analog scale) and
timed vertigo duration. Differences between responses for each condition
on each dependent variable were assessed using one-way ANOVAs for
repeated measures with multiple contrast analyses. Results: While not sig-
nificantly different from each other, the two plantar stimulation conditions
yielded significant reductions in vertigo intensity compared to control (p =
0.019). Analysis of duration of vertigo revealed no significant differences
between the three groups (p = 0.424). Conclusions: These findings sup-
port the hypothesis that plantar pressure may reduce the intensity of calor-
ically induced vertigo, whether that stimulation is from direct plantar pres-
sure or TENS. Both methods of providing plantar pressure appear similarly
efficacious.These findings do not support the hypothesis that plantar pres-
sure reduces the duration of a vertigo episode. Clinical Relevance: Prior
studies have established that plantar stimulation via direct pressure reduces
some aspects of vertigo. The current study assessed whether a passive
approach to delivering plantar stimulation using TENS might also be effec-
tive.While supporting the notion that plantar stimulation may attenuate ver-
tigo, the current findings indicate that plantar TENS produces similar results.
Given further investigation with a clinical sample, results from this study
could directly translate into an easily implemented clinical intervention for
bed-ridden patients suffering from unrelenting vertigo.
SPLIT-BELT TREADMILL ADAPTATION AND GAIT SYMMETRY POST-
STROKE. D.S. Reisman1, A.J. Bastian2, 1Department of Physical Therapy,
University of Delaware, Newark, DE, 2Kennedy Krieger Institute, Baltimore,
MD. (See Post-Stroke Hemiplegia Thematic poster session for abstract)
A MOTOR LEARNING PHYSICAL THERAPY INTERVENTION
APPROACH AND BOTULINUM TOXIN TYPE A INJECTIONS IN THE
TREATMENT OF SPASTICITY AND REHABILITATION OF UPPER
EXTREMITY FUNCTION FOLLOWING STROKE: A CLINICAL CASE
REPORT. W.J. Sanchez, A.D. Kloos, Physical Therapy, The Ohio State
University, Columbus, OH. (See Motor Learning Thematic Poster Session
for Abstract)
SPINAL CORD INJURY PATIENT EDUCATION: HOW TO MAKE IT
WORK IN A RURAL REHAB SETTING. K.M. Stoneman, S.D. Standard,
Inpatient Rehabilitation, Fletcher Allen Health Care, Colchester,VT.
Purpose:The purpose of this presentation is to describe the process used to
develop a consistent and comprehensive interdisciplinary approach to
patient/caregiver education for individuals with an acquired spinal cord
injury (SCI). Another objective is to relate the creation of a clinician-based
documentation system which serves to improve coordination of individual
educational plans and topics. Description:As part of a review of the SCI pro-
gram at our thirty-five bed inpatient rehabilitation hospital, patient/caregiver
education was examined by an interdisciplinary committee. Chart audits
215 J ournal of N eurological P hysical T herapy
revealed inconsistencies in the type, depth and breadth of topics covered
among and between disciplines.A phone survey of former patients reflected
this as well.Through discussions with clinicians, it also became apparent that
paternalistic assumptions existed regarding the amount of information that
an individual with a new diagnosis of SCI could emotionally handle and inter-
nalize.After these limitations of the system were ascertained, a new process
was incrementally developed. |*bund*|Yes|*eund*| |*bund*|You|*eund*|
|*bund*|Can|* eund*|, a book distributed by the Paralyzed Veterans of
America, was identified as the primary resource for education. Based on this
book, knowledge and performance objectives for pertinent topics were cre-
ated. Next, a patient education binder, including these objectives as well as
additional resources, was compiled. This binder follows the patient as s/he
moves through the continuum of care.To supplement these steps, additional
multi-media, patient-focused educational resources were purchased. All
resources were catalogued so that patients could easily access information
on topics of interest. Summary of Use: The new patient/caregiver educa-
tion system was introduced to each rehabilitation discipline. Although ini-
tially enthusiastic about the concept, some members of the treatment team
were slow to adopt the new system.Therefore, a series of six in-service train-
ing sessions was presented regarding key educational points, best practice,
learning styles and pedagogical methods. For each topic, a concise reference
sheet of information was developed for staff.A team leader/point person was
identified to ensure discussion of patient education at Discharge Planning
Rounds. Importance to Members: A consistent, comprehensive approach
to patient/caregiver education is imperative to the health maintenance of
individuals with an acquired spinal cord injury. An interdisciplinary team is
crucial to the success of such a process. Furthermore, clinicians should be
trained to assess learning styles and adjust teaching strategies accordingly in
order to better support the needs of individuals with a spinal cord injury and
their caregivers.
PSYCHOMETRIC PROPERTIES OF THE NATIONAL INSTITUTES OF
HEALTH STROKE SCALE IN SUBJECTS WITH ACUTE LEFT AND
RIGHT CEREBRAL ISCHEMIC STROKE. D. Straube1, S.R. Millis2, C.
Iramaneerat3, E. Smith3, 1Physical Therapy, Univ. of Illinois - Chicago,
Chicago, IL, 2School of Medicine, Physical Medicine and Rehabilitation,
Wayne State University, Detroit, MI, 3College of Education, University of
Illinois - Chicago, Chicago, IL.
Purpose/Hypothesis: The National Institutes of Health Stroke Scale
(NIHSS) is a widely used instrument for the assessment and monitoring of
progress for individuals with stroke. Published factor analyses of the
NIHSS revealed at least two underlying factors, representing left and right
hemispheres.The purpose of this study was to assess the contributions of
the items of the NIHSS in individuals with either left or right hemisphere
stroke in order to improve the validity of the scale to document neurologic
impairment in these two groups. Number of Subjects: NIHSS scores from
387 individuals with acute left hemisphere stroke and 347 individuals with
acute right hemisphere stroke were analyzed. Individuals with bilateral
cerebral stroke or cerebellar stroke were not included. Materials/
Methods: The Rasch partial credit model was used to analyze the NIHSS
raw scores. Data was assessed using principal component analysis of the
person and item residuals and item fit statistics. Based on the results of the
first analysis, two subsequent analyses were performed with NIHSS scores
from the sample of individuals with left hemispheric stroke and right
hemispheric stroke. Results: The findings support previous findings of
two distinct populations with stroke, subjects with left hemisphere and
right hemisphere stroke.Additional analyses performed generated a linear
scale for each subject population consisting of a subset of items of the
NIHSS. Conclusions:The findings provide a more valid and efficient scale
for the assessment of impairment following stroke consistent with hemi-
spheric lateralization of function in either the left or right hemisphere.
Clinical Relevance:The findings support the need for unique scales for
the assessment of impairment following stroke related to the unique roles
of the left and right cerebral hemispheres. The scales presented for each
group contain fewer items, and are thus more efficiently targeted.
STEPPING OUT: IMPROVING COMMUNITY AMBULATION AND
FUNCTION AFTER STROKE. J.Teepen1, K. Baltzer1, K. Dunning1, P. Levine2,
S. Page2, 1Rehabilitation Sciences, University of Cincinnati, Cincinnati, OH,
Vol. 29 • No. 4 • 2005
Department of Physical Medicine and Rehabilitation, University of
2
Cincinnati, Cincinnati, OH.
Background & Purpose: Due to affected leg disability and nonuse, com-
munity-dwelling stroke patients frequently exhibit impaired leg function,
reduced functional aerobic capacity, activity intolerance, low bone density
and increased risk of falls and hip fracture. Research suggests repeated,
bilateral practice incorporating the more affected limb can restore func-
tion.The NuStep machine provides repetitive, bilateral practice to both the
upper and lower extremities. It is commonly available in therapy settings
and is commercially available.We hypothesized that intensive training with
the NuStep could be a safe and effective form of bilateral practice to reduce
affected limb impairment and improve conditioning for stroke patients.The
purpose of this case study was to determine cardiovascular and functional
changes in a stroke patient using NuStep for 10 weeks. Case Description:
This subject is a 60 year-old African American male 4.5 years post stroke
with right hemiplegia. Outcomes: This case is one subject in a larger
crossover study involving 10 weeks of NuStep intervention followed by 10
weeks of home exercise. NuStep sessions emphasize cardiovascular train-
ing and strength building, decreasing or increasing resistance, respectively.
From November 2004 through May 2005, the following assessments were
conducted prior to intervention (pre), after 10 weeks of intervention (post-
intervention) and after 10 weeks of HEP (post-HEP): heart rate and blood
pressure, LE Fugl-Meyer, Berg Balance, and Short Physical Performance
Battery. Resting blood pressure decreased: systolic from 132 to 120 mmHg
and diastolic from 78 to 71 mmHg. Resting heart rate decreased from 70 to
66 bpm. Berg Balance scores improved from 32 (pre) to 33 (post-interven-
tion, post-HEP). Walking speed increased from 44.5 sec (pre) to 31.9 sec
(post-intervention) to 22.0 sec (post-HEP). Fugl-Meyer did not change.
Ability to semi-tandem stand improved from 0 (pre-test) to 1 (post-inter-
vention, post-HEP). Patient reported increased confidence and endurance
with community ambulation. He also reported no longer needing a scooter
for grocery shopping. Discussion: Ten weeks of NuStep resulted in
improved cardiovascular measures and function. Walking speed continued
to improve up to ten weeks after intervention was finished. NuStep offers
promise to improve cardiovascular fitness and function for patients with
chronic stroke. It may be an effective adjunct to PT requiring minimum
supervision with lasting effects after discharge. It also offers promise to
patients discharged from therapy. The combination of cardiovascular and
strength training and reciprocal movements requiring minimum supervi-
sion may make this an ideal exercise for chronic stroke patients.
PROCEDURAL LEARNING OF FUNCTIONAL MOBILITY TASKS IN THE
PRESENCE OF SEVERE MEMORY DEFICITS FROM INTRAVEN-TRICU-
LAR HEMORRHAGE. K.A. Volk, R.O. Myers, E. Fitzpatrick-DeSalme,
MossRehab, Philadelphia, PA. (See Motor Learning Thematic poster session
for abstract)
SENSORIMOTOR IMPAIRMENTS AND REACHING PERFORMANCE IN
PERSONS WITH HEMIPARESIS: RELATIONSHIPS DURING THE
ACUTE AND SUBACUTE PHASE AFTER STROKE. J.M. Wagner1, C.E.
Lang1, S.A. Sahrmann1, D.F. Edwards2, A.W. Dromerick3, 1Program in Physical
Therapy,Washington University School of Medicine, St. Louis, MO, 2Program
in Occupational Therapy, Washington University School of Medicine, St.
Louis, MO, 3Department of Neurology, Washington University School of
Medicine, St. Louis, MO. (See Post-Stroke Hemiplegia Thematic poster ses-
sion for abstract)
THE WOLF MOTOR FUNCTION TEST: NORMATIVE DATA FOR ABLE
BODIED INDIVIDUALS. S. Wolf, J. McJunkin, M. DeGreef, Program in
Physical Therapy, Department of Rehabilitation Medicine, Emory
University School of Medicine,Atlanta, GA.
Purpose/Hypothesis: The purpose of this study was to establish a nor-
mative database for the Wolf Motor Function Test (WMFT) and to deter-
mine trends between and within specific age groups, gender, sequence of
testing, and specific WMFT tasks. We hypothesized that movement times
would increase and strength would decrease among older participants.We
further hypothesized that women would not be as strong as men for the
two strength tasks. Number of Subjects: A convenience sample of 52
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
healthy able-bodied adult individuals, both male and female, between the
ages of 40 and 80 participated.The sample was then grouped by decades.
All participants met pre-established inclusion/exclusion criteria including
no past medical history of stroke or other brain injury and no previous
upper extremity (UE) impairments or limitations.All but one person were
right handed by statement of hand preference for writing. Prior to testing,
all participants read and signed an informed consent and a HIPAA form.
Materials/Methods: Administration of the WMFT required standardized
positions for table and seat height, the correct position of a standardized
template, standard items for testing, and specific verbal instructions.WMFT
tasks remained constant throughout (tasks 1-17, sequentially) and pro-
gressed from proximal single joint movements to more complex multi-seg-
mental UE motions. Both UE for each participant were tested. Limb
sequencing was determined randomly by a coin flip.Two co-investigators
were responsible for administering the WMFT throughout the study. Each
co-investigator established intra-rater reliability prior to administration of
the WMFT (ICC3, 1 = 0.99). Inter-rater reliability was established prior to
and throughout testing (ICC2, 1 = 0.91 - 1.00). Results:An age effect for
timed tasks was observed between the forty - sixty, forty - seventy, and fifty
- seventy year age groups for the right hand and between the forty - sixty
and forty - seventy year age groups for the left hand (p = 0.0027). An inter-
action was also seen within hand by sequencing in timed tasks (p <
0.0001). No gender differences existed for the timed tasks; however, dif-
ferences between genders were found for both strength tasks (p <
0.0001). Conclusions:This study presents a normative database of healthy
able-bodied adult individuals for the WMFT. On timed tasks, older adults
were slower than younger adults and the first hand tested was slower. Men
were consistently stronger than women on strength tasks. Clinical
Relevance: Currently the WMFT is administered to the less affected UE
first; therefore the more impaired UE may yield better scores because of a
sequence effect. Consequently, randomizing the limb sequence for testing
may combat a potential testing effect. Having this normative data set will
help clinicians and third party payers to understand relative improvement
in patients with mild to moderate stroke following interventions. Periodic
assessment of change scores among individual tasks will also assist clini-
cians in modifying treatment programs to target those joint movements
requiring additional attention.
OPTOKINETIC STIMULATION AS A TREATMENT FOR IMBALANCE
WITH VESTIBULAR IMPAIRMENT: 3 CASE REPORTS. N.M.
Wubenhorst, Balance and Vestibular Center, San Joaquin Valley
Rehabilitation Hospital, Fresno, CA.
Purpose: Treating vestibular dysfunction with optokinetic stimulation
(OKS) has been suggested as both efficient and effective. It is based on
the theory that a sensory conflict situation can force central compensation
of a diseased vestibular system to yield successful balance. Studies have
shown that body sway is minimized and optokinetic nystagmus is normal-
ized after 6 to 8 sessions. These case reports are presented with the pur-
pose of demonstrating an effective, easily applied clinical treatment for
vestibular impairment. Description: Three subjects were selected with
diagnoses or clinical evidence of vestibular dysfunction with imbalance.
Physical therapy evaluation included subjective balance and dizziness
questionnaires, vestibulo-ocular testing, computerized balance testing, and
functional measures including Berg Balance Scale and Dynamic Gait Index.
Treatment was provided by an optokinetic device that provided visual
stimuli that could be applied both horizontally and vertically depending on
impairments determined in evaluation. Patient positioning was individual-
ized to maximally challenge balance while still being sustainable by the
patient. Duration was to tolerance with 10 minutes being a goal. Retest
results were compared to established norms for each test. Case One under-
went 9 treatments of traditional vestibular and balance retraining with
modest response. She continued treatment for another 4 visits with OKS.
Re-evaluation showed dizziness resolved and unsteadiness significantly
reduced. Case Two received 5 treatments of OKS in conjunction with tra-
ditional vestibular and balance exercises. Re-evaluation showed her dizzi-
ness resolved and balance confidence improved. Case Three participated
in 6 treatments of OKS in conjunction with traditional vestibular and bal-
ance exercises. Re-evaluation revealed decreased vertigo in addition to
improved functional mobility and stability. Summary of Use: All three
216
cases responded well to this treatment. In the first case, it proved to be
more effective than the traditional approach. Equipment was inexpensive
and readily available.Treatment was easily tolerated by the patients since
challenge levels were tailored to each case. Further studies are needed to
compare these results to a similar amount of time spent with vision elimi-
nated while standing in a challenging balance situation, or with comput-
erized sensory organization training. Long term carryover should be inves-
tigated as well. Importance to Members: Imbalance is a common and
significant impairment that can lead to injury and disability.When vestibu-
lar system pathology is an underlying component, optokinetic stimulation
can be an effective, readily available, and cost efficient method of treat-
ment.
THE EFFECTIVENESS OF THERAPEUTIC YOGA ON COMMUNITY
DWELLING OLDER ADULTS WITH AND WITHOUT BALANCE
DEFICITS. K.K. Zettergren, E. Moriarty, A. Zabel, Physical Therapy,
Quinnipiac University, Hamden, CT.
Purpose/Hypothesis:The purpose of this study was to assess the bene-
fits of a therapeutic yoga program on one group of community dwelling
elderly individuals. A second purpose of the study was to determine the
effects of yoga on the confidence levels of participants while performing
specific activities of daily living. Number of Subjects: Nine community
dwelling elderly adults (aged 62-83) participated in the program. All sub-
jects were female. Four community dwelling elderly adults (aged 63-84)
served as control subjects. Control subjects were evenly divided, two male
and two female. Materials/Methods:All subjects signed an informed con-
sent prior to participating in the study. Subjects were then evaluated using
the Tinetti Balance Scale and the Falls Efficacy Scale. Subjects participating
in the therapeutic yoga received one-hour of yoga for four consecutive
weeks. The yoga program consisted of: Pranayama (concentrated breath-
ing), warm-ups, asana (physical poses, with props and modifications as
needed), and meditation. In addition, participants received a detailed home
therapy program that included several of the postures performed during
the therapeutic yoga session. Control subjects received no intervention.
After four weeks, all subjects were re-tested on both measures. A single
tester performed all evaluations and was blinded to subjects’ group assign-
ment. Results: Paired t-tests were used to assess change scores on the
Tinetti Balance Scale. The Mann Whitney U Analysis was used to assess
change scores on the Falls Efficacy Scale. The intervention group showed
a statistically significant increase on the Tinetti Balance Scale (p = .001).
The control group showed no significant change.There was no statistically
significant change on the Falls Efficacy Scale for either group.
Conclusions: The effects of therapeutic yoga on balance, strength and
flexibility have not been thoroughly studied.This study showed a statisti-
cally significant change with a relatively short intervention program.This
study supports the use of therapeutic yoga for improving functional bal-
ance in community dwelling older adults. Clinical Relevance: Recent
studies reveal that more than half of community-dwelling elderly individu-
als over the age of 62 report a fear of falling. Other studies indicate that
higher levels of physical activity, including strength, flexibility and balance
training, may improve mobility and balance and subsequently reduce falls.
Some researchers propose that community-based exercise programs may
reduce the likelihood of falls. In addition, by the year 1990, Americans
spent approximately 13.7 billion dollars on complementary and alterative
health care.To that end, exercise programs that are community based and
include balance, strength and flexibility training but also consider the
body/mind connection could prove effective in reducing falls and improv-
ing function. Physical therapists are ideal individuals to administer com-
munity based, alternative therapy programs and monitor participants
improvements and changes as they relate to function and quality of life.
NEUROPATHIC PAIN AFTER SPINAL CORD INJURY AND ITS
RELATIONSHIP TO MICROGLIA AND ATP RECEPTOR
UPREGULATION. L.C. Fisher, Z.A. Kloos, A.D. Kloos, D. Basso, Physical
Therapy, The Ohio State University, Columbus, OH; M.R. Detloff,
Neuroscience Graduate Studies Program, The Ohio State University,
Columbus, OH; E.E. McDaniel, V. McGaughy, P.G. Popovich, Department of
Molecular Virology, Immunology & Medical Genetics, The Ohio State
University, Columbus, OH.
217 J ournal of N eurological P hysical T herapy Vol. 29 • No. 4 • 2005

Purpose/Hypothesis: Spinal cord injury (SCI) often causes neuropathic repeated factor and DVA as the variable of interest. Appropriate post-hoc
pain (chronic allodynia and hyperalgesia) but the underlying neu- statistics were performed if a significant main effect or interaction was
roanatomical mechanisms are unknown. In peripheral nerve injury models found (p < 0.05). Factors contributing to change in DVA were examined
of pain, allodynia developed after upregulation of ATP receptors, specifi- using a forward stepwise linear regression. Results: There were no differ-
cally P2X4, on dorsal horn microglia. Since astrocyte networks communi- ences in group characteristics at baseline (p > 0.05). RM ANOVA showed
cate through ATP receptors, altered microglial and astrocytic responses that patients who performed vestibular exercises showed a significant
may underlie neuropathic pain after SCI.Therefore, we investigated if allo- improvement in DVA (p = 0.001), while those performing placebo exer-
dynia and hyperalgesia after SCI is associated with greater microglial and cises did not (p = 0.125). Based on stepwise regression analysis, the leading
astrocytic response and the upregulation of P2X4 receptors in the dorsal factor contributing to improvement in DVA was vestibular exercise, which
horn. Number of Subjects: Thirty-seven adult, female, Sprague-Dawley contributed 41% of the variability pre to post treatment.Vestibular function
rats were used. Materials/Methods: Rats were randomly assigned to: did not change with intervention. Conclusions: The use of vestibular
naive, spinal nerve ligation (SNL), laminectomy, mild (0.5 mm displace- exercises is the main factor involved in the recovery of DVA in patients with
ment) or moderate (1.1 mm displacement) SCI groups.To rule out cellular BVH. Our study suggests that recovery of DVA may be due to mechanisms
responses due to surgery, we included laminectomy and mild SCI groups other than improvement in residual vestibular function. Clinical
because they do not historically develop pain. We assessed allodynia and Relevance: Improvement in visual acuity during head movement in
hyperalgesia with von Frey hair and plantar heat tests for 5 weeks after patients with BVH may contribute to improved quality of life by enabling
surgery. SCI severity was classified by the amount of white matter spared patients to see more clearly while walking or driving. Further studies are
at the lesion epicenter (WMS) and was analyzed via myelin staining. L5 needed to examine the functional implications of improved DVA.
cross-sections were stained for microglia (OX42), astrocytes (GFAP) and
P2X4 ATP receptors, and positively labeled tissue was quantified.To deter-
mine whether intracellular signals which cause more activated microglia,
astrocytes or ATP receptors occurred in rats with neuropathic pain, mRNA
was quantified in a subset of L5 spinal cords (n=2) from naive, SNL, and
moderate SCI groups. Results: Lesion severity was within expected limits
with greater WMS in the mild (26.995.43%) vs. moderate SCI (2.840.475%)
(p<.01). Significant allodynia and hyperalgesia developed in the L5 der-
matome for moderate SCI and SNL groups (p<.01).These groups had more
activated microglia (p<.01) but not astrocytes (p>.01) in the L5 dorsal
horn. Allodynia was positively correlated with microglial activation
(p<.05). Interestingly, there was no significant upregulation of P2X4 ATP
receptors in the dorsal horn of rats exhibiting neuropathic pain.
Conclusions: Robust microglial activation occurs only in rats which
develop neuropathic pain, indicating that microglia but not astrocytes or
P2X4 ATP receptors are key mediators in the development and mainte-
nance of neuropathic pain. Clinical Relevance: Modulating the
microglial response after SCI may prove to be effective at limiting or pre-
venting neuropathic pain after SCI in humans.

EXERCISE-INDUCED RECOVERY OF DYNAMIC VISUAL ACUITY IN

PATIENTS WITH BILATERAL VESTIBULAR HYPOFUNCTION. S.J.
Herdman, Rehabilitation Medicine, Emory University,Atlanta, GA; C.D. Hall,
Rehabilitation Research and Development,Atlanta VAMC,Atlanta, GA; M.C.
Schubert, Otolaryngology, Johns Hopkins University, Baltimore, MD; V.E.
Das, R.J.Tusa, Neurology, Emory University,Atlanta, GA.

Purpose/Hypothesis: Patients with bilateral vestibular hypofunction

(BVH) complain of imbalance, head movement-induced dizziness and head
movement-induced visual blurring (oscillopsia). Little is known about exer-
cise-induced recovery in patients with BVH.A randomized, controlled study
found that performance of customized vestibular and balance exercises
resulted in better stability during stair climbing and faster gait speed than
did performance of placebo exercises (Krebs et al 1993; Oto Head Neck
Surg).There have been no studies that have examined the effect of vestibu-
lar exercises on visual acuity during head movement in patients with BVH.
The purpose of this study was to examine the effect of an exercise inter-
vention on visual acuity during head movement (Dynamic Visual Acuity or
DVA) in patients with BVH. We hypothesized that 1) patients performing
vestibular exercises would have improved DVA compared to patients per-
forming placebo exercises and 2) improvement in DVA would be reflected
by changes in vestibulo-ocular reflex (VOR) gain. Number of Subjects:
Thirteen volunteers were recruited from patients referred to the University
of Miami and Emory University Dizziness and Balance Center with a diag-
nosis of bilateral vestibular hypofunction. Materials/Methods: Patients
were randomly assigned to the vestibular (n=8) or the placebo exercise
group (n=5). DVA was measured using a computerized system. Vestibular
function was measured using rotary chair step tests at 60 and 240 d/s.
Baseline differences between groups for age, DVA, complaints of oscillopsia
and disequilibrium were examined using ANOVA.To determine if vestibular
rehabilitation improved DVA, we performed repeated measures univariate
analysis of variance (RM ANOVA) with time (pre and post treatment) as the
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy 218

2005 Author Index

Amador M, Guest JD. An Appraisal of Ongoing Experimental Procedures in Lien J, Dibble L. Systems Model Guided Balance Rehabilitation in an
Human Spinal Cord Injury. 2005;29(2):70-86. Individual with Declarative Memory Deficits and a Total Knee Arthroplasty:
A Case Report. 2005;29(1):43-49.
Asano M. See Noreau L.

Beekhuizen KS. New Perspectives on Improving Upper Extremity Lindley SD. See Field-Fote E.
Function after Spinal Cord Injury. 2005;29(3):157-162.
Lofald D. See Lehman DA.
Bolton M. See Mount J.
Lum PS. See Kim CM.
Bouyer LJ. Animal Models for Studying Potential Training Strategies in
Persons with Spinal Cord Injury. 2005;29(3):117-125. Mollinger LA. See Steffen TM.

Bunge MB. See Moon L. Moon L, Bunge MB. From Animal Models to Humans: Strategies for
Promoting CNS Axon Regeneration and Recovery of Limb Function after
Cesari M. See Mount J. Spinal Cord Injury. 2005;29(2):55-69.

Deutsch JE. (Editorial) Enabling Our Patients. 2005;29(1):1.
Deutsch JE. (Editorial) JNPT Special Topic Issues—Transitional Research
and Educational Resources. 2005;29(2):53.
Deutsch JE. (Editorial) JNPT is Indexed in MEDLINE. 2005;29(3):113.
Deutsch JE. (Editorial) JNPT is Officially Indexed in MEDLINE. 2005;
29(4):169.
Dibble L. See Lien J.
Field-Fote E, Lindley SD, Sherman AL. Locomotor Training Approaches for
Individuals with Spinal Cord Injury: A Preliminary Report of Walking-
related Outcomes. 2005;29(3):127-137.
Field-Fote E. (Editorial) Guest Editorial: Promoting Functional Recovery
after Spinal Cord Injury. 2005;29(2):54.
Mount J, Bolton M, Cesari M, Guzzardo K,Tarsi J. Group Balance Skills Class
Stroke:A Case Series. 2005;29(1):24-33.
Myslinski MJ. Evidence-based Exercise Prescription for Individuals with
Spinal Cord Injury. 2005;29(2):104-106.
Nash MS. Exercise as a Health-Promoting Activity Following Spinal Cord
Injury. 2005;29(2):87-103.
Newstead AH, Hinman MR, Tomberlin JA. Reliability of the Berg Balance
Scale and Balance Master Limits of Stability Tests for Individuals with Brain
Injury. 2005;29(1):18-23.
Noreau L, Fougeyrollas P, Post M, Asano M. Participation after Spinal Cord
Injury:The Evolution of Conceptualization and Measurement. 2005;29(3):
147-156.
Noreau L. See Post M.

Field-Fote E. (Editorial) Guest Editorial: Standardization of Outcome Patten C. See Kim CM.
Measure: The First Step Toward a Classification Approach to Treatment.
2005;29(3):114-115. Post M, Noreau L. Quality of Life after Spinal Cord Injury. 2005;29(3):139-
146.
Fougeyrollas P. See Noreau L.
Post M. See Noreau L.
Fulk GD. Locomotor Training and Virtual Reality-based Balance Training for
Individuals with Multiple Sclerosis:A Case Report. 2005;29(1):34-42. Roehrs TG. See Karst GM.

Guest JD. See Amador M. Sherman AL. See Field-Fote E.

Guzzardo K. See Mount J. Steffen TM, Mollinger LA. Age and Gender-Related Test Performance in
Community-Dwelling Adults. 2005;29(4):181-188.
Henderson CE. Application of Ventilatory Strategies to Enhance Functional
Activities for an Individual with Spinal Cord Injury. 2005;29(2):107-111. Tarsi J. See Mount J.

Hinman MR. See Newstead AH. Tomberlin JA. See Newstead AH.

Hirsch MA. See Lehman DA. Toole T. See Lehman DA.

Karst GM, Venema DM, Roehrs TG, Tyler E. Center of Pressure Measures Tyler E. See Karst GM.
During Standing Tasks in Minimally Impaired Persons with Multiple
Sclerosis. 2005;29(4):170-180. Venema DM. See Karst GM.

Kim CM, Kothari DH, Lum PS, Patten C. Reliability of Dynamic Muscle
Performance in the Hemiparetic Upper Limb. 2005;29(1):9-17.

Kothari DH. See Kim CM.

Lehman DA,Toole T, Lofald D, Hirsch MA. Training with Verbal Instructional

Cues Results in Near-term Improvement of Gait in People with Parkinson
Disease. 2005;29(1):2-8.
219 J ournal of N eurological P hysical T herapy
2005 Subject Index
Balance
Karst GM,Venema DM, Roehrs TG,Tyler E. Center of Pressure Measures dur-
ing Standing Tasks in Minimally Impaired Persons with Multiple Sclerosis.
2005;29(4):170-180.
Lien J, Dibble L. Systems Model Guided Balance Rehabilitation in an
Individual with Declarative Memory Deficits and a Total Knee Arthroplasty:
A Case Report.2005;29(1):43-49.
Mount J, Bolton M, Cesari M, Guzzardo K,Tarsi J. Group Balance Skills Class
Stroke:A Case Series.2005;29(1):24-33.
Newstead AH, Hinman MR, Tomberlin JA. Reliability of the Berg Balance
Scale and Balance Master Limits of Stability Tests for Individuals with Brain
Injury. 2005;29(1):18-23.
Steffen TM, Mollinger LA. Age And Gender-Related Test Performance In
Community-Dwelling Adults: Multi-directional Reach Test, Berg Balance
Scale, Sharpened Romberg Tests, Activities-Specific Balance Confidence
Scale, and Physical Performance Test. 2005;29(4):181-188.
Brain Injury
Newstead AH, Hinman MR, Tomberlin JA. Reliability of the Berg Balance
Scale and Balance Master Limits of Stability Tests for Individuals with Brain
Injury.2005;29(1):18-23.
Editorials
Deutsch JE. (Editorial) Enabling Our Patients.2005;29(1):1.
Deutsch JE. (Editorial) JNPT Special Topic Issues - Transitional Research and
Educational Resources.2005;29(2):53.
Deutsch JE. (Editorial) JNPT is Indexed in MEDLINE.2005;29(3):113.
Deutsch JE. (Editorial) JNPT is Officially Indexed in MEDLINE. 2005;
29(4):169.
Exercise
Myslinski MJ. Evidence-based Exercise Prescription for Individuals with
Spinal Cord Injury.2005;29(2):104-106.
Nash MS.Exercise As A Health-Promoting Activity Following Spinal Cord
Injury.2005;29(2):87-103.
Locomotion
Field-Fote E, Lindley SD, Sherman AL. Locomotor Training Approaches for
Individuals with Spinal Cord Injury: A Preliminary Report of Walking-
related Outcomes.2005;29(3):127-137.
Fulk GD. Locomotor Training and Virtual Reality-based Balance Training for
Individuals with Multiple Sclerosis:A Case Report.2005;29(1):34-42.
Lehman DA,Toole T, Lofald D, Hirsch MA.Training with Verbal Instructional
Cues Results in Near-term Improvement of Gait in People with Parkinson
Disease.2005;29(1):2-8.
Mutiple Sclerosis
Fulk GD. Locomotor Training and Virtual Reality-based Balance Training for
Individuals with Multiple Sclerosis:A Case Report. 2005;29(1):34-42.
Karst GM,Venema DM, Roehrs TG,Tyler E. Center of Pressure Measures dur-
ing Standing Tasks in Minimally Impaired Persons with Multiple Sclerosis.
2005;29(4):170-180.
Parkinson Disease
Lehman DA,Toole T, Lofald D, Hirsch MA.Training with Verbal Instructional
Cues Results in Near-term Improvement of Gait in People with Parkinson
Disease. 2005;29(1):2-8.
Participation and Quality of Life
Post M, Noreau L. Quality of Life after Spinal Cord Injury. 2005;29(3):139-
146.
Vol. 29 • No. 4 • 2005
Noreau L, Fougeyrollas P, Post M, Asano M. Participation after Spinal Cord
Injury:The Evolution of Conceptualization and Measurement. 2005;29(3):
147-156.
SCI
Amador M, Guest JD.An Appraisal of Ongoing Experimental Procedures in
Human Spinal Cord Injury. 2005;29(2):70-86.
Beekhuizen KS. New Perspectives on Improving Upper Extremity
Function after Spinal Cord Injury. 2005;29(3):157-162.
Bouyer LJ. Animal Models for Studying Potential Training Strategies in
Persons with Spinal Cord Injury. 2005;29(3):117-125.
Field-Fote E, Lindley SD, Sherman AL. Locomotor Training Approaches for
Individuals with Spinal Cord Injury: A Preliminary Report of Walking-
related Outcomes. 2005;29(3):127-137.
Field-Fote E. (Editorial) Guest Editorial: Promoting Functional Recovery
after Spinal Cord Injury.2005;29(2):54.
Henderson CE.Application of Ventilatory Strategies to Enhance Functional
Activities for an Individual with Spinal Cord Injury. 2005;29(2):107-111.
Moon L, Bunge MB. From Animal Models to Humans: Strategies for
Promoting CNS Axon Regeneration and Recovery of Limb Function after
Spinal Cord Injury. 2005;29(2):55-69.
Myslinski MJ. Evidence-based Exercise Prescription for Individuals with
Spinal Cord Injury. 2005;29(2):104-106.
Nash MS. Exercise as a Health-Promoting Activity Following Spinal Cord
Injury. 2005;29(2):87-103.
Noreau L, Fougeyrollas P, Post M, Asano M. Participation after Spinal Cord
Injury:The Evolution of Conceptualization and Measurement. 2005;29(3):
147-156.
Post M, Noreau L.Quality of Life after Spinal Cord Injury. 2005;29(3):139-
146.
Stroke
Kim CM, Kothari DH, Lum PS, Patten C. Reliability of Dynamic Muscle
Performance in the Hemiparetic Upper Limb. 2005;29(1):9-17.
Mount J, Bolton M, Cesari M, Guzzardo K,Tarsi J. Group Balance Skills Class
Stroke:A Case Series. 2005;29(1):24-33.
Training
Karst GM,Venema DM, Roehrs TG,Tyler E. Center of Pressure Measures dur-
ing Standing Tasks in Minimally Impaired Persons with Multiple Sclerosis.
2005;29(4):170-180.
Lehman DA,Toole T, Lofald D, Hirsch MA.Training with Verbal Instructional
Cues Results in Near-term Improvement of Gait in People with Parkinson
Disease.2005;29(1):2-8.
Lien J, Dibble L. Systems Model Guided Balance Rehabilitation in an
Individual with Declarative Memory Deficits and a Total Knee Arthroplasty:
A Case Report.2005;29(1):43-49.
Upper Extremity
Beekhuizen KS. New Perspectives on Improving Upper Extremity
Function after Spinal Cord Injury.2005;29(3):157-162.
Kim CM, Kothari DH, Lum PS, Patten C. Reliability of Dynamic Muscle
Performance in the Hemiparetic Upper Limb.2005;29(1):9-17.
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy 220

Literature Reviewed
YOU MISSED IIISTEP?
Abstracts
Not to worry, we can get you back in sequence…
Fullerton HD, Borckardt JJ,Alfano AP. Shoulder Pain: A
We are pleased to announce that the
Comparison of Wheelchair Athletes and Nonathletic
plenary sessions at III STEP (nearly 30
Wheelchair Users. Medicine and Science in Sports and
Exercise. 2003:1958-1961. Reviewed by Elrod M. hours of presentations) were profes-
sionally videotaped and recorded, for
Ferris DP, Gordon KE, Beres-Jones JA, Harkema SJ. Muscle you to re-live, review or share. These
Activation During Unilateral Stepping Occurs in the high-quality recordings have a split-
Nonstepping Limb of Humans with Clinically Complete screen view of the speaker and their
Spinal Cord Injury. Spinal Cord. 2004;42:14-23. Reviewed power point presentation simultane-
by Winchester P. ously. Read, listen and watch as you follow along the
footsteps toward the future of rehabilitation.
Important Note: Conference recordings will be avail-
Books able in for Windows-based (PC) operating systems ONLY.
Canadian Spinal Research Organization/American Spinal Order your copy of this limited edition product today,
Research Organization. The After and Beyond Spinal Cord in DVD or CD for $99.95 By going on line www.iiistep.org
Injury Resource Manual. 2004. Reviewed by Snowdon LC. or contacting our section office:
Neurology Section Executive Office
III Step Order Fulfillment
Videos c/o American Physical Therapy Association
Neumann D, Lanouett M. Clinical Kinesiology Applied to 1111 N. Fairfax Street
Persons with Quadriplegia. Part I: Maximizing Movement Alexandria, VA 22314
Potential, Part II: Enhancing Function. 2002. Reviewed by
Fax: 703/706-8575 • neuro@apta.org
Behrman AL.

THE NEUROLOGY SECTION of the AMERICAN PHYSICAL THERAPY ASSOCIATION

WILLINGNESS TO SERVE CALL FOR NOMINATIONS
The Neurology Section welcomes its’ members with a willingness to serve at the level of Section,
SIG/Special Interest Group, Committee or Advisory.

The following positions are open in the 2006 election:

Section: SIGs:
Vice President (3 year term) Nominating Committee (3 year term)
Nominating Committee (3 year term)
If you are interested in getting involved and serving your section now or in the future, contact our Nominating Committee Chairperson,
Marcia Hall Thompson at Marcia@onbalance.com or contact your SIG nominating chair:

Vestibular/Balance & Falls SIG Nominating Chairs: Spinal Cord Injury SIG Nominating Chair:
Lisa Selby-Silverstein Robin F. Moss
610/558-5645 • lisasss2@comcast.net 540/932-4018 • rmoss@augustamed.com
Laura Morris
412/647-8091 • morrislo@upmc.edu Stroke SIG Nominating Chair:
Kristin Parlman
Brain Injury SIG Nominating Chair: 617/724-7489 • kparlman@partners.org
Anne McCarthy Jacobson
617/724-6363 • ajacobson@mghihp.edu Section Nominating Chair:
Marcia Hall Thompson
Degenerative Diseases SIG Nominating Chair: 503/653-2144 x 3345 • marcia@onbalance.com
Donna Fry-Welch
810/762-3373 • dkfw@umich.edu
221 J ournal of N eurological P hysical T herapy
SECTION BUSINESS
President’s Address
Shared Vision: The Foundation of Strategic Stewardship
Katherine J. Sullivan, PT, PhD
President, Neurology Section
Volunteer associations such as the Neurology Section face
many challenges. Members entrust elected officers to direct the
Section’s business and financial affairs. Section officers ensure
that the Section is financially solvent, efficiently managed, meet-
ing the needs of its members, promoting and advancing the pro-
fession, and advocating for the beneficiaries of our services.1 But
more importantly, the elected or appointed leaders are entrusted
by the members to be stewards; individuals who are “morally
responsible for the careful use of money, time, talents, or other
resources, especially in respect to the principles or needs of a
community or group (Webster’s New World Dictionary 1988, p
1315).”
Strategic stewardship reflects the self-reflective, thoughtful,
and visionary process that the Section’s leadership team has
embarked upon in order to develop a strategic plan that will
guide our efforts in the next 5 years.The last weekend in October
the Neurology Section invited Section leaders to an initial strate-
gic planning meeting at the American Physical Therapy
Association (APTA) headquarters in Alexandria, VA. Section lead-
ers included the elected and appointed officers of the Executive
Committee and the Chairs/representative of the Special Interest
Groups and Committees.We were skillfully led through the initial
step of the strategic planning process by Dr Jody Gandy, Director
of Physical Therapy Education, APTA. Dr Gandy challenged us to
leverage the Neurology Section’s strengths and acknowledge our
weaknesses in order to craft a new vision for the Section.
It is evident that the Neurology Section has several strengths
that are recognized in the national arena and the APTA at large.
We are a highly motivated group with accomplishments in
advancing the science and practice of neurologic physical ther-
apy. We were the first section to fund doctoral student scholar-
ships. We have consistently offered programming that reflects
the “cutting edge” of the science and practice of neurologic
physical therapy. We have effective dissemination vehicles such
as the recently MEDLINE indexed Journal of Neurologic
Physical Therapy (JNPT) and our Neurology Section and JNPT
websites. In addition, because of careful management, the
Section is financially strong.
Members value the Section for the caliber of its educational
programming and publications; however, we acknowledged that
we may not be as well-recognized in other communities or
amongst grassroots physical therapists that may benefit from the
strengths of our Section. This is highlighted by a recent trip I
made to present on neurologic physical therapy for individuals
with stroke at the Ohio Physical Therapy Association Meeting. Of
the 40 participants who attended, 2 had been to IIISTEP, 5 had
heard of IIISTEP, and 35 had never heard of IIISTEP.The physi-
cal therapists and physical therapist assistants who attended this
conference are a cross-section of the grassroots practitioners
who care for individuals with neurologic disease or injury. It
appears they are missing our message.
Vol. 29 • No. 4 • 2005
Looking beyond our current membership opens the doors to
wonderful opportunities for Section growth and collaboration.
Currently, the Neurology Section is the 6th largest of 18 APTA
sections. Sections larger than us include (in rank order):
Orthopaedics, Sports, Pediatrics, Geriatrics, and Private Practice.
There is a perception among non-Neurology Section members
that we are not accessible either in reaching out to therapists
who cannot get to the Combined Sections Meeting or in provid-
ing a balance of programming and educational materials that
deal with real-life issues related to neurologic physical therapy
practice. Increasing access to basic and essential information on
neurologic physical therapy will undoubtedly increase our
growth, but more importantly, by increasing membership, we
have the potential to increase the quality of care for individuals
with neurologic disease or injury.
Many opportunities exist for the Section in the next 5 years
and beyond. Examples include the opportunity to collaborate
with the international physical therapy community and other
organizations such as the American Stroke Association,American
Congress of Physical Medicine & Rehabilitation, and the
American Spinal Cord Injury Association, to name but a few. Like
us, these physical therapists and organizations share similar
visions—to improve care, advocate, and change health care pol-
icy for individuals who receive our services.
Now is the time for us to act. Real threats do exist that affect
access to neurologic physical therapy services and reimburse-
ment for the services we do provide. In many health care arenas,
there is limited recognition of the scope and expertise of physi-
cal therapists who specialize in neurology.There is great dispar-
ity not only in the health care delivery system but amongst phys-
ical therapists who deliver physical therapy services; the Section
can provide leadership in these areas.
We want a shared vision for our Section that includes the
voice of our members.We need your insights, perspectives, and
volunteerism to make this Section move beyond our current
capabilities. In January, all Section members will receive an email
blast with a document link. The document will include the
revised vision and mission statements and goals and objectives
that will guide the Section’s leadership in the next 5 years.The
Myelin Melter and Section Business Meeting is scheduled for
Friday, February 3 from 6:30 – 8:00 PM. The major focus of the
meeting is to share the strategic plan with the membership, seek
your feedback in making the changes that will lead to final adop-
tion, and provide opportunities for you to participate.
The Section leadership looks forward to your participation.
Come, be heard, and shape the future of the Neurology Section.
REFERENCE
1
Dimitru D. Strategic servitude: what has the Academy done
for me lately? Arch Phys Med Rehabil. 2004; 85:1393-1394.
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy 222

2006 PODS Announcement

For 2006, two Foundation for Physical Therapy’s Promotion of Doctoral Studies Scholarships (PODS I & II) will be funded
by the Neurology Section of the American Physical Therapy Association and the Foundation’s Neurology Endowment Fund.
Both scholarships will be given to applicants whose doctoral studies are in neurology.These scholarships honor 2
esteemed Neurology Section members.

The Patricia Leahy, PT, Doctoral Scholarship:

PODS I – $7,500 in support of the coursework phase of post-professional doctoral studies prior to candidacy (as defined
by the applicant’s institution).

The Marylou Barnes, PT, FAPTA, Doctoral Scholarship:

PODS II – Up to $15,000 in support of the post-candidacy phase of post-professional doctoral studies (as defined by the
applicant’s institution).

The PODS I & II applications are now available on-line at www.apta.org/foundation.

Should a hardcopy of the PODS guidelines and application be preferred, please contact the Foundation at 800/999-2782,
ext. 8438.The deadline for returning the completed application is January 17, 2006.

Promotion of Fitness and Prevention of Neurocurriculum Across the Lifespan:

Secondary Complications Educating the Next Generation
in People with Neurologic Disorders January 31-February 1, 2006 • San Diego, CA

Clinical Scientists: Richard F Macko, MD & James

Rimmer, PhD
Clinicians: Leizl M Adolphi, PT, ART, Bill Bodry
Maria A Fragala-Pinkham, PT, Heather A Hayes, PT, DPT
Cynthia Miles, PT, MEd, PCS
January 31 and February 1, 2006
CSM 2006 Pre-Conference Course
San Diego, California
Can a fitness program help children with CP and adults with
stroke in a functional and meaningful way?
How can the evidence on fitness programs for individuals
with neurologic disorders be put into clinical practice?
This 2-day intensive course will focus on the evidence of
the effects of regular intensive training on recovery from
impairments, improvement of function, participation and
quality of life in persons with neurologic disease and will
offer practical recommendations for translating scientific
evidence into both clinical and community fitness environ-
ments.
• Complete brochure and registration materials for this APTA
Neurology Section, Section on Pediatrics , and Section on
Geriatrics co-sponsored course are available at
www.neuropt.org or www.apta.org.
• Tel: 800-999-2782, ext. 3395; or Fax: 703-706-3396.
Judith Deutsch, PT, PhD; Sally Westcott, PT,
PhD
Ann VanSant, PT, PhD
All clinicians and educators are encouraged to attend
this dynamic workshop that will synthesize and apply
relevant conceptual frameworks and specific content
gleaned from the IIIStep conference held this past
summer. The focus will be on developing strategies
for updating curricula and relevant clinical education.
Topics covered will include: models for clinical deci-
sion making, task analysis for movement examination,
levels and analysis of measurements, and application
of research on neural plasticity and motor develop-
ment. Incorporation of technologies and complemen-
tary therapies into physical therapy education will also
be discussed. There will be active learning sessions
throughout allowing time for discussion and the
exchange of ideas.
• Complete brochure and registration materials for
this APTA Neurology Section, Section on Pediatrics,
and Section on Geriatrics co-sponsored course are
available at www.neuropt.org or www.apta.org/
•Tel: 800-999-2782, ext. 3395 or Fax: 703-706-3396.
223 J ournal of N eurological P hysical T herapy
Neurology Section Programming at CSM 2006
January 31-February 04, 2006 San Diego, California
Tuesday, January 31, 2006
12:30pm – 6:30pm Preconference Course A:
Neurocurriculum Across the Life
Span: Educating the Next Generation.
Speakers: Judy Deutsch, PhD, PT
Sally Westcott, PhD, PT
Ann VanSant, PhD, PT
7:30pm – 5:00pm Preconference Course B: Promotion
of Fitness and Prevention of
Secondary Complications in
Individuals with Neurologic
Disorders
Speakers: Jim Rimmer, PhD, Richard
Macko, MD, Heather Hayes, PT, DPT,
Bill Brody, Leizel Adolphi, PT, ART,
Maria A Fragala-Pinkham, PT, MS,
Cindy Miles, PT, MEd, PCS
Wednesday, February 01, 2006
8:30am – 6:30pm Preconference Course A:
Neurocurriculum Across the Life
Span: Educating the Next Generation.
Speakers: Judy Deutsch, PhD, PT
Sally Westcott, PhD, PT
Ann VanSant PhD, PT
7:30am – 5:00pm Pre-Conference Course B:
Promotion of Fitness and Prevention
of Secondary Complications in
Individuals with Neurologic
Disorders
Speakers: Jim Rimmer, PhD, Richard
Macko, MD, Heather Hayes, PT, DPT,
Bill Brody, Leizel Adolphi, PT, ART,
Maria A Fragala-Pinkham, PT, MS,
Cindy Miles, PT, MEd, PCS
Thursday, February 02, 2006
6:30 – 7:45am First Time at CSM? Welcome to the
First Timers’ Breakfast
8:00am – 3:00pm Planning for the Future:
The Neurology Section at Work -
Executive Committee Meeting
11:30am – 3:30pm Understanding Adaptation:Why Should
Clinicians Care?
Speakers: Anne Shumway–Cook,
PhD, PT; Amy Bastian, PhD, PT;
JoAnn Kluzik, PhD, PT, PCS
Vol. 29 • No. 4 • 2005
1:00pm – 3:00pm Patient Perspectives and Quality of
Life: Early PTClinResNet Outcomes
Speakers: James Gordon, EdD, PT,
FAPTA; Bryan Kemp, PhD; Sara
Mulroy, PhD, PT; Sharon DeMuth,
DPT; Loretta Knuttson, PhD, PT, NCS;
Kornelia Kulig, PhD, PT; Tara
Klassen, MS, PT, NCS
3:00 -4:30pm Degenerative Diseases Special
Interest Group: Intervention Issues
in Degenerative Disease- A Case
Based Approach
Speakers: Herb Karpatkin, PT, MS,
NCS; Willia Werner EdD, PT; Peggy
Ingels PT, Sue Imbriglio PT
3:00 -4:30pm Spinal Cord Injury Special Interest
Group: Current Trends in SCI
Research - An Update of What’s
Happening
Speaker: Deborah Backus, PhD, PT
3:45 –4:30pm Become a Contributor to the Journal
of Neurologic Physical therapy: Meet
the Editor and Editorial Board
Speaker: Judy Deutsch, PhD, PT
6:30 – 8:30pm Journal of Neurologic Physical
Therapy Editorial Board Meeting
Friday, February 03, 2006
6:30 – 8:30am Neurologic Clinical Specialists’
Breakfast: Exercising Leadership
Speaker: Janice Benzer, PhD, PT
8:00 – 11:00am The Best of III Step: Implications for
Neurologic Practice
Speakers: Darcy Umphred PhD, PT,
FAPTA; Kathy Gill-Body DPT, MS,
NCS; Andrea Behrman PhD, PT
9:00 – 11:00am To Brace or Not to Brace: Making
Evidence-based Decisions for our
Clients with Neurologicial
Impairments.
Speakers:Valerie Eberly PT, NCS
Kelley Kubota PT, MS, NCS
Walter Weiss PT, MPT, NCS
11:00am – 1:00pm Neurology Section SIG Officers
Meeting
Vol. 29 • No. 4 • 2005 J ournal of N eurological P hysical T herapy
1:00 – 4:00pm The EXCITE Trial: Formulation,
Implementation, and Results
Speakers: Steve Wolf, PhD, PT,
FAPTA; Patricia C. Clark, PhD, RN; J.
Philip Miller, PhD; Carolee J.Winstein,
PhD, PT, FAPTA
1:00 – 5:00pm Understanding Sensory Dysfunction:
Evidence-based Evaluation, Retraining,
and Mechanisms of Recovery
Speakers: Deborah Nichols-Larsen,
PhD, PT; D. Michele Basso EdD, PT,
Nancy Byl PhD, PT, FAPTA
4:30–6:00pm Vestibular, Balance and Falls Special
Interest Group: Management of the
Dizzy Patient – Team Approach
Speakers: Michael Hoffer, MD; Kim
Gottshall Col, USAR, PT, PhD, ATC
4:30 – 6:00pm Brain Injury Special Interest Group:
Evaluation and Management of the
Dizzy Patient- A Team Approach
Speakers: Michael Hoffer, MD; Kim
Gottshall Col, USAR, PT, PhD, ATC
4:30 – 6:00pm Stroke Special Interest Group:
One Hand or Two? Designing
Interventions for successful
Outcomes Post-Stroke
Speaker: Dorian Rose, PhD, PT
4:30 – 6:00pm Thematic Poster Session I: Imagery
and Imaging
Moderator: Carolynn Patten, PhD, PT
6:00 – 8:30pm Myelin Melter: Neurology Section
Business Meeting and Reception
Saturday, February 04, 2006
8:00 – 11:00am Thematic Poster Session II:
Post-Stroke Hemiplegia
Moderator: Carolynn Patten, PhD, PT
8:00 – 11:00am Research Platform Session I:
Biomechanics and Motor Control
Moderator: Martin Bilodeau, Ph.D.,
PT
9:00- 11:00am Spinal Cord Injury: Maximizing
Sensory and Motor Recovery by
Targeting Cellular Responses
Speaker: D. Michele Basso, EdD, PT
1:00 – 3:00pm Mild Brain Injury and Dizziness
Speaker: Laura Morris, PT, NCS
224
1:30- 3:00pm Thematic Poster Session III: Motor
Learning
Moderator: John Buford, PhD, PT
1:30- 3:00pm Research Platform Session II:
Parkinson Disease
Moderator: Gammon Earhart, PhD, PT
3:00- 5:00pm Practice Issues Forum: Development
of an Evaluation Database to Guide
Clinical Effectiveness
Facilitator: Edee Field-Fote, PhD, PT
3:00 – 5:00 pm Neurology Section Roundtables
Brain Injury SIG
Multisensory Impairments in Relation
to Postural Control in the BI
Population
Facilitator: Michelle Peterson, PT, NCS
Degenerative Diseases SIG
Cognitive Issues in Degenerative
Diseases
Facilitator: Vanina Dal Bello-Haas,
PhD, PT
Spinal Cord Injury SIG
Outcome Measures – How Do We
Use Them in Spinal Cord Injury Care?
Facilitators: Leslie Van Hiel, PT;
Mary Schmidt-Reed, MS, PT
Stroke SIG
Using “Hooked on Evidence” within
Stroke Rehabilitation
Facilitator: David Scalzitti, PT, MS, OCS
Vestibular SIG
The Do’s and Don’ts of Migrainous
Vertigo
Facilitator: Colin Grove, MS, PT
Balance and Falls: Bubbles, Balloons,
and PVC
Facilitator: Cecelia Griffith, PT, DPT
Coding, Reimbursement, and Payment
Policy Challenges in Vestibular Rehab
Facilitator: Helene Fearon, PT
Body-Weight Support Systems:
Practical Considerations in PT I
Facilitators: Tara Klassen, MS, PT,
NCS; Jim Cavannaugh, PhD, PT,
NCS; Paul Hansen, PhD, PT
Body-Weight Support Systems:
Practical Considerations in PT II
Facilitators: Mark Bowden, MS, PT;
George Fulk, MS, PT