Background/Objective: What is the relationship of what we do and what we think we can do? The perception of illness has been linked to decreased activity participation, but what is the relationship of what we actually do during the day and our perception of physical limitations. tended to build self-perception of capability more connected to work outside the home. Once retired, some older men lose this work definition and do not participate in household activities because of gender role perception of tasks. The purpose of this study was to examine the relationship of physical limitation perception to the types of everyday activities performed at home. Design: Correlation and Forward Step-wise Regression Analysis. Setting: Geriatric Gait and Balance Clinic. Participants: 120 older males (mean age = 78+ 8), referred by physicians to a Balance Clinic because of a history of falling (>2 in past year) and complaint of walking instability. Intervention: None. Measurements: MOS-36 and Frenchay IADLs. Results: Five instrumental activities of daily living (Frenchay IADLs) had the strongest linear relationship with the physical capability perception (MOS-36). Those five were: Washing clothes, heavy housework, social outings, household/car maintenance, and walking outside >15 minutes. Conclusion: These results indicate a strong relationship between perception of physical capacity and performing what has been considered traditionally female tasks, i.e., washing clothes, heavy housework, social outings as well as the more typical male tasks of household /car maintenance and the neutral gender task of walking outside.

BACKGROUND AND PURPOSE:To determine the benefit of a weekly telephone contact on balance control for community-dwelling frail older adults participating in home-exercise programs. Falls in frail older adults often lead to hospitalization and sometimes death. Evidence supports the effectiveness of home exercise programs in reducing fall risk in older adults. As well, there is a high cost for the delivery of a home exercise program in a traditional manner. Poor adherence to a home exercise program can limit the expected reduction in fall risk in the older adult population. We hypothesized that a weekly telephone call would improve adherence to a home-exercise program and, therefore, improve outcomes on the Berg Balance Test.METHODS:Seventy-five community-dwelling, frail older adult participants, at risk for falling (mean age: 76 years, range: 64-88 years; 3 women), were randomized in alternating pairs to a Telephone Call or No Telephone Call group. All participants received physical therapy home-exercise programs focused on balance control and were assessed and progressed 4 times over 12 weeks. All participants used an exercise log in which they were asked to record the amount of time and the number of repetitions performed of all daily exercises. The Telephone Call group received an additional 15-minute weekly telephone call with standard questions and encouragement to discuss their program. The primary outcome measure was the Berg Balance Scale.RESULTS:A total of 11 subjects dropped out of the study with 8 from the No Telephone Call group and 3 from the Telephone Call group. For both groups, a significant effect for time was noted, demonstrating that both groups improved significantly in balance control with the home exercise intervention. For the Berg Balance Scale, an interaction occurred whereby the Telephone Call group improved significantly more in balance control than the No Telephone Call group (Telephone Call group = 6.3 points; No Telephone Call group = 3.9 points).CONCLUSIONS:A home exercise program was beneficial to improve the balance of community-dwelling frail older adults. More importantly for health policy consideration, a simple, weekly, telephone call made a significant difference in how much balance improvement was made. Telephone calls are a cost-effective way to provide effective follow-up support for older adults participating in home exercise programs.

BACKGROUND AND PURPOSE:One method for defining successful rehabilitation outcomes is to use a threshold of performance on a clinical measure. Patients also have their own criteria for success. The aim of this study was to examine the association between clinical measures and patient criteria for determining successful intervention. METHODS:Twenty-two participants participated in a 12-week intervention program for balance disorders. Participants were tested using the Berg balance scale (BBS) and dynamic gait index (DGI) at the first and final visits. They also used the patient's perspective outcomes questionnaire (PPOQ) at the first visit to rate impairments in the core domains from the international classification of Function. Participants rated their usual levels of impairment across domains, their desired levels of impairment after intervention (success criteria), and how important it was to change in each domain. At the final visit, all participants used the PPOQ to rate their current impairment across domains and completed a 15-point global rating of change (GRC). The intervention was defined as a success if the participant rated himself or herself as "a great deal" or "a very great deal" better using the GRC. Changes in the BBS and the DGI were dichotomized on the basis of whether the change exceeded the minimal detectable change (MDC) of the instrument. Participants' ratings of impairment at 12 weeks were compared with their success criteria and dichotomized on the basis of whether the success criteria had been met. The Freidman test was used to test differences across domains at baseline with Wilcoxon tests for follow-up. Wilcoxon tests were also used to examine the importance of change across domains. Chi-square tests were used to explore the association among the GRC, performance on clinical tests, and whether success criteria were met. RESULTS:Significant changes were noted for the group for both BBS (P < .001) and DGI (P = .006). Only 40% of participants exceeded or met their desired or expected change in impairment for mobility. No significant associations were noted between exceeding MDC on the BBS or DGI and any of the domains on the PPOQ (all Ps = .263). Bivariate associations were noted between baseline measures of psychological factors and many of the participant ratings of impairment. Fifty-five percent of participants indicated that they were a great deal better or a very great deal better. Significant association was identified between success and exceeding MDC on the BBS (χ = 5.84, P = .016) but not the DGI. When considering participants' desired change in impairment, only meeting desired changes in mental function was associated with considering the intervention a success (χ = 4.55, P = .033). DISCUSSION:Treatment success from the perspective of this group of older adults was related to improvement on a clinic-based performance measure and not the participants' intrinsic success criteria assessed at the beginning of the intervention. CONCLUSION:Making measurable change in gait and balance translates into perceived success for the patient with a balance disorder.

Background:The Berg Balance Scale (BBS) and the Dynamic Gait Index (DGI) are often the central components of the physical therapy evaluation to identify older adults at risk of falling. Purpose:The purpose of this study was to use the standard error of measurement to investigate the minimal detectable change associated with these clinical instruments. Methods:A sample of 42 community dwellers (older than 65 years) with a history of falls or near falls was evaluated with the BBS and DGI. Evaluations were videotaped and later rescored by 2 experienced physical therapists. Results:The mean initial BBS was 39 points (SD = 8.9, range 17–53). Rescored mean value was 40 points (SD = 8.8, range 19–55). The DGI mean initial value was 12.9 (SD = 4.5, range 3–21), and the rescored mean was 12.7 (SD = 4.6, range 4–22). MDC95% values were 6.5 BBS and 2.9 DGI points, respectively. Conclusion:These results suggest that a change of 6.5 point in the BBS and 2.9 points in the DGI is necessary to be 95% confident that genuine change in function has occurred between 2 assessments. This information is important for assessing and monitoring progress and guiding treatment for community dwellers at high risk of falling.

BACKGROUND:Low fall-related efficacy is associated with the number and severity of future falls in older adults with balance disorders.OBJECTIVE:The purpose of this study was to examine whether improvements in clinical measures of balance after an intervention program were associated with changes in efficacy.DESIGN:A prospective, nonexperimental, pretest-posttest design was used.METHODS:Sixty-three people (43 men, 20 women; mean [±SD] age=76.6±4.9 years) with a history of at least 2 falls in the previous 12 months were enrolled between 2004 and 2008 to participate in a 12-week home exercise program. Balance deficits were identified using the Berg Balance Scale (BBS) and the Dynamic Gait Index (DGI), and participants were evaluated monthly. Hierarchical linear regression was used to assess the relationship between measures of balance (BBS and DGI) and efficacy (Falls Efficacy Scale) before intervention. A second model examined the relationship between changes in balance and changes in efficacy after participation in the program.RESULTS:Preintervention scores of efficacy were significantly associated with age, depression, and BBS and DGI scores. After controlling for age, depression, and strength (force-generating capacity), BBS and DGI scores together accounted for 34% of the variance in preintervention efficacy. Significant improvements were noted in efficacy, BBS and DGI scores, and depression after intervention. When controlling for preintervention efficacy and changes in depression, the changes in DGI and BBS scores together explained 11% of the variance in the change in fall-related efficacy; however, only DGI scores contributed uniquely. Limitations These results are tempered by the absence of a control group to examine the role of time on changes in efficacy.CONCLUSIONS:The results suggest that increased emphasis on mobility during rehabilitation leads to improved confidence to perform activities of daily living without falling.

Background. Tools chosen to measure poststroke upper-extremity rehabilitation outcomes must match contemporary theoretical expectations of motor deficit and recovery because an assessment’s theoretical underpinning forms the conceptual basis for interpreting its score. Objective. The purpose of this study was to investigate the theoretical framework of the Wolf Motor Function Test (WMFT) by (1) determining whether all items measured a single underlying trait and (2) examining the congruency between the hypothesized and the empirically determined item difficulty orders. Methods. Confirmatory factor analysis (CFA) and Rasch analysis were applied to existing WMFT Functional Ability Rating Scale data from 189 participants in the EXCITE (Extremity Constraint-Induced Therapy Evaluation) trial. Fit of a 1-factor CFA model (all items) was compared with the fit of a 2-factor CFA model (factors defined according to item object-grasp requirements) with fit indices, model comparison test, and interfactor correlations. Results. One item was missing sufficient data and therefore removed from analysis. CFA fit indices and the model-comparison test suggested that both models fit equally well. The 2-factor model yielded a strong interfactor correlation, and 13 of 14 items fit the Rasch model. The Rasch item difficulty order was consistent with the hypothesized item difficulty order. Conclusion. The results suggest that WMFT items measure a single construct. Furthermore, the results depict an item difficulty hierarchy that may advance the theoretical discussion of the person ability versus task difficulty interaction during stroke recovery.

Background and Purpose— Although constraint-induced movement therapy (CIMT) has been shown to improve upper extremity function in stroke survivors at both early and late stages after stroke, the comparison between participants within the same cohort but receiving the intervention at different time points has not been undertaken. Therefore, the purpose of this study was to compare functional improvements between stroke participants randomized to receive this intervention within 3 to 9 months (early group) to participants randomized on recruitment to receive the identical intervention 15 to 21 months after stroke (delayed group). Methods— Two weeks of CIMT was delivered to participants immediately after randomization (early group) or 1 year later (delayed group). Evaluators blinded to group designation administered primary (Wolf Motor Function Test, Motor Activity Log) and secondary (Stroke Impact Scale) outcome measures among the 106 early participants and 86 delayed participants before delivery of CIMT, 2 weeks thereafter, and 4, 8, and 12 months later. Results— Although both groups showed significant improvements from pretreatment to 12 months after treatment, the earlier CIMT group showed greater improvement than the delayed CIMT group in Wolf Motor Function Test Performance Time and the Motor Activity Log (P<0.0001), as well as in Stroke Impact Scale Hand and Activities domains (P<0.0009 and 0.0214, respectively). Early and delayed group comparison of scores on these measures 24 months after enrollment showed no statistically significant differences between groups. Conclusions— CIMT can be delivered to eligible patients 3 to 9 months or 15 to 21 months after stroke. Both patient groups achieved approximately the same level of significant arm motor function 24 months after enrollment. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00057018.

OBJECTIVE:To examine the influence of tobacco use status on outcome after an exercise program designed to improve gait and balance.DESIGN:Review of clinical database.SETTING:Standardized assessment clinic in a tertiary care setting.PARTICIPANTS:Patients (N=136, 77.2+/-5.8 y, 3 women) who were attending a Gait and Balance Disorders clinic.INTERVENTIONS:Individualized home exercise programs based on findings of an extensive gait and mobility examination. Patients were evaluated every 4 weeks for 12 weeks.MAIN OUTCOME MEASURES:Berg Balance Scale (BBS), Dynamic Gait Index (DGI), and Medical Outcomes Study 36-item Short Form Health Survey Physical Functioning subscale (SF-36 PF). Differences were assessed preintervention, and separate hierarchical linear regression models were used to examine the unique contribution of tobacco use to changes in each of primary outcome measures.RESULTS:Current tobacco users had higher frequencies of chronic obstructive pulmonary disease (P=.009) and depression (0.037). No differences were noted on preintervention measures of the primary outcomes based on tobacco use. Tobacco use explained a significant amount of additional variance in the postintervention score on each of the primary outcomes (BBS, 25.4%; DGI, 8.7%; SF-36 PF, 30.3%) after controlling for preintervention score, depression, and limb strength. Inspection of the adjusted means indicated that the group that had never used tobacco showed greater improvement than the current users for all variables after adjusting for factors used in the regression models.CONCLUSIONS:Older adults who never used tobacco showed greater improvement than the current users for all variables after adjusting for factors used in the regression models. Current tobacco users perceived themselves to be more limited by their health after participation in the rehabilitation exercise program.

Purpose/Hypothesis: Parkinson's Disease (PD) is a movement disorder that leads to balance and movement control difficulty and resultant falls. Individuals with PD often appear fatigued and lacking in motivation to participate in activities. The purpose of this study was to explore differences in endurance, strength, perception of activities and perception of balance control between those fallers seen in a Geriatric Gait and Balance Disorders clinic with PD and those without PD. Subjects: We performed a retrospective review of 355 charts from patients referred to the Geriatric Gait and Balance Disorders Clinic. Participants were referred to this clinic because of problems resulting in falls. Charts were randomly selected from a pool of over one thousand and divided into two groups. Group one consisted of subject charts with a primary diagnosis of Parkinson's disease. Group two included the rest of the charts with individuals referred to the clinic for multiple reasons. Individuals with cerebral-vascular conditions and other cognitive disorders were excluded from this review. Materials/Methods: Individuals participating in the Gait and Balance clinic receive a comprehensive evaluation before, during and after completion of the recommended training program. This evaluation consists of multiple assessment tools to explore physical and cognitive aspects associated with falls. For the purpose of this study we reviewed results from the MOS-36 survey, the Falls Efficacy Scale, the Frenchay activities index, the 2-minute walk test, and dynamometry measurements of ankle dorsi-flexion, ankle plantar-flexion, knee extension, and hip abduction. Independent samples t-tests were used to compare both groups. Significance levels were established at 5% (p<.05). Results: Individuals with Parkinson's Disease did not differ significantly from those without PD in tests of strength and endurance. Independent sample t-tests revealed no significant differences between groups in the 2-minute walk test (p=.13) and strength measurements (all measurements p>.05). The two groups were significantly different in the Falls-Efficacy Scale (p=.02). Inspection of the two group means indicate that the PD group scored significantly lower (60.2) than the Non-PD group (70.1). This difference was not seen in the Frenchay Activities Index (p=.12) or MOS 36 Index (p=.14). Conclusions: Results of this study indicate that fallers with PD and those without PD are similar in endurance, strength, perception of physical limitations and IADLs. Clients with PD scored significantly lower in their confidence for balance control. A “floor” effect is possible when you use the MOS 36 and Frenchay Activity Index in frail elders, and we plan to explore a different method of activity analysis in the future. Clinical Relevance: Clients with PD who have significant falling problems demonstrate less confidence in their balance control than other clients who have falling problems. The low self-efficacy could impact motivation and interest in exercise and activities.

Purpose: To examine the relationship between change scores on the log mean Wolf Motor Function Test (lmWMFT) and the intensity of supervised Constraint Induced Movement Therapy (CIMT) in participants with subacute and chronic stroke.Methods: A retrospective analysis of data from 169 EXCITE participants who received CIMT either immediately after randomization or one year later was undertaken. During waking hours, participants wore a restraining mitt on the less affected extremity. The lmWMFT was administered before and after the two week treatment block.Results: Significant relationships were seen between the intensity of training and functional score in the immediate, lower functional group for whom more training in adaptive task practice resulted in poorer outcomes (p = 0.01) and in the immediate, higher functioning group for whom more training in repetitive task practice resulted in poorer outcomes (p = 0.02). Female participants in the immediate group showed less progress in lmWMFT scores with greater amounts of total training ( p = 0.01). Functional level, gender, and concordance did not modify any other relationship. Both higher functioning participants who trained within the normal ratio (N = 50) and who were exposed to more than the prescribed adaptive task practice ( N = 11) experienced a significant improvement in the lmWMFT score (p = 0.03 and p = 0.02, respectively) compared to those higher functioning participants who experienced excessive repetitive task practice.Conclusion: Applying CIMT to a large sample of participants with stroke resulted in directionally inappropriate but significant relationships between intensity and lmWMFT scores in the immediate but not the delayed group. Our data also suggest that functional improvements observed in the EXCITE Trial might be attributable to training components other than the designated ratio of training approaches (adaptive and repetitive task practice).

This study determined the extent to which pain and depression influenced changes in fear of falling, mobility, and balance in older veterans with mobility disorders. Data were reviewed from 95 consecutive patients (aged 60 to 95 yr) who attended the Geriatric Gait and Balance Disorders Clinic at the Malcom Randall Department of Veterans Affairs Medical Center between 1998 and 2000. All subjects performed an individualized exercise program and were assessed four times over 12 weeks with a standardized evaluation battery. We used separate hierarchical regression models to examine the influence of measures of bodily pain and depression on outcomes (Berg Balance Test, Dynamic Gait Index, and Falls Efficacy Scale). Approximately half of the patients attended all evaluation sessions. Attendance at follow-up visits was a significant predictor of improvement in all outcome measures. Pain was a significant predictor of a decrease in balance and mobility outcome scores but not fear of falling. Thus, completing the program increased the amount of improvement, while having pain decreased the amount of improvement. These data suggest that targeted interventions for pain and improving adherence to rehabilitation recommendations should be included in the rehabilitation of older veterans with balance or mobility disorders to maximize potential improvements in balance and mobility.

OBJECTIVE:To test the potential adjuvant effect of repetitive transcranial magnetic stimulation (rTMS) on motor learning in a group of stroke survivors undergoing constraint-induced therapy (CIT) for upper-limb hemiparesis. DESIGN:This was a prospective randomized, double-blind, sham-controlled, parallel group study. Nineteen individuals, one or more years poststroke, were randomized to either a rTMS + CIT (n = 9) or a sham rTMS + CIT (n = 10) group and participated in the 2-wk intervention. RESULTS:Regardless of group assignment, participants demonstrated significant gains on the primary outcome measures: the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL)--Amount of Use, and on secondary outcome measures including the Box and Block Test (BBT) and the MAL--How Well. Participants receiving rTMS failed to show differential improvement on either primary outcome measure. CONCLUSIONS:Although this study provided further evidence that even relatively brief sessions of CIT can have a substantial effect, it provided no support for adjuvant use of rTMS.

Stroke is the leading cause of disability in the United States. Stroke survivors often experience motor sequelae characterized by hemiparesis in the upper extremity contralateral to the brain lesion. Constraint-Induced Movement Therapy (CIMT) is an effective treatment for post-stroke hemiparesis. In this study, two stroke survivors completed clinic-based CIMT and, subsequently, a home-based CIMT trial (tele-CIMT) incorporating telecommunications technology. Outcome measures were administered at pre-, post-, and follow-up time points. Partial confirmation was obtained for the effectiveness of tele-CIMT as an alternate mode of treatment. Improvements in motor skills were evidenced across both clinic-and tele-CIMT modalities, from baseline to follow up, for both participants. Future research directions are addressed, especially studies comparing the efficacy and cost-effectiveness of tele-CIMT versus standard clinic CIMT. doi:10.1300/J018v31n01_02 [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: docdelivery@haworthpress.com Website: http://www.HaworthPress.com (C) 2007 by The Haworth Press, Inc. All rights reserved.]

Background and Purpose Changes in function following constraint-induced movement therapy (CIMT) are characterized primarily by improvements in performance; however, the importance of these outcome measures to the participant may be unclear. The primary purpose of this study was to determine whether either change scores or raw follow-up scores for the Motor Activity Log amount scale (MALa) and the Wolf Motor Function Test (WMFT) predicted participants' self-reports of recovery of upper-extremity function at 4 to 6 months after starting CIMT. Subjects and Methods This study was a secondary analysis of a cohort of subjects (N=46) who participated in CIMT trials. Subjects completed measures at baseline and 4 to 6 months later. Hierarchical regression models determined whether change scores or raw follow-up scores of CIMT outcome measures were predictive of perceived recovery. Receiver operating characteristic (ROC) curves determined cutoff scores for measures that significantly contributed to participants' reports of perceived recovery. Results The regression models indicated that raw follow-up MALa scores (β=0.80, P=.024) and WMFT scores (β=−0.37, P=.03) contributed to perceived recovery. Proposed cutoff scores for the MALa scores were less than 1.15 (negative likelihood ratio [LR]=0.17) for predicting less than 50% recovery and greater than 2.50 (positive LR=2.75) for predicting 50% or greater recovery. Proposed cutoff scores for follow-up WMFT scores were greater than 34.0 seconds (negative LR=0.24) for predicting less than 50% recovery and less than 11.0 seconds (positive LR=5.96) for predicting 50% or greater recovery. Discussion and Conclusion Raw follow-up scores for the MALa and WMFT were better predictors of self-report of recovery in comparison with change scores. These data also serve as a starting point for developing cutoff scores that accurately predict self-report of recovery.

CONTEXT:Single-site studies suggest that a 2-week program of constraint-induced movement therapy (CIMT) for patients more than 1 year after stroke who maintain some hand and wrist movement can improve upper extremity function that persists for at least 1 year.OBJECTIVE:To compare the effects of a 2-week multisite program of CIMT vs usual and customary care on improvement in upper extremity function among patients who had a first stroke within the previous 3 to 9 months.DESIGN AND SETTING:The Extremity Constraint Induced Therapy Evaluation (EXCITE) trial, a prospective, single-blind, randomized, multisite clinical trial conducted at 7 US academic institutions between January 2001 and January 2003.PARTICIPANTS:Two hundred twenty-two individuals with predominantly ischemic stroke.INTERVENTIONS:Participants were assigned to receive either CIMT (n = 106; wearing a restraining mitt on the less-affected hand while engaging in repetitive task practice and behavioral shaping with the hemiplegic hand) or usual and customary care (n = 116; ranging from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions); patients were stratified by sex, prestroke dominant side, side of stroke, and level of paretic arm function.MAIN OUTCOME MEASURES:The Wolf Motor Function Test (WMFT), a measure of laboratory time and strength-based ability and quality of movement (functional ability), and the Motor Activity Log (MAL), a measure of how well and how often 30 common daily activities are performed.RESULTS:From baseline to 12 months, the CIMT group showed greater improvements than the control group in both the WMFT Performance Time (decrease in mean time from 19.3 seconds to 9.3 seconds [52% reduction] vs from 24.0 seconds to 17.7 seconds [26% reduction]; between-group difference, 34% [95% confidence interval {CI}, 12%-51%]; P<.001) and in the MAL Amount of Use (on a 0-5 scale, increase from 1.21 to 2.13 vs from 1.15 to 1.65; between-group difference, 0.43 [95% CI, 0.05-0.80]; P<.001) and MAL Quality of Movement (on a 0-5 scale, increase from 1.26 to 2.23 vs 1.18 to 1.66; between-group difference, 0.48 [95% CI, 0.13-0.84]; P<.001). The CIMT group achieved a decrease of 19.5 in self-perceived hand function difficulty (Stroke Impact Scale hand domain) vs a decrease of 10.1 for the control group (between-group difference, 9.42 [95% CI, 0.27-18.57]; P=.05).CONCLUSION:Among patients who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 1 year. Trial Registration clinicaltrials.gov Identifier: NCT00057018.

Participant recruitment is considered the most difficult aspect of the research process. Despite the integral role of recruitment in randomized clinical trials, publication of data defining the recruitment effort is not routine in rehabilitation initiatives. The recruitment process for the Extremity Constraint-Induced Therapy Evaluation (EXCITE) trial illustrates obstacles to and strategies for participant accrual and retention that are inherent in rehabilitation clinical trials. The purpose of this article is to increase awareness of the multiple facets of recruitment necessary for successful clinical trials, thus supporting the continued development of evidence-based practice in physical therapy. The Recruitment Index is presented as a variable to measure recruitment efficacy. In addition, ethical aspects of recruitment are explored, including informed consent and the concept of therapeutic misconception.

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