Abstracts

CSM 2014 Neurology Section PLATFORM Presentations 

Found 24 Abstracts TITLE: The Battery of Rehabilitation Assessments and INterventions: A Case of Successful Knowledge TranslationAUTHORS/INSTITUTIONS: J. Moore, L. Pickering, G. Mathur, Rehabilitation Institute of Chicago, Chicago, Illinois,UNITED STATES|T. Hornby, University of Illinois at Chicago, Chicago, Illinois, UNITED STATES|K. Van Der Laan,Northwestern University, Chicago, Illinois, UNITED STATES|ABSTRACT BODY: Background & Purpose : Clinicians struggle with application of evidence-based practice (EBP) because of limitedaccessibility to research, lack of education on critical appraisal, and time constraints. Several facilitators to EBP havebeen identified, including providing clinicians with research that is written in an understandable manner andpublications in summary forms that can be accessed quickly and understood easily. To overcome many of the common barriers to EBP, the Battery of Rehabilitation Assessment and INterventions(BRAIN) was developed for physical, occupational and speech therapists throughout the Rehabilitation Institute ofChicago (RIC). The BRAIN provides RIC staff with summaries of evidence, including concise descriptions of how toappropriately use an assessment or intervention in the clinic. Assessment descriptions include psychometrics andclinical utility. Intervention summaries include the parameters for successful application (dosage, intensity, etc) andlinks to the appropriate outcome measures to monitor progress. Case Description : Therapists volunteered to participate as a BRAIN Specialist or Champion. Specialists wereresponsible for the development of outcome measurement or intervention summaries. Within small groups thespecialists discussed the summaries and determined the most salient details for staff to use in clinical practice. OneChampion was designated for each site of care. These individuals were educated on the summaries and facilitatedadoption of the practices at the site in which they worked. All of the BRAIN summaries were stored in a database onthe RIC intranet and accessible at the point of care. A survey was completed before and two years after implementation of the BRAIN and its dissemination (champion)model. Survey results were compared to identify the impact of the project. A chart audit to compare utilization of EBPbefore and after the implementation of the BRAIN is now underway.Outcomes : Since the development of the BRAIN, 58 to 90 therapists have volunteered annually to participate in theproject as Specialists, and 47 to 52 individuals have participated as Champions. In total, 170 topics have beenreviewed, and over 20 outcome measurements have been implemented throughout the system of care. Survey resultsindicate a 77% increase in utilization of outcome measures in clinical practice and a 52% increase in utilization ofevidence based interventions as a result of the BRAIN. Approximately 58% use the BRAIN to educate other cliniciansand 54% use it to educate patients. Clinicians also indicated that the BRAIN has led to more discussions about EBPwith colleagues (72%), and a better understanding of clinical translation of research (65%), of research (53%) andstatistics (42%).Discussion : As a result of the BRAIN, RIC clinicians are more routinely using EBP. The impact of this project hasreached beyond our clinical practice, to staff and patient education, and a greater engagement in and understandingof research among the PT staff.

TITLE: Investigating the Immediate and Retention Effects of Contralesional Inhibitory rTMS and Functional TaskPractice to Enhance Arm Recovery Post-StrokeAUTHORS/INSTITUTIONS: D.K. Rose, C. Patten, M. Pastula, C. Reese, Physical Therapy, University of Florida,Gainesville, Florida, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : The interhemispheric competition model hypothesizes that the balance of cortical excitabilitybetween the two hemispheres observed in health is altered post-stroke producing a hyperexcitability of thecontralesional primary motor cortex (M1) which in turn exerts an abnormally increased interhemispheric inhibition onthe ipsilesional M1. Low-frequency repetitive transcranial magnetic stimulation (rTMS) can down-regulate corticalexcitability. The purposes of this study were to determine if low-frequency rTMS applied to the contralesional M1would reduce hemispheric cortical hyperexcitability and augment upper extremity (UE) functional task practice (FTP)in those with chronic stroke following a 4-week intervention and at 1-month retention.Number of Subjects : Twenty individuals (12 male; 9 LCVA; mean age: 63.2±8.1 years; mean time post-stroke:47.3±38.9 months).Materials/Methods : Participants were randomly assigned to receive either real-experimental (EXP (n=10)) or sham-control (CON) (n=10)) 1-Hz rTMS for 20 minutes (1200 pulses) to the contralesional hemisphere followed by 1hour ofUE FTP 4x/week for 4 weeks. Contralesional short intracortical inhibition (CL-SICI), reflecting inhibitory interneuronalmodulation, was assessed using paired-pulse TMS, CL resting motor threshold (rMT) with single-pulse TMS. UEmotor ability was evaluated with the Wolf Motor Function Test (WMFT) the UE Fugl-Meyer Assessment (FMA) andGrip Strength (GS) pre- and post-intervention and at a 1-month retention assessment. The WMFT performance timemean value was transformed to natural logarithm to normalize the skewed data distribution. Group differences weretested using Wilcoxon’s rank-sum test.Results : Groups were equivalent at baseline on all parameters (p’s > 0.05). Post-intervention, the magnitude of CL-SICI increased, as hypothesized, with significant differences detected between EXP (26%) and CON groups (1%) (p <0.05) but differences were not retained at 1-month. CL hemisphere rMT did not change following the intervention.Small, yet statistically significant treatment effects were observed in clinical measures at the post-test and retained at1-month (p < 0.05), although no differences were detected between groups (Change scores: FMA: EXP 4.4±1.5; CON3.6±1.5; WMFT: EXP 0.13±0.13; CON 0.27±.10; GS: EXP 1.2±1.1; CON 1.6±.0.7 (p’s > 0.05)). Conclusions : Inhibitory rTMS induced significant effects on the contralesional circuitry in chronic post-strokeparticipants but these were not retained at 1-month. The potential effect of rTMS on paretic UE motor ability may havebeen limited in the presence of the small observed behavioral changes. A more robust rehabilitation intervention toinduce greater behavioral gains may be prerequisite for an augmentative effect of rTMS to be produced.Clinical Relevance : The role of rTMS as an adjuvant to behavioral intervention in this population, although promising,has not been equivocally determined. rTMS should continue to be investigated as a potential rehabilitation modality.

TITLE: An intense running program to retrain gait and mobility in a 23-year old woman post strokeAUTHORS/INSTITUTIONS: M. Petrosky, P.M. Spigel, Brooks Rehabilitation Hospital, Jacksonville , Florida, UNITEDSTATES|E.J. Fox, Department of Physical Therapy, University of Florida, Gainesville, Florida, UNITED STATES|ABSTRACT BODY: Background & Purpose : Hemorrhagic stroke is most common in individuals 30 to 50 years of age and returning torecreational activities is a common goal. Therapeutic interventions post-stroke focus on intensity and task-specificityto promote neural plasticity and recovery. These strategies are particularly effective in younger adults and suggestrunning may be a salient and effective intervention for young adults post-stroke. Running requires increased muscleactivation and force production compared to walking. Although running may be an effective intervention, it is usuallynot included as part of rehabilitation post-stroke due to many factors. The purpose of this case study is to examinethe use of running as a treatment intervention to improve gait, balance and strength in a 23 year old female posthemorrhagic stroke. Case Description : Four months after her stroke, the patient participated in ten visits of outpatient physical therapy.Her goal was to complete a 5k run within 6 months. An interval running program was initiated using partial bodyweight support over a treadmill and wearing a posterior leaf spring AFO. The patient then progressed to over groundwith the use of a Bioness 300 perioneal nerve stimulator and eventually used a custom dorsiflexion-assist AFO. Eachsession the patient was challenged to run for longer periods of time. The patient used an application on her phone totrack her running as part of a home exercise program. Her vital signs were monitored during each session and athome. Following the training program, walking function was assessed while the patient walked on a 12-ft instrumentedwalkway (GaitRITE). Strength, balance, and falls also were assessed. Outcomes : The patient improved her gait speed from 1.0 m/s at fastest selected walking speed to 1.6 m/s. She didnot report any falls during the intervention period and no adverse reactions during running. Her balance improvedbased on a Berg Balance score increase from 26 to 54/56. The patient’s left lower extremity strength increased(dorsiflexion from 2+/5 to 4/5; plantarflexion from 3/5 to 4/5). The patient reported she felt safer and did not use theAFO when ambulating at home or during short distances. Discussion : An intense running program increased strength, balance, and walking function in a 23 year old followingstroke. The patient was able to continue with a home exercise program and community running program and sheachieved her goal of completing a 5K. Running affords young adults post-STROKE an intense and gait specificactivity may improve strength, walking function and cardiovascular health. Communication with the patient’sphysician as well as continued monitoring of vital signs is pivotal when using a running program.

TITLE: Auditory impairments and their impact on postural controlAUTHORS/INSTITUTIONS: N. Bugnariu, R.M. Patterson, Physical Therapy, University of North Texas Health ScienceCenter, Fort Worth, Texas, UNITED STATES|L. Thibodeau, R. Roeser, P. Wilson, Callier Center for CommunicationDisorders, University of Texas at Dallas, Dallas, Texas, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : We investigated the relationship between hearing loss and balance in adults using advancedvirtual reality technologies that provide realistic, ecologically valid, yet controlled and safe testing conditions. A secondaim was to evaluate the effects of two types of hearing aid (HA) technologies on measures of balance and gait. Weused a regular HA that amplifies sound from all directions and frequencies and a Frequency Modulator (FM) systemdesigned to be work in conjunction with the regular HA and to selectively amplifies only one frequency of interest andnot the ambient noise.Number of Subjects : Twelve adults newly diagnosed with hearing loss, without vestibular or other neurologicimpairment, and twelve age- and gender- matched healthy controls participated in this study. Materials/Methods : Participants were tested for balance, gait and functional activities, at the time of hearing lossdiagnosis and enrollment in the study and after a two months accommodation and use of their hearing aid. Outcomemeasures included: standing center of pressure sway, performance of dual task involving cognitive decisions, andself- selected gait speed on flat and uneven terrain in the virtual environment. Testing conditions were: No HA, HA, Ha+FM; auditory task conditions either listening only or repeating back sentences form standard audiology tests. Clinicaltests of Dynamic Gait Index, TUG, Activities Specific Balance confidence Scale and Short Physical PerformanceBattery were also administered. ANOVA was conducted for each of the dependent variables with respect to: group;condition of HA and condition of auditory task.Results : Center of pressure sway variability in M/L direction was increased (p<.05) in participants with hearing lossvs. controls when subjects had to perform a dual standing/cognitive task. Without HA, self- selected gait speed waslower (p<.05) in individuals with hearing loss vs. controls, as long as they attended to the auditory task of repeatingback sentences. Use of HA+FM significantly improved (p<.01) performance on auditory repeating back sentences taskbut also increased self-selected speed. Clinical measures showed no difference between groups.Conclusions : Hearing loss negatively impacts postural control particularly in dual task conditions when individualsattend to both auditory and postural tasks. Use of hearing aids, especially the FM system, significantly improves notonly speech recognition but also measures of balance and gait, and ability to successfully perform dual tasks. Clinical Relevance : Age-related hearing loss affects a large percentage of the older adults population. Individuals withhearing loss may be at greater risk of falling than individuals without hearing loss. One possible explanation could bethat reduced or conflicting auditory information increases the cognitive load and thus, attentional resources may betaxed particularly in older adults. Majority of current PT clinical outcome measures are not designed to evaluate theimpact of hearing loss on measures of postural control, therefore further studies are necessary.

TITLE: Sleep promotes off-line motor skills learning and visuospatial memory consolidation in people with multiplesclerosis: A pilot studyAUTHORS/INSTITUTIONS: C. Siengsukon, A. Al-Sharman, M. Aldughmi, Physical Therapy & Rehabilitation Science,University of Kansas Medical Center, Kansas CIty, Kansas, UNITED STATES|S. Lynch, Neurology, University ofKansas Medical Center, Kansas City, Kansas, UNITED STATES|J. Bruce, Psychology, University of Missouri-KansasCity, Kansas City, Missouri, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Evidence demonstrates sleep promotes learning of new motor skills off-line (without furtherpractice) in people with neurologic injury. However, the effect of sleep on motor skill learning and declarative memoryconsolidation has never been examined in people with multiple sclerosis (MS). The purpose of this study was toexamine if sleep enhances motor skill learning and declarative memory consolidation in people with MS.Number of Subjects : Seven individuals with primary-progressive or secondary-progressive MS (59 ± 5.57 years ofage) participated in this cross-over design study. Materials/Methods : Participants practiced a continuous tracking task and took three declarative memory tests [ReyAuditory Verbal Learning Test (RAVLT), Brief Visuospatial Memory Test (BVMT), and Symbol Digit Modalities Test,Oral form (SDMT)], and then underwent retention testing approximately 12 hours later following sleep (sleepcondition) or following a period of being awake (no-sleep condition). The sleep and no-sleep conditions werecounterbalanced in order and separated by 2-3 weeks. To examine off-line learning, paired t-tests were used toassess change in performance from the last practice block to the retention test for the tracking task, RAVLT, andBVMT for the sleep and no-sleep conditions. A one-way ANOVA was used to assess group difference in number ofsymbols recalled at retention on the SDMT. Results : The sleep group demonstrated a significant improvement in performance with less error on the tracking task(p=.033) whereas the no-sleep group failed to demonstrate an improvement in tracking performance (p=.513). Thesleep group demonstrated a stabilization in performance on the BVMT (p=1.00) while the no-sleep groupdemonstrated a significant worsening (p=.001). Although both groups demonstrated a worsening of performance onthe RAVLT (p=.031 sleep group, p=.002 no-sleep group), the sleep group retained more information than the no-sleepgroup. The sleep group recalled more symbols at retention on the SDMT than the no-sleep group, although thisdifference was not statistically significant (p=.348).Conclusions : This pilot study is the first to demonstrate sleep produces off-line improvements in performance of amotor learning task and sleep appears to stabilize or enhance consolidation of visuospatial types of declarativememories in people with MS. Additional studies are needed to verify these conclusions. Clinical Relevance : Multiple sclerosis is a devastating disease with progressive worsening of physical and cognitivefunctions. Individuals with MS frequently experience sleep issues, physical impairments, and cognitive difficulties.Interventions designed to improve sleep quality and quantity may enhance cognition and improve motor learning inindividuals with MS.

TITLE: The Relationship Between the Energy Cost of Transport and Walking Activity in Individuals Post StrokeAUTHORS/INSTITUTIONS: K.A. Danks, T. Wright, M. Roos, S. Binder-Macleod, D. Reisman, Physical Therapy,University of Delaware, Newark, Delaware, UNITED STATES|E. Matthews, W. Farquhar, Kinesiology and AppliedPhysiology, University of Delaware, Newark, Delaware, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Daily walking activity in individuals post stroke is very low, well below that of sedentary adults(<5,000 steps/day). Stroke survivors also have elevated energy demands, specifically, the energy cost of transport(CT) or the oxygen consumption per unit distance walked (mL O2/kg/m). CT is known to have a negative relationshipwith gait speed; however, it has not been investigated if CT is related to decreased activity levels after stroke.Identifying the relationship between activity levels and CT may provide insight as to why stroke survivors are inactive.The purpose of this study was to examine the relationship between CT and daily walking activity after stroke. Wehypothesized that individuals with the greatest CT would show the greatest impairment in daily walking activity. Wealso hypothesized that the relationship between CT and walking activity may be mediated by walking speed.Number of Subjects : 50 subjects with chronic (>6 months) stroke Materials/Methods : To obtain activity levels, subjects wore a step activity monitor during waking hours for at least 3days. Oxygen consumption (VO2) was measured as they walked at their self-selected speed on a treadmill. VO2 wasnormalized to body mass and speed, resulting in energy cost per kilogram of body mass, per meter walked (mL/kg/m)(CT).The descriptors of step activity were averaged across the days monitored, and were used to analyze therelationship to CT. Descriptors of step activity included: number of steps per day (SPD) and walking bouts per day(BPD), total time walking per day (TTW), and percent time walking (PTW). To investigate “real-world” communitymobility, we analyzed how community distances; short bouts (<40 steps/bout), medium bouts (40-500 steps/bout), andlong bouts (>500 steps/bout), were related to CT. All data was normally distributed; Pearson’s r correlations wereutilized to examine the relationship between CT and walking activity. Partial correlations between CT and stepactivity, controlling for walking speed, were also completed.Results : There was a negative correlation between CT and SPD (r=-0.31, p<0.05), BPD (r=-0.30, p<0.05), andmedium walking bouts (r=-0.34,p<0.05). When controlling for speed, these relationships disappeared (r=-0.059,p=0.67; r=-0.219, p=0.14; r=-0.158, p=0.28, respectively). There was a relationship between speed and SPD (r=0.40,p<0.01) and medium walking bouts (r=0.329, p<0.05). The correlation between speed and BPD was not significant(r=0.21, p=0.14).Conclusions : There were significant, but small correlations between CT and SPD, BPD, and the number of mediumbouts of walking. When controlling for speed, these relationships disappeared, suggesting that walking speed is amediator between CT and walking activity post-stroke. However, the speed-activity relationship is also weak. Theseresults suggest that neither walking speed nor CT play a substantial role in post-stroke walking activity.Clinical Relevance : Post-stroke walking activity does not appear to be strongly related to the CT or walking speed.

TITLE: Comparison of outcomes and exercise behaviors in persons with Parkinson disease who participate in differentmodes of exercise: a mixed-method studyAUTHORS/INSTITUTIONS: S.A. Combs, D. Diehl, M.E. Bentz, K.T. Hojnacki, L.D. Sewell, S.L. Steider, KrannertSchool of Physical Therapy, University of Indianapolis, Indianapolis, Indiana, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : The purposes of this study were to 1) investigate differences in physical function andparticipation between regular exercisers with Parkinson disease (PD) who either participate in boxing training or othermodes of exercise, and to 2) explore perceptions related to initiation and adherence to exercise as well as perceivedhealth-related benefits between groups.Number of Subjects : Eighty-three people with PD completed testing as part of a larger, longitudinal study. Of these,63 were categorized as regular exercisers on the Stages of Readiness to Exercise Questionnaire and included in theanalysis. Regular exercisers were dichotomized into boxers (n=39) and non-boxers (n=24) depending on self-reportedtype of exercise participation.Materials/Methods : A mixed-method design was used to analyze a subset of quantitative and qualitative data.Demographics (age, gender), PD characteristics (time since diagnosis, Hoehn & Yahr Stage), physical measuresincluding grip strength, functional reach test (FRT), and 6-minute walk test (6MWT), and participation on the activities-specific balance confidence scale (ABC) were collected. Participants were asked questions regarding exerciseinitiation, adherence, and perceived health-related changes due to exercise habits. Comparison of quantitative databetween boxers and non-boxers were analyzed with independent t-tests and effect sizes (Cohen’s d). Qualitativeresponses were analyzed using content analysis.Results : Demographics and PD characteristics were not significantly different between boxers and non-boxers(p<.05). The boxers demonstrated significantly greater distance reached on the FRT (p=.01). Moderate betweengroup effect sizes in favor of the boxers were found on all physical measures (dominant grip strength, d=.41; non-dominant grip strength, d=.44; FRT d=.65; 6MWT, d=.42) and for participation (ABC, d=.54). Primary themes relatedto what initially attracted participants to their exercise program common to both groups were program structure andadvantages of exercise. Themes unique to boxers were camaraderie and type of exercise, while enjoyment wasdistinctive to non-boxers. Primary themes related to exercise adherence discussed by both groups were socialsupport/interaction, health benefits, and source of motivation. Improvement in fitness and health was a primary themecommon to both groups regarding perceived health-related changes due to exercise. Increased confidence inactivities and participation was an additional primary theme identified for the boxers.Conclusions : Physical function and participation were enhanced in the boxers compared to non-boxers. Qualitativeanalysis revealed that higher exercise intensity, camaraderie within a disease-specific group atmosphere, andinvested trainers contributed to positive perception of health benefits, exercise adherence, and self-efficacy in theboxers.Clinical Relevance : These factors may be critical for clinicians developing exercise programs for people with PD thatencourage long-term adherence.

TITLE: Outcomes Following a Student Led Group Exercise Class for Individuals with Parkinson DiseaseAUTHORS/INSTITUTIONS: M. Lomaglio, K. Mallini, Doctor of Phsical Therapy, University of St Augustine for HealthSciences, St Augustine, Florida, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Access to inexpensive, supervised exercise classes is necessary to meet the needs ofindividuals living with Parkinson’s disease (PD). A physical therapy school is an ideal environment to provide free,supervised exercise classes that target the impairments and activity limitations of individuals with PD. The primarypurpose of this study was to examine the feasibility and effects of a student led group exercise class on gait, balance,and quality of life in individuals with PD. The second purpose was to determine whether any improvements aremaintained after the exercise is withdrawn.Number of Subjects : Eleven community dwelling volunteers with PD (Hoehn and Yahr stages I - III).Materials/Methods : Participants exercised for up to 60 minutes, 2 times a week, for 8 weeks. All classes were led by8 students under the direct supervision and assistance of a physical therapy faculty member. Sessions focused onrepetitive functional activities and whole body movements to improve flexibility, strength, gait, and balance. Allsessions ended with progressive treadmill walking with a target of 2.0 miles per hour and 26 continuous minutes. Gaitwas measured with the Timed Up and Go test, at both comfortable and fast walking speeds (TUGc and TUGfrespectively), and the Two-Minute Walk Test (2MWT). Balance and balance confidence were measured with the FiveTimes Sit to Stand test (5xSTS) and the Activity Specific Balance Confidence Scale (ABC). Quality of life wasmeasured by the Nottingham Health Profile (NHP). All outcomes were assessed before, after, and at an 8 weekfollow up. A repeated measures ANOVA was performed on each outcome measure and, when appropriate, followedby paired T tests to determine whether significant changes over the 3 time points occurred.Results : There was a 90% attendance rate and no injurious adverse events occurred. A comparison of the measurestaken before and after the intervention revealed significant improvements on the TUGc, TUGf, 2MWT, 5xSTS, and theABC (P = 0.001 - 0.037). At the 8 week follow up there were no significant differences on any of the measures whencompared with baseline values (P = 0.103 - 0.441), suggesting a loss of the gains over time. Exercise had no effecton the NHP (P = 0.572).Conclusions : Student led group exercise is safe and feasible and can be provided without cost to the participant. Theresults suggest that improvements in gait and balance occur with exercise but there may be no effect on quality of life. In addition, the results suggest that the exercise needs to be on-going as the effects may be lost when the exercise iswithdrawn.Clinical Relevance : Student led group exercise provides a win-win situation in that students are offered theopportunity to interact with individuals living with PD, and individuals with PD are offered free, supervised exercise thatmay improve their functional mobility and slow down the negative effects of disease progression.

TITLE: Improvements in locomotor kinematics and kinetics in individuals post-stroke following high intensity steppingtraining in variable contextsAUTHORS/INSTITUTIONS: T. Hornby, Physical Therapy, University of Illinois at Chicago, Chicago, Illinois, UNITEDSTATES|C. Kinnaird, C. Holleran, A. Leddy, Sensory Motor Performance Program, Rehabilitation Institute of Chicago,Chicago, Illinois, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Previous work suggests that high intensity forward stepping training on a treadmill improveslocomotor performance in individuals post-stroke, although gains in walking function are not consistently observed .Despite recent animal data to suggest its utility, few studies have focused on variable stepping practice at highintensities in individuals post-stroke, perhaps secondary to the substantial difficulty of performing these tasks andgeneration of kinematic errors. If individuals post-stroke are able to correct such errors, however, stepping may beimproved. Kinematic and kinetic locomotor strategies following high intensity stepping training in variable contexts hasnot been documented. Number of Subjects : Twenty-two individuals with subacute or chronic hemiparesis post-stroke.Materials/Methods : Participants completed an 8-10 week stepping training paradigm (<40 sessions) on a treadmilland overground at high aerobic intensities (70-80% heart rate reserve) within variable contexts (altered directions,speeds or perturbations). Lower limb kinematics and kinetics were captured using a motion capture system and asplit-belt force treadmill during graded treadmill testing prior to and following training. Primary kinematic outcomesincluded spatiotemporal measures and sagittal plane lower extremity joint excursions during stepping at the highestpossible speeds. Kinetic measures included sagittal moments and powers, including average positive and negativepower in both limbs (e.g., average positive power calculated by determining positive joint work performed byintegrating joint power within normalized gait cycles and dividing by average step time). Joint powers were alsoanalyzed within specific phases of the gait cycles consistent with power generation in unimpaired individuals. Results : Peak treadmill speed improvements from 0.53±0.40 m/s to 0.94±0.48 m/s were accompanied by 20-40%improvements in stride length and cadence (all p<0.01). Specific improvements included increased peak paretic hipand knee flexion and bilateral joint excursions (all p < 0.01), and consistent improvements in peak paretic extensormoments (27-106% above baseline, p < 0.01) with large but variable changes in flexor moments. Averaged jointpowers in the paretic limb improved significantly (p < 0.01), with similar improvements only in positive hip and negativeknee non-paretic limb powers. Despite smaller improvements, regression analysis revealed that changes in peaktreadmill speed were significantly correlated only to altered positive non-paretic hip and ankle powers.Conclusions : These preliminary results suggest improvements in gait kinematics and kinetics with stepping training athigh intensities in variable contexts, with potential changes related to non-paretic limb powers.Clinical Relevance : This work may advance our understanding of allowing movement errors during stepping trainingand potential movement strategies underlying increased gait speed.

TITLE: The Association of Rehabilitation Service Use on Hospital Readmission for Patients with Acute StrokeAUTHORS/INSTITUTIONS: A.W. Andrews, Physical Therapy Education, Elon University, Elon, North Carolina,UNITED STATES|D. Li, J.K. Freburger, Sheps Center for Health Services Research, University of North Carolina atChapel Hill , Chapel Hill, North Carolina, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : To determine if the intensity of speech, physical, and occupational therapy services for patientswith acute stroke was associated with 30-day and 90-day hospital readmissions.Number of Subjects : Patients 45 years and older residing in Arkansas or Florida who were hospitalized with anincident stroke in 2010 or 2011 (N=64,065) and who survived their acute hospitalization.Materials/Methods : This was a retrospective, cohort study using data on acute care hospital admissions from theState Inpatient Databases for Arkansas and Florida. The independent variable, intensity of rehabilitation services, wasdetermined by examining charges for speech, physical, and occupational therapy during the acute admission. Thesecharges were summed for each patient and categorized as No Therapy or as Low Intensity, Medium Low Intensity,Medium High Intensity, or High Intensity, based on the quartile distribution of the charges. The dependent variableswere the presence of a readmission within 30 or 90 days of hospital discharge for the incident stroke. Multilevel Coxregression analyses, adjusting for demographic variables, stroke severity, comorbidities, hospital quality indicators,and other hospital effects, were used to examine the association between rehabilitation use and readmission. Results : The risk of 30-day and 90-day hospital readmission decreased as intensity of rehabilitation services receivedduring the acute care hospitalization increased. Relative to the Low Intensity group, the odds of 30-day readmissionranged from 0.91 (0.85-0.98) for the Medium Low intensity group to 0.87 (0.80, 0.94) for the High Intensity group.Findings for 90-day readmission were similar, with odds of readmission ranging from 0.95 (0.89-1.00) for the MediumLow intensity group to 0.90 (0.85, 0.96) for the High Intensity group, relative to the Low Intensity group. Individualswho received no therapy also had an increased risk of 30-day and 90-day readmission, odds ratios of 1.31 (1.22,1.41) and 1.40 (1.33, 1.48) respectively, relative to the Low Intensity group.Conclusions : Increased intensity of rehabilitation service use in the acute setting was associated with a lower risk of30-day and 90-day hospital readmission for patients with an incident stroke.Clinical Relevance : Interventions, education, and recommendations made by physical therapists and otherrehabilitation professionals may positively influence the probability of readmission in patients who are admitted to anacute-care hospital with an incident stroke.

TITLE: Body-weight supported treadmill training is no better than overground gait training during Intensive MobilityTraining for individuals with chronic stroke, a randomized control trialAUTHORS/INSTITUTIONS: S. Fritz, A. Middleton, D.M. Peters, E.L. Blanck, Exercise Science- Physical TherapyProgram, University of South Carolina, Columbia, South Carolina, UNITED STATES|A.R. Merlo, Physical Therapy,Northern Arizona University, Phoenix, Arizona, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : To determine if an intensive intervention (Intensive Mobility Training) including body-weightsupported treadmill training (BWSTT) provided superior gait, balance and mobility outcomes as compared to anintervention of equal intensity, using overground gait training in place of BWSTT.Number of Subjects : 43 individuals with chronic stroke [average age 61.5 (13.5) years, average time since stroke 3.3(3.8) years].Materials/Methods : Participants were randomized to either a treatment group incorporating BWSTT (n=23) or acontrol group incorporating overground gait training (n=20). All participants received 3 hours of intervention for 10consecutive weekdays, totaling 30 hours of therapy. Each 3-hour session consisted of 1 hour of gait training(experimental group=BWSTT; control group=overground gait training), 1 hour of balance activities and 1 hour ofstrength, range of motion and coordination. All treatment activities were specific to individual deficits and progressedas appropriate. Assessments were conducted by an evaluator (blinded to group) prior to intervention, immediatelyfollowing the intervention, and at a 3 month follow up. Outcome assessments included: step length differential, self-selected and fast walking speed, 6 minute walk, Berg Balance Scale (BBS), Dynamic Gait Index (DGI), ActivitiesBalance Confidence Scale (ABC), single limb stance, Timed Up and Go (TUG), Fugl-Meyer (FM), and perceivedrecovery (PR). A repeated measures ANOVA for each outcome measure followed with a post hoc Tukey-Krameranalysis was used to locate differences between and within treatment groups. Effect size was calculated for eachoutcomeResults : No significant differences (α = 0.05) were found between groups on any of the outcome measures assessedeither immediately following training or at follow-up. For this reason, groups were combined for all remaininganalyses. Pre-test to post-test analyses found significant differences (α=0.05) for fast walking speed, BBS, DGI, ABC,TUG, FM and PR. Four of these measures (DGI, ABC, TUG and PR) remained significant at follow-up. Calculatedeffect sizes ranged from small to moderate, moving in the direction of improvement.Conclusions : Individuals with chronic stroke did demonstrate improvements in gait, balance and mobility followingintensive therapy, however only limited improvements were maintained at 3 months.Clinical Relevance : This study supports previous research demonstrating that clinicians do not need expensiveequipment, such as body-weight supported treadmill systems, to make functional gains in individuals with chronicstroke. BWSTT was not more beneficial in this study than overground gait training. Predictors of who benefits mostfrom certain therapies and optimal dosage for maximal benefit still need to be determined.

TITLE: The Relationships Between Gait Speed, Efficiency, and Symmetry with Daily Step Counts in Individuals withChronic StrokeAUTHORS/INSTITUTIONS: M.D. Lewek, Division of Physical Therapy, University of North Carolina, Chapel Hill, NorthCarolina, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Individuals post-stroke walk less in the home and community on a daily basis than age-matchedpeers. Limited physical activity, in the form of daily step counts, has been attributed to reduced gait speed. Slow gaitspeed, however, has been linked with both gait asymmetry and greater energy cost of walking. It is important todetermine how these factors relate to daily stepping to understand which factors to address in rehabilitation to improvedaily stepping. The purpose of this study was to determine the association between gait speed, efficiency, andsymmetry with daily step counts in individuals with chronic stroke. It was hypothesized that each of these variableswould be related to daily step counts.Number of Subjects : 21 individuals (15M/6F; 62±11 y/o) with chronic (>6 months) hemiparesis following stroke.Materials/Methods : Subjects walked across a GAITRite mat to determine comfortable gait speed (CGS) and steplength (SLA) and stance time asymmetry (STA) ratios. A 6 minute walk (6MW) test was performed with a portablemetabolic cart to estimate cost of transport (COT). Subjects wore a Stepwatch monitor for 7 days to measure averagedaily step count. A stepwise regression analysis was performed to determine the primary factors (i.e., CGS, SLA,STA, COT) associated with daily step counts. Correlational analyses were performed to determine the presence ofsignificant linear relationships between variables (α=0.05).Results : Subjects had a CGS of 0.45±0.23 m/s (range: 0.10-0.94m/s) and substantial spatiotemporal asymmetryratios (SLA: 1.29±0.21; STA: 1.18±0.11). During the 6MW test, subjects completed 181±98m (range: 30-341m) andhad a COT of 7.6±6.0 J/kg/m. Subjects walked an average of 1662±1172 steps/day. The stepwise regression modelfound only SLA to predict average daily step count (r2=0.44; p=0.003). The collinearity between variables, however,was likely responsible for excluding other variables. In particular, CGS was significantly related to COT (r=-.77;p<0.001), SLA (r=-.72; p=0.001) and step count (r=0.68; p=0.003). COT was also related to SLA (r=0.78; p<0.001)and step count (r=-.55; p=0.012). STA was not related to any variable.Conclusions : Daily step counts were best predicted by SLA. This suggests that the inability to take equal step lengthsmay be an underlying factor in reduced home/community stepping following stroke. Previous literature has relatedSLA to propulsive asymmetry, which may require energetically inefficient movement compensations that increaseCOT and reduce CGS. The interrelationships between these variables, but not STA, suggests that spatial symmetriesare more important for enhancing functional mobility than temporal symmetries. Clinical Relevance : Rehabilitation to emphasize reduced step length asymmetries may be important for improving gaitspeed, efficiency, and daily stepping.

TITLE: Sensory and cognitive deficits post-stroke may be interrelated and impact motor recoveryAUTHORS/INSTITUTIONS: D.S. Nichols-Larsen, A. Borstad, P. Kaur, School of Health & Rehabilitaton Sciences, TheOhio State University , Columbus, Ohio, UNITED STATES|P. Schmalbrock, Radiology, The Ohio State University,Columbus, Ohio, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Sensory (SD) and mild cognitive deficits (MCD) often go undiagnosed post-stroke, sinceappropriate tests are rarely done in the clinic setting. However, when these tests are conducted, almost 90% of strokesurvivors demonstrate either SD or MCD; studies have not looked at both in the same cohort, and no study has lookedat the relationship between these deficits. Purpose: To examine the relationship between measures of cognition,specifically working memory, and sensorimotor behavior of the hand. Hypothesis: 1) Post-stroke subjects will performworse on measures of sensory discrimination and cognition than age-matched peers; 2) Deficits in sensory andcognitive function will relate to poorer motor function; 3) fMRI analyses will differentiate activation patterns betweencontrols and post-stroke participants.Number of Subjects : 14 controls,12 chronic post-stroke subjects were tested in a single behavioral and imagingsession. Inclusion criteria: 1) single hemiparetic documented stroke; 2) aged 21-85; 3) hand movement sufficient tograsp and release objects; 4) ability to understand test instructions. Exclusion criteria: 1) prior diagnosis of cognitive(eg. dementia), sensory (eg. neuropathy) or neurologic (eg. Parkinsons) disorders; 2) metal device or otherincompatibility with MRI testing; 3) Mini Mental Exam <24.Materials/Methods : Testing: Sensory=Hand Active Sensation Test (HASTe), Brief Kinesthesia Test (BKT), FormPerception Test (FPT); Cognition = Paced Auditory Serial Addition Test (PASAT), Choice Reaction Test (CRT); Motor= Box and Blocks (BBT), 9 Hole Peg (9NP); imaging = fMRI sensory (brush discrimination) and cognitive task (n-back).Results : Significant group differences were found for the paretic hand versus the non-dominant hand of the controlsfor all measures. HASTe strongly correlated with PASAT (r=.722, p<.0001). PASAT strongly correlated with BBT(r=.685, p<.001); HASTe moderately correlated with BBT (r=.431, p<.05). Networks supporting sensory discriminationand working memory overlap with the parietal lobe and dorsal frontal cortex playing a key role in both; post-strokesubjects demonstrated disruption of both networks.Conclusions : Sensory and working memory deficits are common after stroke and may be related to disruption ofcommon neural networks. These hidden deficits may impact motor recovery.Clinical Relevance : Therapists need to include measures of sensory discrimination and cognition within their standardassessment procedures for stroke survivors.

TITLE: Is Multi-tasking Impaired in Older Adults with Type 2 Diabetes Mellitus?AUTHORS/INSTITUTIONS: J. Rucker, A.J. Britton, N. Utech, P. Kluding, Physical Therapy and RehabilitationScience, University of Kansas Medical Center, Kansas City, Kansas, UNITED STATES|J. McDowd, Psychology,University of Missouri - Kansas City, Kansas City, Missouri, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Deficits in the ability to multi-task contribute to gait abnormalities and falls in many at-riskpopulations. However, it is unclear whether older adults with type 2 diabetes mellitus (DM) also demonstrateimpairments in multi-tasking. This study examined whether multi-tasking was impaired in older adults with DM whencompared to those without DM.Number of Subjects : 40 individuals with type 2 DM (65% female, age 72.9±8.3 years) and 40 individuals without DM(65% female, age 72.9±7.7 years). Groups were matched for age, sex, education, and presence/absence ofhypertension.Materials/Methods : Multi-tasking was assessed via the Walking and Remembering Test (WART), in which subjectsambulated along a 6.1m, 19cm wide path while attempting to remember a random number sequence of individuallydetermined length. Four trials of the digit recall and walking tasks were completed both individually (e.g. single-taskconditions) and simultaneously (e.g. multi-task conditions), and the average number of digits recalled, walking speed,and number of steps off path were recorded for each condition. Two-tailed paired t-tests assessed between-groupdifferences in digit recall, walking speed, and number of steps off path, as well as the percent change from single- tomulti-task conditions for each variable. The significance level was set at 0.05. Results : Under single-task conditions subjects with DM exhibited similar digit recall (6.7±1.2 vs. 6.5±1.4 digits;p=0.55), but ambulated more slowly (1.1±0.3 vs. 1.4±0.4 m/s; p<0.001) and took more steps off path (0.6±0.7 vs.0.2±0.3 steps off; p=0.004) than control subjects. Likewise, under multi-tasking conditions, subjects with DMdemonstrated similar digit recall (4.6±1.3 vs. 4.9±1.9 digits; p=0.48), but ambulated more slowly (1.1±0.8 vs. 1.4±0.3m/s; p<0.001) and took more steps off path (1.2±1.2 vs. 0.4±0.5 steps off; p<0.001). Both groups exhibited similarchanges in digit recall (29.5±19.4 vs. 24.2±14.3%; p=0.20) and walking speed (-0.1±8.0 vs. 2.3±5.9%; p=0.13) fromsingle- to multi-tasking conditions; however subjects with DM demonstrated a greater change in steps off path(107.5±138.3 vs. 45.4±116.3%; p=0.03).Conclusions : This study indicates that older adults with type 2 DM exhibit decreased walking speed and stability whilemulti-tasking. Additionally, it suggests that those with DM may not allocate attention appropriately when multi-tasking –in this case preserving cognitive function and walking speed at the expense of gait stability. Clinical Relevance : Older adults with DM are known to exhibit gait abnormalities and a greater risk of falls than theirpeers without DM. Our study suggests that neuropsychological factors such as multi-tasking may negatively affect gaitin this population. Clinicians should consider employing measures of multi-tasking when assessing gait and fall risk inolder adults with DM.

TITLE: Can Cool Ambient Temperature affect Cognitive Performance in Persons with Tetraplegia?AUTHORS/INSTITUTIONS: J.P. Handrakis, S. Liu, M. Krajewski , Physical Therapy, New York Institute ofTechnology, Old Westbury, New York, UNITED STATES|D. Rosado Rivera , A.M. Spungen , W.A. Bauman, NationalCenter of Excellence for the Medical Consequences of Spinal Cord Injury, Bronx, New York, UNITED STATES|C.Bang , James J Peters VA Medical Center, Bronx, New York, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Purpose: To determine the effects of cool ambient temperature (18°C) exposure on body coretemperature, cognitive performance and distal skin temperatures in persons with a cervical spinal cord injury(tetraplegia). Primary Hypothesis: Body core temperature and cognitive performance will decline in persons withtetraplegia after cool temperature exposure but will be maintained in controls. Secondary Hypothesis: The decrease indistal skin temperatures after cool temperature exposure will be greater in controls than in persons with tetraplegia. Number of Subjects : Seven male individuals with tetraplegia (C3-C7, AIS A-C, DOI 16.4±6.5 years, mean age 43±6.4years, BMI 23±1.6 kg/m2 and 7 age- and gender-matched controls (mean age 41±4.2 years, BMI 27±0.9 kg/m2)signed a consent form approved by the James J Peters Bronx VA MC IRB.Materials/Methods : Persons with tetraplegia and able-bodied controls were exposed to temperatures of 27°C baseline(BL) for 30 minutes, followed by up to 120 minutes of 18°C exposure (Cool Challenge) while wearing only shorts in theseated position. Rectal temperature (Tcore) and distal skin temperatures (Tsk) were measured by thermocouples andcontinuously collected throughout. The protocol was terminated if Tcore ≤ 35°C (hypothermia) or the subjectexpressed discomfort. A neuropsychological battery, including Delayed Recall (working memory) and Stroop Colorand Word tests (executive function), was administered at the end of BL and after Cool Challenge. Results : After Cool Challenge, Tcore decreased -1.2±0.12°C (p<0.0001) in the group with tetraplegia after anaverage of 109±16 minutes compared to no change (0.07±0.08°C) in able-bodied controls after 120 minutes. Theaverage of distal skin temperatures declined in both groups but the decline in controls was significantly greater than inthose with tetraplegia (-31.6±7.9% versus -8.6±5.8%, respectively; p<0.0001). In the group with tetraplegia, DelayedRecall and Stroop Interference scores declined -55±47.4%; p<0.05 and -3.9±3.8%; p<0.05, respectively, both of whichwere different (p<0.05) than the consistent cognitive performance maintained by controls. Conclusions : Even limited exposure to cool temperatures can overwhelm the impaired thermoregulatory mechanismsof persons with tetraplegia as evidenced by the attenuated decline in Tsk which most likely contributed to acceleratedheat loss and the inability to maintain Tcore. The decline in Tcore was associated with deterioration of cognitiveperformance in the areas of working memory and executive function. Clinical Relevance : The findings of this pilot study call attention to the cognitive implications of thermoregulatoryfragility in persons with tetraplegia and the need to address this impairment by efficacious medical interventions(targeting impaired thermoregulatory mechanisms), specific guidelines for safe temperature exposure for patienteducation and novel bioengineering solutions (insulated outdoor transportation areas, wheelchair-mounted coretemperature monitoring devices, etc).

TITLE: The Content of “Rehabilitation Education for Caregivers and Patients” (RECAP) in Stroke Physical TherapyPracticeAUTHORS/INSTITUTIONS: M. Danzl, Physical Therapy, Bellarmine University, Louisville, Kentucky, UNITEDSTATES|A. Harrison, P. Kitzman, P. McKeon, Rehabilitation Sciences, University of Kentucky, Lexington, Kentucky,UNITED STATES|G. Rowles, Graduate Center for Gerontology, University of Kentucky, Lexington, Kentucky, UNITEDSTATES|E.G. Hunter, Cardinal Hill Rehabilitation Hospital, Lexington, Kentucky, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Patient and caregiver education is suggested as a critical component of stroke rehabilitation andphysical therapy (PT) practice. Research indicates that the informational needs of stroke survivors and caregivers arelargely unmet. Previous studies provide insight into the frequency and type of educational statements made byphysical therapists, however, they are limited to the outpatient setting and general patient population. As a first steptoward developing optimal educational interventions in stroke PT practice, examination of the content of educationprovided by physical therapists to stroke survivors and their caregivers is needed. The purpose of this study is todescribe the content of “Rehabilitation Education for Caregivers and Patients” (RECAP) in post-acute care strokerehabilitation by physical therapists.Number of Subjects : A purposeful, criterion sampling paradigm was used and 19 physical therapists from 2healthcare organizations were recruited.Materials/Methods : Qualitative research methods with a grounded theory approach were used in a study examiningthe phenomenon of RECAP by physical therapists in stroke rehabilitation. A component of this study involved an in-depth examination of RECAP content. As a pre-interview activity, each participant listed all topics educated about tostroke survivors and/or caregivers. The master list of topics was analyzed for patterns and domains of contentemerged. Participants discussed the domains during interviews and focus groups. Verification strategies for credibilityincluded member checking, peer debriefing, and reflexivity. Results : The master list included 126 topics of stroke-related RECAP content. The analysis of the master list yielded10 domains of content: Stroke Knowledge, Functional Mobility, Equipment and Devices, Safety and Precautions,Promoting Optimal Recovery, Psychological and Emotional Issues, Community Reintegration, Advocacy, InstitutionalSupport and Resources, and Healthcare Continuum and Team. Participants shared perceptions regarding theimportance, comfort level, prioritization, frequency, and ideal timing for each domain. Participants described providingeducation within the context of a multidisciplinary team.Conclusions : The findings represent an extensive advancement in the description of stroke-related RECAP in PTpractice. Ten domains of RECAP content, provided by physical therapists to stroke survivors and their caregivers,were identified. The findings provide a springboard for assessing the content of educational interventions in strokerehabilitation. Further, the research design provides a model with which to assess RECAP in other patientpopulations.Clinical Relevance : The stroke-related content domains of RECAP that emerged provide practicing clinicians with aframework to provide comprehensive education to stroke survivors and caregivers. The domains, as well as theirdescriptions and examples, can be used to inform entry-level curricula by providing a guide to a formerly abstract areaof practice.

TITLE: The Effects of Age and Parkinson's Disease on Temporal and Spatial Learning During a Posturally DemandingImplicit Motor Sequence TaskAUTHORS/INSTITUTIONS: H. Hayes, N. Hunsaker, K.B. Foreman, L.E. Dibble, Physical Therapy, University of Utah,Salt Lake City, Utah, UNITED STATES|L. Boyd, Brain Behavior Lab, University of British Columbia, Vancouver, BritishColumbia, CANADA|ABSTRACT BODY: Purpose/Hypothesis : Age and disease may adversely affect the performance of implicit motor learning tasks. In orderto evaluate the effects of age and disease on the temporal and spatial error components of a standing implicit motorsequence task we examined individuals with Parkinson's disease compared to healthy controls. We hypothesized thatthere would be differences in temporal and spatial error between groups. Number of Subjects : Healthy Young (HY), (N=10); Healthy Elders (HE), (N=10); and Parkinson's Disease (PD),(N=18).Materials/Methods : HY, HE and individuals with PD practiced tracking a series of random and repeating waves byshifting their center of pressure (COP) anteriorly and posteriorly to match a target wave. Both their COP and the targetwave were projected on a screen in front of them. Two days of practice (each day with 6 blocks of 10 trials) wereperformed. Two dependent variables were calculated: temporal tracking accuracy (TTA) and spatial tracking accuracy(STA) as components of overall Root Mean Square Error (RMSE). TTA accuracy was assessed using a time seriesanalysis, by serially correlating the data points from the participant’s tracking pattern with the target pattern until amaximum correlation coefficient was achieved. STA was measured by assessing the remaining lag error that persistsafter the correction for TTA based on the RMSE in centimeters that remains. Sequence-specific learning of TTA andSTA was the difference in performance of the random and repeated waves across the 12 blocks. A 3 (Group) x 2(Day) ANOVA to assess learning was performed for both sequence-specific TTA and STA to examine interaction andmain effects, using Tukey's HSD for post-hoc analysis.Results : H&Y, M=1.81(0.62). TTA results revealed significant day (p<.01), group (p<.001) effects, but no significantinteraction (p=0.44) with the following between group differences; HY to HE (p<.001), HY to PD (p=0.05) and HE toPD (p=0.02). Overall, the PD group improved more than the HE group on the temporal accuracy (ES=0.20). STAresults revealed significant day (p<.001), group (p<.001) and interaction (p=0.038) effects, with the following betweengroup differences in STA; HY to HE (p<.001), HY to PD (P<.001), but not HE to PD (p=.95); furthermore, theinteraction indicated that the HE improved more than the PD on spatial accuracy (ES=0.91). Conclusions : These results indicate that while all groups benefit from practice, both age and PD degrade spatial andtemporal accuracy on this task. The magnitude of changes in temporal and spatial components of sequence-specificlearning in persons with PD suggests that basal ganglia damage may have a differential effect on practice mediatedimprovements in the timing and amplitude of movements. Clinical Relevance : Recognizing difficulties in subcomponents of sequence-specific learning in individuals with PDand HE during an implicit motor task may aid clinicians in developing more appropriate motor learning strategies in theclinic.

TITLE: Locomotor Requirements for Bipedal Locomotion: A Delphi SurveyAUTHORS/INSTITUTIONS: L.D. Hedman, Physical Therapy, Northwestern University, Chicago, Illinois, UNITEDSTATES|ABSTRACT BODY: Purpose/Hypothesis : A variety of constructs have been proposed for physical therapy (PT) diagnostic classifications.Bipedal locomotor control requirements may be useful as classifications for walking dysfunction because they gobeyond traditional observational gait analysis to address all issues contributing to locomotor movement problems. Theobjective of this study was to determine if locomotor experts could achieve consensus about requirements for bipedallocomotion. Number of Subjects : Expert panel: Round 1: n = 115; Round 2: n = 78; Round 3: n = 58 Materials/Methods : Locomotor experts from PT and other related professions were recruited using purposive andsnowball methods to participate in an electronic mail Delphi survey. Experts recommended additions, deletions,rewording and merges for 15 proposed locomotor requirements in Round 1. In Rounds 2 and 3 panelists commentedon and rated the validity, mutual exclusiveness and understandability of each requirement using Likert ratings.Consensus was defined a priori as: 1) 75% or more panelists agree or strongly agree that a requirement is valid,mutually exclusive and understandable in Round 3; 2) no difference between Rounds 2 and 3 ratings with Kappacoefficients > .60; and 3) a reduction in panelists who commented and convergence of comments between Rounds 1and 3. Content analysis and non-parametric statistics were used (p < 0.05). Results : The expert panel reached full consensus on five locomotor requirements: Initiation, Termination, AnticipatoryDynamic Balance, Multi Task Capacity, and Walking Confidence and partial consensus for six other requirements intheir Likert ratings. There were no significant differences in Likert ratings between Rounds 2 and 3 and a decrease inthe percentage of panelists who commented between Rounds 1 and 3. There was a correspondence in the issues thatemerged from the qualitative comments and the Likert ratings of the requirements. Conclusions : This is the first systematic attempt to achieve consensus amongst a cross-disciplinary group of expertsin locomotion about fundamental requirements of bipedal locomotion as a precursor to developing a diagnosticclassification framework. The results of this study provide initial face and content validation for the five requirementsfor which the experts reached consensus. Further work is needed to establish the validity of all of the locomotorrequirements. Consensus on the underlying constructs and language should be prioritized. The next step will be toidentify and test clinical measures and interventions for each requirement. Clinical Relevance : A clinical framework based on locomotor requirements representing the spectrum of walkingdysfunction could help PTs identify issues that may not be easily derived from traditional gait analysis. With validation,these requirements, along with associated clinical measures and interventions, can provide the framework for aclinically feasible and systematic diagnostic tool for PTs to categorize locomotor problems and standardizeintervention for walking dysfunction.

TITLE: Fall Risk Assessment at Admission and Discharge in Clients with Acquired Brain Injury in Post-Acute InpatientRehabilitation: a Theoretical and Clinical ModelAUTHORS/INSTITUTIONS: L.N. Kerr, E.G. Hunter, Outpaitent Services, Cardinal Hill Rehabilitation Hospital ,Lexington, Kentucky, UNITED STATES|C. Killian, P. Rundquist, Physical Therapy , University of Indianapolis ,Indianapolis , Indiana, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : The purpose of this study was to identify fall risk for clients with ABI in a post-acute inpatientrehabilitation center at admission and discharge. The information gained may enhance health professionals’understanding of fall risk assessment, ultimately assisting in the prevention of falls in this vulnerable population. Theseclinical measures are necessary for safe client progression toward functional independence. Number of Subjects : 36 adults who were admitted to the Acute Rehabilitation Hospital Brain Injury Unit with a primarydiagnosis of ABI. The sample consisted of 19 (52.8%) males and 17 (47.2%) females, with a median age of 40.5years.Materials/Methods : A prospective exploratory cohort study in which participants were assessed for fall risk atadmission and discharge. Fall risk inventory included 11 clinical cognitive, fall history, and motor measures routinelycompleted in this setting.Results : The Wilcoxon signed-rank test determined significant reduction in fall risk for all tests from admission todischarge (alpha 0.005). The McNemar binominal exact test determined significant reduction in fall risk categories forall tests from admission to discharge. The significant fall risk category across the 11 measures at admission was95.8% and 55.6% at discharge. A principal component analysis at admission and again at discharge yielded a three-component model supporting the importance of motor, cognitive, and an inventory including fall history indetermination of fall risk. The three-component model at admission accounted for 79% of the variance and atdischarge, it accounted for 74% of the variance. This result reduced the complexity of the 11 clinical tests to threemain concepts. Conclusions : An important finding of this study was the crucial importance of assessing motor, cognitive and fallhistory to adequately evaluate fall risks for people with ABI in a post- acute inpatient rehabilitation setting. Individuallyeach component does contribute in the assessment of fall risk, but clinicians must understand that the threecomponents being assessed together gives a more inclusive comprehensive assessment for each patient. This studythen identified the best clinical instruments, for each of the three components, to detect fall risk in clients at admissionand discharge. Using this information, two models were developed, one clinical and one theoretical. One last issuewas uncovered during this study: during the rehabilitation process clients had significant reduction in fall risk fromadmission to discharge. However, it is unsettling that 55.6% of the clients remained at significant fall risk at discharge.With this in mind, it is incumbent that clinicians and discharge planners consider this risk of falls in the continuity ofappropriate care. Clinical Relevance : The clinical and theoretical models that were developed out of the findings in this project can beuseful tools for providing best practice care for people with ABI to enhance their health and quality of life.

TITLE: Development of an electrophysiologic and behavioral methodology to assess consciousness after severe braininjuryAUTHORS/INSTITUTIONS: K.V. Day, J. Whyte, Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania,UNITED STATES|ABSTRACT BODY: Purpose : A primary rehabilitation goal for patients with Disorders of Consciousness (DoC) is to assess level ofawareness accurately; physical therapists play a key role in this interdisciplinary assessment. Command followingserves as powerful evidence of consciousness, demonstrating a contingent relationship between environmentalevents and behavior unaccounted for by reflex mechanisms. Recent studies reported persons with DoC capable offollowing commands via voluntary modulation of brain activity on EEG in the absence of overt movement. Thesefindings were interpreted to suggest that covert command following may be a more sensitive indicator ofconsciousness than overt movement. However, systematic studies of the stability and sensitivity of these differentforms of evidence have not been published. While our ultimate aim is to address the psychometrics of overt andcovert command following during DoC recovery, initial steps are required to ensure accurate data collection and torefine analyses that characterize response accuracy. Thus, the purpose of this report is to discuss the development ofan EEG and behavioral methodology to aid in assessment of awareness.Description : We developed a mobile laboratory containing a state-of-the-art EEG system as well as accelerometersfor quantitative measurement of subtle limb motion. This set-up allows for efficient testing in patient rooms on ourbrain injury unit. As part of the refinement process to optimize our data acquisition protocol, we are testing 5 healthycontrols and 5 participants with severe brain injuries who are conscious and can follow commands (e.g. “move yourhands” vs. “hold still”). Subsequently, data are applied to a machine classifier to determine accuracy of responses.This strategy ensures our equipment accurately measures any movements and brain activity when commands arefollowed appropriately. Data will be presented demonstrating optimization of EEG and accelerometry signals as wellas classification analyses.Summary of Use : Evidence suggests as many as 43% of persons with DoC are misdiagnosed as being in vegetativestate based on clinical evaluation, when they indeed retain some degree of awareness. In an attempt to reduce thiserror using advanced technologies, development of a methodology for assessment of consciousness requires aninitial effort to guarantee collection of the most accurate data possible. The testing paradigm developed here will beapplied next in our longitudinal study for persons with DoC.Importance to Members: Diagnostic errors may result from a clinical team briefly observing a patient’s fluctuating levelof awareness or using standardized tests that fail to circumvent sensorimotor confounds, thus limiting demonstrationof consciousness. With literature reporting a much better prognosis for persons in minimally conscious state comparedto vegetative state early after injury, such a misdiagnosis could have a profound impact on continuation ofrehabilitation, subsequent recovery potential, quality of life, and cost of care.

TITLE: Influence of structural vs. functional corticospinal tract integrity on gait performance post-strokeAUTHORS/INSTITUTIONS: V.L. Little, Physical Therapy, University of Florida , Gainesville, Florida, UNITEDSTATES|T.E. McGuirk, C. Patten, Brain Rehabilitation Research Center, Malcom Randall VA Medical Center,Gainesville, Florida, UNITED STATES|N. Lodha, Applied Physiology & Kinesiology, University of Florida, Gainesville,Florida, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Impaired paretic limb advancement (PLA) is among the most prominent manifestations ofwalking dysfunction post-stroke. Consistent with previous findings, our recent investigation of gait neuromechanicspoints to plantarfexion (PF) dysfunction as a causal mechanism of impaired PLA. However, neither the underlyingmechanisms of PF dysfunction nor its capacity for recovery following stroke are well understood. Damage tocorticospinal projections may contribute to PF dysfunction following stroke. To link corticospinal integrity withfunctional PF performance, we investigated: a) the structural and functional corticospinal tract integrity serving pareticplantarflexors following stroke and b) paretic plantarflexor muscle activity patterns during overground gait.Number of Subjects : We studied 8 participants (age: 55.3±5.1yrs; 8 male) with chronic (91.7±46.6mo) post-strokehemiparesis and 4 controls (age: 64±15.1yrs; 3 male).Materials/Methods : We used single-pulse transcranial magnetic stimulation to evoke responses in paretic leggastrocnemius (MG), soleus (SO), and tibialis anterior (TA) during isometric and dynamic PF at three positions:dorsiflexion, neutral, and plantarflexion. Dynamic contractions were preloaded (20% MVC) to control backgroundactivation. Motor evoked potential area (MEParea) was normalized to maximal M-wave. The greatest difference innormalized MEParea during dynamic, relative to isometric, PF quantified modulation. We also studied the sameindividuals using motion analysis during overground walking at self-selected speed to compare gait mechanics withMEP data. We calculated the proportion of integrated EMG (iEMG) activity present in a given phase of the gait cycleto evaluate the temporal pattern of activation for the MG, SO, and TA muscles.Results : Normalized MEParea was comparable between groups during isometric PF revealing spared connectivity toMG (p=.26) and SO (p=.30). However, modulation of cortical drive to the plantarflexors is markedly reduced duringdynamic PF (MG: p<.01, SO: p=.01). Similarly, the proportions of MG and SO EMG activity during mid- and terminalstance are reduced following stroke (all p’s <.01). Interestingly, connectivity to (p=.63) and functional integrity of(p=.64) the TA appear to be preserved following stroke. Of note, individuals post-stroke reveal a greater proportion ofTA activity at the stance-to-swing transition (p<.05) than controls.Conclusions : Profound impairment in modulating PF activity suggests inability to mediate cortical activity duringmovement, consistent with reduced plantarflexor EMG during gait. Finally, robust TA responses complement our priorwork indicating dorsiflexor dysfunction does not underlie impaired PLA post-stroke.Clinical Relevance : Demonstration of spared connectivity to the plantarflexors reveals presence of a neurologicsubstrate for locomotor plasticity. Interventions that increase corticospinal tract activity serving the pareticplantarflexors may produce better gait outcomes.

TITLE: Action selection for paretic hand movements leads to increased activation in the contralesional hemisphereafter strokeAUTHORS/INSTITUTIONS: J.C. Stewart, P. Dewanjee, U. Shariff, S.C. Cramer, Depts. of Neurology and Anatomy &Neurobiology, University of California Irvine, Irvine, California, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Action selection (AS) is a critical feature of voluntary movement. After stroke, damage to themotor system often leads to compensatory brain activation for simple movement tasks. It is not known, however, howthe motor system responds after stroke when additional AS requirements are placed on movement. The purpose ofthis study was to determine the neural correlates of motor AS in individuals post-stroke.Number of Subjects : Ten individuals with right-sided hemiparesis (mean±SD): age: 68.0±8.2; Upper Extremity Fugl-Meyer motor score: 50.5±9.7; time post-stroke: 38.5±25.5 months) and sixteen age-matched controls (age: 65.0±9.0).Materials/Methods : Participants performed a right or left joystick movement with the right hand under two conditions.In the action selection (AS) condition, participants moved right or left based on an abstract visual rule. In theexecution only (EO) condition, participants moved in the same direction on every cue. After a practice period (3blocks of 36 trials), the two conditions (AS, EO) were performed during functional MRI (fMRI) in a 3T scanner.Results : Response accuracy in the AS condition was >90% during fMRI. In both groups, reaction time (RT) in the AScondition was longer than in the EO condition (p<0.001). RT was longer in the stroke group but RT cost (AS RT-EORT) did not differ between groups and did not correlate with degree of motor impairment. Strokes were bothsubcortical and cortical but primary motor (M1) and PMd cortices were spared in all participants. Task performanceacross conditions and groups activated a motor network that included left M1, supplementary motor area (SMA),cingulate motor, and bilateral PMd, parietal cortex, and cerebellum. The two groups differed, however, in their neuralresponse to the change in task condition. When contrasting the AS condition to the EO condition, the control groupshowed increased activation in the left inferior parietal lobule (IPL) while the stroke group increased activation in righthemisphere sites (PMd, anterior cingulate, IPL, visual cortex). Region of interest analyses confirmed these results;the stroke group but not the control group showed increased activation for the AS condition in right M1, PMd, andSMA.Conclusions : Despite a similar RT cost in the stroke and control groups, the neural resources used to perform the AStask differed between groups. In the control group, the AS condition resulted in increased activation of the IPL, aregion shown to play a role in visuomotor actions. In the stroke group, the AS condition resulted in increasedactivation of right, contralesional motor regions (M1, PMd) and areas that support visuomotor task performance (IPL,visual cortex). Engagement of the contralesionsal side after stroke may reflect compensatory activation to maintaintask performance or a different phase of learning.Clinical Relevance : Increased neural resource utilization in the contralesional hemisphere during AS after stroke mayimpact motor learning under complex conditions that require AS.

TITLE: Dual-Task Walking Variability Relates to Stroop and Dual-Task Questionnaire Performance in Individuals withMultiple SclerosisAUTHORS/INSTITUTIONS: N. Fritz, D. Kegelmeyer, D.S. Nichols-Larsen, A. Kloos, The Ohio State University,Columbus, Ohio, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Individuals with multiple sclerosis (MS) demonstrate cognitive dysfunction and gait impairmentswhich may increase fall risk. Although gait impairments in forward walking are well documented in MS, backwardwalking has not been examined. Cognitive deficits are associated with decreased performance on dual-task walking(e.g., walking while talking) in older adults, but little is known about this relationship in MS. Therefore, we comparedspatiotemporal gait measures during backward and dual-task walking between individuals with MS and healthy adultsand examined the relationships between gait variability measures [i.e., coefficients of variation (CV)],neuropsychological measures, and Dual-Task Questionnaire (DTQ) scores in individuals with MS. We hypothesizedthat individuals with MS would demonstrate greater gait parameter variability during backward and dual-task walkingthan healthy adults and that greater variability would be related to poorer performance on neuropsychological testsand the DTQ. Number of Subjects : Eleven individuals with relapsing remitting MS [mean age= 44.0 ± 9.4 SD (range 31-56), 11females, EDSS mean= 2.8 ± 1.0 SD (range 1.5-4)] and 11 age and gender matched healthy adults [mean age=43.7±9.3 SD (range 31-55), 11 females] participated in the study. Materials/Methods : Spatiotemporal gait measures and their CVs during forward, backward and dual-task walking(walking with subtraction) were obtained using a GAITRITE system. Participants also completed neuropsychologicaltests of processing speed (Stroop and Symbol Digit Modality Test), and the DTQ, a subjective rating of dual-taskability.Results : There were no significant differences between individuals with MS and healthy adults on any measures ofbackward or dual-task walking. Increased double support time CV in forward (ρ=-.803, p=.005; ρ=-.764, p=.006 ) andbackward (ρ=-.789, p=.005; ρ=-.758, p=.011) dual-task walking conditions was correlated with poorer performance onthe Stroop and Symbol Digit Modality Tests respectively . Individuals who self-reported more difficulty with dual-tasks(higher DTQ scores) demonstrated poorer performance on the Stroop (ρ=-.803, p=.003) and increased double supporttime CV in backward (ρ=.843, p<.001) and backward dual-task walking (ρ=.754, p<.012). Poor Stroop performancewas also associated with high backward dual-task gait variability; indeed 79% of Stroop test variance was explainedby dual-task variability measures.Conclusions : This study highlights the important relationship between mobility and cognition in individuals with MS.Poor performance on the Stroop and Symbol Digit Modality Tests and high DTQ scores was related to increased gaitparameter variability in both backward and dual-task walking. Clinical Relevance : Strong correlations between gait variability, neuropsychological test performance and the DTQsuggest that increased gait variability may be related to cognitive and perceived dual-task deficits in MS.

TITLE: Brief kinesthesia test scores are poorer after strokeAUTHORS/INSTITUTIONS: A. Borstad, Physical Medicine and Rehabilitation, The Ohio State University, Columbus,Ohio, UNITED STATES|D.S. Nichols-Larsen, School of Health and Rehabilitation Sciences, The Ohio StateUniversity, Columbus, Ohio, UNITED STATES|ABSTRACT BODY: Purpose/Hypothesis : Clinicians lack tools to quantify sensorimotor impairment following upper motor neuron damage. The Brief Kinesthesia Test (BKT), considered for inclusion in the NIH Toolbox, was recently validated in healthyindividuals across the lifespan. The objectives of this descriptive study were 1) To report BKT scores from aheterogeneous group of person’s with chronic stroke and a control group matched for age, gender and handedness.2) To examine the relationship between BKT and other valid sensorimotor measures. Number of Subjects : 24Materials/Methods : A convenience sample of community dwelling person’s with chronic stroke (n=12) were recruitedfor a one-time evaluation of sensorimotor function of both upper extremities (UE). Control participants (n=12)recruited by word of mouth and using Research Match, were matched within 3 years of age and for gender andhandedness to chronic stroke participants. Criteria were a single clinical stroke diagnosed greater than 3 months ago,≥10 degrees active finger extension in the more involved hand. Participants were excluded if they had cognitive orlanguage impairment that precluded following test directions. Outcome measures included the BKT, Wolf MotorFunction Test (Wolf), and the Motor Activity Log (MAL), Box and Blocks Test (BBT).Results : Post-stroke participants performed significantly poorer than control participants on the BKT (t=4.24;p<0.001). Average deviation (mean, SD) was 14.2(3.5) cm and 9.1(2.0) cm, respectively. Impaired UE BKT wasstrongly correlated with the MAL-how much (r=0.84, p=0.001), the MAL-how well (r=0.76, p=0.007), Wolf (r=0.80,p=0.005) and the BBT (r=0.77, p=0.006). Conclusions : The BKT was sensitive to kinesthetic differences between persons with stroke and matched controls. Astrong relationship exists between valid UE motor function measures and the BKT. Clinical Relevance : The BKT is brief and freely available. Based on these preliminary data the BKT may be a usefultool screen for kinesthetic impairment in person’s with stroke.