Biomedical subjects

Subashan Perera

Publications and source records attributed to Subashan Perera.

At least 19 recordsLinked to original sources

PubMed2006

Striatal dopamine denervation and sensory integration for balance in middle-aged and older adults.

UNLABELLED: The dopaminergic system of the basal ganglia has been implicated in the integration of sensory information important for balance based on studies in patients with Parkinson's disease. Striatal dopaminergic activity decreases with normal aging. OBJECTIVE: To investigate the relationship between regional striatal dopaminergic denervation and sensory information integration important for balance in middle-aged and older adults. METHODS: Community-dwelling subjects (N=35; age 41-83) with no clinical diagnoses of conditions affecting balance underwent dynamic posturography testing (Sensory Organization Test/SOT) and C-11-beta-CFT dopamine transporter positron emission tomography. RESULTS: Reduced ventral striatal dopamine was significantly correlated with increased anterior-posterior sway in three SOT conditions. Specifically, during quiet standing (SOT Conditions #1, 2) and when repeatedly to sway-referenced visual environments (SOT Condition #3, Trial #3), pre-synaptic dopaminergic denervation in the anteroventral striatum explained over 20-25% of the variability in sway magnitude above and beyond that explained by age (p<or=0.01). Striatal dopaminergic denervation did not impact balance in sway-referenced floor conditions. CONCLUSIONS: The SOT Condition #3 findings suggest that, in normal aging, the central ability to inhibit balance destabilizing vision-related postural control processes depends at least partially on striatal dopaminergic pathways. In contrast, striatal dopaminergic denervation does not appear to impair the ability to disengage destabilizing proprioceptive inputs and to trigger the vestibular control system during challenging sensory perturbations (SOT Conditions #4-6). Finally, quiet standing results (SOT Conditions #1, 2) justify the need to further investigate the impact of striatal dopaminergic denervation on the ability to tune muscle tone in healthy adults.

Accidental Falls↗

PubMed2006

Measuring stroke impact with SIS: construct validity of SIS telephone administration.

OBJECTIVES: The purpose of this study was to examine the construct validity of the Stroke Impact Scale (SIS) using telephone mode of administration. METHODS: Stroke patients were identified using national VA administrative data and ICD-9 codes in 13 participating VA hospitals. Stroke was confirmed by reviewing electronic medical records. Patients were administered SIS by telephone at 12-weeks post-stroke, and administered the Functional Independence Measure (FIM) and SF-36V at 16 weeks post-stroke. The instrument's convergent validity and its ability to differentiate between groups of stroke patients with different disability levels were examined using Pearson's correlations and Kruskal-Wallis one way ANOVA tests. RESULTS: All the relevant relationships yielded high correlation coefficients with statistical significance: 0.86 for FIM-motor vs. SIS-ADL, and 0.77 for PF in SF-36V vs. SIS-PHYSICAL. The SIS presented better score discrimination and distribution for different severity of stroke than FIM and SF-36V without severe ceiling and floor effects. Kruskal-Wallis tests showed the Physical Component Score of SF-36V did not discriminate any disability levels. Physical functioning (PF) in SF-36V, FIM-motor, SIS-PHYSICAL, SIS-16, and SIS-ADL showed better discrimination in person's functioning. The pairwise comparisons showed that SIS-PHYSICAL, SIS-16, and SIS-ADL discriminated more Rankin levels than FIM-motor and PF in SF-36V. CONCLUSIONS: SIS telephone survey had superior convergent validity and was better at differentiating between groups of stroke patients with different disability levels than the FIM and SF-36V with no evidence of ceiling and floor effects. Telephone administration of SIS would be a useful and cost-effective method to follow-up community dwelling veterans with stroke.

Activities of Daily Living↗

PubMed2006

Chronic low back pain in older adults: prevalence, reliability, and validity of physical examination findings.

OBJECTIVES: To develop a structured physical examination protocol that identifies common biomechanical and soft-tissue abnormalities for older adults with chronic low back pain (CLBP) that can be used as a triage tool for healthcare providers and to test the interobserver reliability and discriminant validity of this protocol. DESIGN: Cross-sectional survey and examination. SETTING: Older adult pain clinic. PARTICIPANTS: One hundred eleven community-dwelling adults aged 60 and older with CLBP and 20 who were pain-free. MEASUREMENTS: Clinical history for demographics, pain duration, previous lumbar surgery or advanced imaging, neurogenic claudication, and imaging clinically serious symptoms. Physical examination for scoliosis, functional leg length discrepancy, pain with lumbar movement, myofascial pain (paralumbar, piriformis, tensor fasciae latae (TFL)), regional bone pain (sacroiliac joint (SIJ), hip, vertebral body), and fibromyalgia. RESULTS: Scoliosis was prevalent in those with (77.5%) and without pain (60.0%), but prevalence of SIJ pain (84% vs 5%), fibromyalgia tender points (19% vs 0%), myofascial pain (96% vs 10%), and hip pain (48% vs 0%) was significantly different between groups (P < .001). Interrater reliability was excellent for SIJ pain (0.81), number of fibromyalgia tender points (0.84), and TFL pain (0.81); good for scoliosis (0.43), kyphosis (0.66), lumbar movement pain (0.75), piriformis pain (0.71), and hip disease by internal rotation (0.56); and marginal for leg length (0.00) and paravertebral pain (0.39). CONCLUSION: Biomechanical and soft tissue pathologies are common in older adults with CLBP, and many can be assessed reliably using a brief physical examination. Their recognition may save unnecessary healthcare expenditure and patient suffering.

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PubMed2006

Therapeutic exercise and depressive symptoms after stroke.

OBJECTIVES: To examine the effect of exercise on depressive symptoms and the effect of baseline depressive symptoms on the benefits from exercise in stroke survivors who have completed acute rehabilitation. DESIGN: Planned secondary analysis of the data from a 9-month randomized, controlled trial. SETTING: Participant homes. PARTICIPANTS: One hundred stroke survivors who had completed acute rehabilitation. INTERVENTION: A progressive, structured, 3-month physical exercise program. MEASUREMENTS: Demographics, stroke characteristics, impairments, functional limitations, the Geriatric Depression Scale, the Stroke Impact Scale, and the Medical Outcomes Study 36-Item Short Form. RESULTS: Baseline rates of depressive symptoms and other stroke sequelae were similar between the two arms. Ninety-three participants were assessed immediately after the intervention (3 months after enrollment), and 80 were assessed 9 months after enrollment. Six (14%) of the exercise group and 16 (35.6%) of the usual-care group had depressive symptoms at 3 months (P = .03). At 9 months, three (7.5%) of the exercisers had significant depressive symptoms compared with 10 (25%) who received usual care (P = .07). Participants with and without baseline depressive symptoms had equivalent treatment-related gains in impairments and functional limitations, but only participants with depressive symptoms had improved quality of life. CONCLUSION: Exercise may help reduce poststroke depressive symptoms. Depressive symptoms do not limit gains in physical function due to exercise. Exercise may contribute to improved quality of life in those with poststroke depressive symptoms.

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PubMed2006

Meaningful change and responsiveness in common physical performance measures in older adults.

OBJECTIVES: To estimate the magnitude of small meaningful and substantial individual change in physical performance measures and evaluate their responsiveness. DESIGN: Secondary data analyses using distribution- and anchor-based methods to determine meaningful change. SETTING: Secondary analysis of data from an observational study and clinical trials of community-dwelling older people and subacute stroke survivors. PARTICIPANTS: Older adults with mobility disabilities in a strength training trial (n=100), subacute stroke survivors in an intervention trial (n=100), and a prospective cohort of community-dwelling older people (n=492). MEASUREMENTS: Gait speed, Short Physical Performance Battery (SPPB), 6-minute-walk distance (6MWD), and self-reported mobility. RESULTS: Most small meaningful change estimates ranged from 0.04 to 0.06 m/s for gait speed, 0.27 to 0.55 points for SPPB, and 19 to 22 m for 6MWD. Most substantial change estimates ranged from 0.08 to 0.14 m/s for gait speed, 0.99 to 1.34 points for SPPB, and 47 to 49 m for 6MWD. Based on responsiveness indices, per-group sample sizes for clinical trials ranged from 13 to 42 for substantial change and 71 to 161 for small meaningful change. CONCLUSION: Best initial estimates of small meaningful change are near 0.05 m/s for gait speed, 0.5 points for SPPB, and 20 m for 6MWD and of substantial change are near 0.10 m/s for gait speed, 1.0 point for SPPB, and 50 m for 6MWD. For clinical use, substantial change in these measures and small change in gait speed and 6MWD, but not SPPB, are detectable. For research use, these measures yield feasible sample sizes for detecting meaningful change.

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PubMed2006

Chronic low back pain in older adults: What physicians know, what they think they know, and what they should be taught.

Chronic low back pain (CLBP) is a common and debilitating problem in older adults. Little exists in the literature about primary care physicians' (PCPs') knowledge of and confidence in managing this problem. A self-administered survey was mailed to PCPs in western Pennsylvania to measure knowledge of the evaluation and treatment of common contributors to CLBP in older adults, confidence in diagnosing these contributors through physical examination, and the association between confidence levels and knowledge. The survey combined items with an ordinal scale on which PCPs ranked their confidence in detecting various contributors to CLBP (e.g., fibromyalgia) using physical examination and patient vignettes followed by multiple choice questions designed to assess knowledge. One hundred fifty-three of 634 surveys were returned (24.1%). Overall, the majority of PCPs did not feel "very confident" in their ability to diagnose any of the contributors of CLBP listed (most items <40%). PCPs felt most confident in detecting scoliosis and least confident detecting myofascial pain of the piriformis muscle. There was a wide range in the number of respondents answering all questions related to a particular topic correctly (3.9% for sacroiliac joint syndrome to 70.4% for hip osteoarthritis). There was no relationship between knowledge scores and confidence ratings (P > .05 for all comparisons). The results point to a need for more PCP education about CLBP in older adults. It also suggests that accurate needs assessment should not rely on physician confidence ratings alone.

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PubMed2005

Daily functioning and quality of life in a randomized controlled trial of therapeutic exercise for subacute stroke survivors.

BACKGROUND AND PURPOSE: The ability of therapeutic exercise after stroke to improve daily functioning and quality of life (QOL) remains controversial. We examined treatment effects on these outcomes in a randomized controlled trial (RCT) of exercise in subacute stroke survivors. METHODS: This is a secondary analysis of a single-blind RCT of a 12-week program versus usual care. Baseline, post-treatment and 6-month post-treatment daily functioning and QOL were assessed by Barthel index, Functional Independence Measure, instrumental activities of daily living, Medical Outcomes Study short-form 36-item questionnaire (SF-36), and Stroke Impact Scale (SIS). RESULTS: Of 100 randomized subjects, 93 completed the postintervention assessment, (mean age 70; 54% male; 81% white; mean Orpington Prognostic Score 3.4), and 80 had 6-month post-treatment assessment. Immediately after intervention, the intervention group improved more than usual care in SF-36 social function (14.0 points; P=0.0051) and in SIS (strength [9.2 points; P=0.0003], emotion [5.6 points; P=0.0240], social participation [6.6 points; P=0.0488], and physical function [5.0 points; P=0.0145]). Treatment was marginally more effective on Barthel score (3.3 points; P=0.0510), SF-36 (physical function [6.8 points; P=0.0586], physical role function [14.4 points; P=0.0708]), and SIS upper extremity function (7.2 points; P=0.0790). Effects were diluted 6 months after treatment ended. CONCLUSIONS: This rehabilitation exercise program led to more rapid improvement in aspects of physical, social, and role function than usual care in persons with subacute stroke. Adherence interventions to promote continued exercise after treatment might be needed to continue benefit.

Activities of Daily Living↗

PubMed2005

Patterns of potentially inappropriate medication use across three cohorts of older Medicaid recipients.

BACKGROUND: Potentially inappropriate medication use is a serious quality concern, especially when it occurs in more vulnerable older adults or for extended durations. OBJECTIVE: To characterize patterns of inappropriate medication use and duration among 3 cohorts with differing health status. METHODS: We identified unconditionally inappropriate drug use, using Beers 1997 criteria, among 3185 older Kansas Medicaid beneficiaries. Claims from May 2000 to April 2001 provided data for 3 cohorts: nursing facility (NF) residents, recipients of home- and community-based services through the Frail Elderly (FE) program, and persons with neither NF/FE care (Ambulatory). Duration, categorized as short-term (< or = 1 month's supply), extended (> 1-9 mo), or chronic (> 9-12 mo), was determined for each drug and cohort. Drug-disease associations were explored. RESULTS: Any inappropriate medication use occurred in 21%, 48%, and 38% of Ambulatory, FE, and NF cohorts, respectively. Inappropriate analgesics, antihistamines, antidepressants, muscle relaxants, and oxybutynin were most common, but prevalence and duration varied by cohort. Short-term analgesic and antihistamine use was common. FE cohort members had the highest use rates for all drugs. The NF cohort had less antidepressant and muscle relaxant use. Drug-disease associations were noted for amitriptyline use in diabetes mellitus, propoxyphene use in musculoskeletal and upper gastrointestinal conditions, and muscle relaxant use in musculoskeletal conditions. CONCLUSIONS: Cross-sectional, one-year prevalence figures are comprised of both short- and long-term use that varies by drug and cohort. NF residence is associated with reduced use of drugs scrutinized during mandated medication review. Relevant diseases are associated with specific inappropriate prescribing. Future efforts should target extended and chronic duration of use and persons at highest risk for adverse effects, including recipients of home- and community-based care.

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PubMed2005

Magnitude and patterns of decline in health and function in 1 year affect subsequent 5-year survival.

BACKGROUND: Indicators of physical function and health status can predict important outcomes in older persons, but little is known about the meaning of change in these measures. This study assessed the magnitude and patterns of change occurring in 1 year in six measures of health and function and estimated the effects on survival for 5 years. METHODS: This prospective cohort study was based in two health care systems. Data were collected during home visits at baseline and every 3 months for 1 year. Subsequent deaths occurring within 5 years were ascertained using the National Death Index. RESULTS: Of 439 older adults, 88 (20%) died within the subsequent 5 years. The optimal magnitude of decline to predict 5-year mortality was 0.1 meters/second for gait speed, 1 point for the Short Physical Performance Battery, and 0.05 points for Euroqol. Independent contributions were found for decline in gait speed (p =.001 to.002), Short Physical Performance Battery (p =.014 to.026), global health (p <.001), and activities of daily living (p =.005 to.019). More than one half of the episodes of decline were transient. Persistent decline in 1 year consistently predicted death, and transient decline in gait speed and global health increased mortality risk compared with no change. CONCLUSIONS: A decline in gait speed of 0.1 m/s or 1 point in the Short Physical Performance Battery within 1 year increased the subsequent 5-year mortality rate. Transient declines in gait speed and self-reported health are as common as persistent declines and affect mortality risk.

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PubMed2005

Measuring stroke impact with the stroke impact scale: telephone versus mail administration in veterans with stroke.

OBJECTIVES: The purpose of this study was to examine response rate, mode effects, and reliability of the Stroke Impact Scale (SIS) in a veteran stroke population using mail and telephone modes of administration. METHODS: Patients who had suffered a stroke were identified using national VA administrative data and International Classification of Diseases, 9th Revision codes in 13 participating Veterans Affairs hospital. Stroke was confirmed by reviewing electronic medical records. Patients were randomized to SIS administration by mail or telephone at 12-weeks after their stroke. Comparison of response rate, nonresponse bias, domain scores, administration costs, and instrument reliability were performed. RESULTS: Four hundred fifty-eight patients with stroke were identified, validated, and randomly assigned into 2 administration groups. No significant cluster effect was observed. Response rates for mail and telephone were 45% and 69%, respectively. Mail nonresponders were more likely to have had severe stokes, cognitive deficits, and be unmarried. No difference was observed between telephone responders and nonresponders. Responders in mail and telephone modes were not different, and the SIS score distribution did not indicate the presence of mode effects. Test-retest reliability was good to excellent in the mail group (0.77-0.99) except social participation (0.62). Test retest reliability was excellent in the telephone mode (0.90-0.99) except emotion (0.68). CONCLUSIONS: Telephone mode of survey administration yielded a higher response rate, less bias in responder selection, and higher test-retest reliability. The cost of telephone administration was 2 times the cost of mail. Mode effects in SIS score distribution were not observed in this study but additional research with larger sample sizes is needed to provide more definitive evidence.

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PubMed2005

The state of chronic pain education in geriatric medicine fellowship training programs: results of a national survey.

A survey of U.S. geriatric medicine fellowship training programs was performed to assess the status of teaching about chronic pain evaluation and management and identify opportunities for improvement. After an initial e-mail query, 43 of 96 programs agreed to participate. A self-administered questionnaire, with items adapted from a 2002 consensus panel statement, was mailed to their 171 fellows-in-training and 43 fellowship directors. Thirty-two programs (33% of nationwide sample) including 79 fellows (30% of nationwide sample) and 25 directors (26% of nationwide sample) returned surveys; 21 institutions returned both faculty and fellow surveys. Overall, directors endorsed the 19 items identified by the consensus panel as essential components of fellowship training, but fellows identified deficiencies, both before and during fellowship training. Specific areas of undereducation included comprehensive musculoskeletal assessment, neuropathic pain evaluation, indications for low back pain imaging, the role of multidisciplinary pain clinics and nonpharmacological modalities, the effect of physical and psychosocial comorbidities in formulating treatment goals, and the effect of aging on analgesic metabolism and prescription. Both groups were generally positive about fellows' abilities to implement pain-related clinical skills. Discrepancies existed between fellowship directors' ratings of importance of teaching individual items and the degree to which teaching was actually done, as well as faculty versus fellow assessments of whether some of the 19 items were taught. Primary care training programs (e.g., internal medicine, family medicine, geriatric medicine) should pay more systematic attention to educating trainees about chronic pain to optimize patient care, decrease suffering, and diminish healthcare expenditures.

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PubMed2005

Coordination of hemiparetic locomotion after stroke rehabilitation.

OBJECTIVES: Determine whether a rehabilitation program targeting functional motor recovery of persons with poststroke hemiparesis improved motor coordination. METHODS: A subgroup of 20 persons with poststroke hemiparesis (n = 11 in intervention and n =9 in control group) was investigated from within a larger randomized controlled single-blind clinical trial of 100 patients. Motor coordination was measured using a pedaling task, and subjects in the intervention group pedaled during an intensive broad-based home exercise program that targeted flexibility, strength, balance, and endurance. Coordination variables based on paretic leg pedal forces and EMG of 4 thigh muscles were measured while pedaling pre- and postintervention. RESULTS: Despite extensive pedaling practice, up to 30 half-hour sessions that were progressively more intense, there was no effect (P > 0.05) of the intervention on percent of total work done by the paretic leg, quantitative measures of EMG, or pedaling speed. However, walking speed was improved and pedaling and walking faster were associated after the intervention. CONCLUSIONS: There is no evidence of improved locomotor coordination postintervention. The increased walking and pedaling speed was likely achieved by a more proficient use of the same impaired pattern without EMG timing changes, likely because of increased strength and endurance postintervention. A more task-specific intervention may be required to improve coordination, consistent with principles of use-dependent plasticity.

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PubMed2005

Impaired grip force modulation in the ipsilesional hand after unilateral middle cerebral artery stroke.

Understanding grasping control after stroke is important for relearning motor skills. The authors examined 10 individuals (5 males; 5 females; ages 32-86) with chronic unilateral middle cerebral artery (MCA) stroke (4 right lesions; 6 left lesions) when lifting a novel test object using skilled precision grip with their ipsilesional ("unaffected") hand compared to healthy controls (n = 14; 6 males; 8 females; ages 19-86). All subjects possessed normal range of motion, cutaneous sensation, and proprioception in the hand tested and had no apraxia or cognitive deficits. Subjects lifted the object 10 times at each object weight (260 g, 500 g, 780 g) using a moderately paced self-selected lifting speed. The normal horizontal ("grip") force and vertical tangential ("lift") force were separately measured at the thumb and index finger. Regardless of the object weight or stroke location, the stroke group generated greater grip forces at liftoff of the object (> or =39%; P < or = 0.05) and across the dynamic (P < or = 0.05) and static portions (P < or = 0.05) of the lifts compared to the healthy group. Peak lift forces were equivalent between groups, suggesting accurate load force information processing occurred. These results warrant further investigation of altered sensorimotor processing or compensatory biomechanical strategies that may lead to inaccurate grip force execution after strokes.

Adult↗

PubMed2004

Comparison of the association between disease burden and inappropriate medication use across three cohorts of older adults.

BACKGROUND: Use of potentially inappropriate medications is common in nursing facilities (NFs), in which frail older adults are particularly vulnerable to adverse drug effects. The community-dwelling elderly are generally healthier and have lower overall rates of medication use, but their prescribed medications are not subjected to the same degree of regulatory scrutiny as those of residents in NFs. Frail elderly (FE) adults who are nursing home eligible but are receiving home- and community-based services (HCBS) constitute a distinct group sharing a high disease burden and high levels of medication use with the NF population. OBJECTIVE: The goal of this study was to examine the relationship between disease burden and inappropriate medication use in these 3 cohorts, with adjustment for demographic and clinical differences. METHODS: We performed retrospective analyses of Medicaid claims data from May 2000 through April 2001 to identify 3 cohorts of Kansas Medicaid beneficiaries: community-dwelling older adults (the ambulatory cohort); persons receiving HCBS through the Kansas Frail Elderly Program (the FE cohort); and elderly NF residents (the NF cohort). Demographic, clinical, and medication data were extracted from the Medicaid claims data. Unconditionally inappropriate medications were identified using the 1997 Beers criteria. The Cumulative Illness Rating Scale for Geriatrics was used to calculate the disease burden sum, classified as 0 or 1, 2 or 3, 4 or 5, or > or =6 disease categories. Odds ratios for inappropriate medication use at each level of disease burden in each cohort were derived using multivariable models adjusted for demographic and clinical factors, including overall level of medication use. RESULTS: The final sample included 3185 persons in the 3 cohorts (1163 ambulatory, 858 FE, 1164 NF). Inappropriate medication use was determined to have occurred in 21%, 48%, and 38% of the respective cohorts and was highest in FE cohort members with the greatest disease burden (61%). For the ambulatory and FE cohorts, inappropriate medication use rose as the disease burden increased. The same was not observed in the NF cohort, in whom rates of inappropriate medication use showed little variation regardless of disease burden. CONCLUSIONS: The relationship between disease burden and inappropriate medication use varied by setting. Those members of the FE cohort with the highest disease burden had the greatest risk for inappropriate medication use.

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PubMed2004

Clinical Global Impression of Change in Physical Frailty: development of a measure based on clinical judgment.

OBJECTIVES: To expand the ability to assess physical frailty by developing a Clinical Global Impression of Change in Physical Frailty (CGIC-PF) instrument. DESIGN: Qualitative and quantitative instrument development. SETTING: Academic centers. PARTICIPANT: s Six expert panel members, 46 clinicians, 24 patients, and 12 caregivers. MEASUREMENTS: Literature review and structured group processes with experts, clinicians, and consumers were used to generate an initial list of domains and indicators. Structured interviews with clinical experts in the area of frailty were used to establish relevance and feasibility of measurement of domains. Interrater reliability was assessed through a Web-based study. Geriatricians pilot tested the feasibility of the baseline CGIC-PF with 10 patients. RESULTS: The CGIC-PF includes six intrinsic domains (mobility, balance, strength, endurance, nutrition, and neuromotor performance) and seven consequences domains (medical complexity, healthcare utilization, appearance, self-perceived health, activities of daily living, emotional status, and social status). Each domain has two to four clinical indicators. Change is scored on a 7-point scale from markedly worse to markedly improved. Average interrater reliability of the CGIC-PF for the Web-based cases was 0.97. Geriatricians completed a baseline CGIC-PF on their own patients in 10 minutes or less. CONCLUSION: The CGIC-PF is a structured assessment of change in physical frailty with defined content and process. It has strong face validity, reliability, and feasibility for use in clinical research. It may be useful as one criterion of change and as an anchor for change in other measures.

Activities of Daily Living↗

PubMed2004

Bicycle ergometry in subacute-stroke survivors: feasibility, safety, and exercise performance.

This study evaluated the feasibility, safety, and findings from a protocol for exercise-bicycle ergometry in subacute-stroke survivors. Of 117 eligible candidates, 14 could not perform the test and 3 discontinued because of cardiac safety criteria. In the 100 completed tests, peak heart rate was 116 +/- 19.1 beats/min; peak VO(2) was 11.4 +/- 3.7 ml x kg x min(-1), peak METs were 3.3 +/- 0.91, exercise duration was 5.1 +/- 2.84 min, and Borg score was 14 +/- 2.6. Among 71 tests, anaerobic threshold was achieved in 3.0 +/- 1.7 min with a VO(2) of 8.6 +/- 1.7 ml x kg x min(-1). After screening, this protocol is feasible and safe in subacute-stroke survivors with mild to moderate deficits. These stroke survivors have severely limited functional exercise capacity. Research and clinical practice in stroke rehabilitation should incorporate more comprehensive evaluation and treatment of endurance limitations.

Acute Disease↗

PubMed2004

Gains in distance walking in a 3-month follow-up poststroke: what changes?

STATEMENT OF PROBLEM: Distance walking remains compromised for many adults poststroke. The purpose of this study was to examine if the amelioration of stroke-related neuromuscular impairments, improved cardiovascular fitness, or better balance contributed to gains in distance walking. METHOD OF STUDY: The authors gathered baseline data of 92 adults at an average of 75 days poststroke and again 3 months later. Participants performed a bicycle ergometry stress test, a 6-min walk, and a Fugl-Meyer assessment for motor control, strength, and balance testing. The gain in walk distance was modeled using multiple regression with the variables of gains in peak VO2, lower limb control, plantar flexion strength, and balance. Separate analyses were done for poor performers, that is, participants who walked less than the median distance (213 m) at baseline and good performers, that is, participants who walked more than 213 m. RESULTS: For poor performers, the gain in balance was the only significant predictor of the gain in distance walking and accounted for 16% of the variance. For good performers, gains in peak VO2 and the lower limb Fugl-Meyer score were significant predictors and accounted for 28% of the variance. DISCUSSION: These results suggest that rehabilitation efforts to improve distance walking should focus on different factors depending on initial distance walked.

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PubMed2003

Randomized clinical trial of therapeutic exercise in subacute stroke.

BACKGROUND AND PURPOSE: Rehabilitation care after stroke is highly variable and increasingly shorter in duration. The effect of therapeutic exercise on impairments and functional limitations after stroke is not clear. The objective of this study was to determine whether a structured, progressive, physiologically based exercise program for subacute stroke produces gains greater than those attributable to spontaneous recovery and usual care. METHODS: This randomized, controlled, single-blind clinical trial was conducted in a metropolitan area and 17 participating healthcare institutions. We included persons with stroke who were living in the community. One hundred patients (mean age, 70 years; mean Orpington score, 3.4) consented and were randomized from a screened sample of 582. Ninety-two subjects completed the trial. Intervention was a structured, progressive, physiologically based, therapist-supervised, in-home program of thirty-six 90-minute sessions over 12 weeks targeting flexibility, strength, balance, endurance, and upper-extremity function. Main outcome measures were postintervention strength (ankle and knee isometric peak torque, grip strength), upper- and lower-extremity motor control (Fugl Meyer), balance (Berg and functional reach), endurance (peak aerobic capacity and exercise duration), upper-extremity function (Wolf Motor Function Test), and mobility (timed 10-m walk and 6-minute walk distance). RESULTS: In the intention-to-treat multivariate analysis of variance testing the overall effect, the intervention produced greater gains than usual care (Wilk's lambda=0.64, P=0.0056). Both intervention and usual care groups improved in strength, balance, upper- and lower-extremity motor control, upper-extremity function, and gait velocity. Gains for the intervention group exceeded those in the usual care group in balance, endurance, peak aerobic capacity, and mobility. Upper-extremity gains exceeded those in the usual care group only in patients with higher baseline function. CONCLUSIONS: This structured, progressive program of therapeutic exercise in persons who had completed acute rehabilitation services produced gains in endurance, balance, and mobility beyond those attributable to spontaneous recovery and usual care.

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