ABSTRACTS - Platform Presentations Academy of Neurologic Physical Therapy

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ABSTRACTS - Platform Presentations Academy of Neurologic Physical Therapy

   Academy of Neurologic
     Physical Therapy

Platform Presentations
TITLE: Impaired Dynamic Balance in Young Adults with Unilateral Hearing Loss or Vestibular Hypofunction
AUTHORS: Brittani Morris, Jennifer Lynn Kelly, Maria Mavrommatis, Andrew B. Medlin, Maura Cosetti, Anat
Vilnai Lubetzky
Individuals with Unilateral Vestibular Hypofunction often demonstrate balance dysfunction.1,2 In particular, middle-
aged adults with vestibular hypofunction have demonstrated slower times on the Timed Up & Go (TUG) and the
Four-Square Step Test (FSST)3 as compared to age-matched controls, both valid tests of dynamic balance
performance. In addition, balance deficits have been demonstrated in older adults and children with unilateral hearing
loss4,5 but the implications for young adults is unclear. It is often assumed that balance dysfunction in people with
hearing loss is explained by an underlying vestibular dysfunction but recent studies suggest an independent relationship
between hearing loss and balance impairment.6 The purpose of this pilot study was to compare FSST and TUG scores
in young adults with Unilateral hearing loss, Unilateral vestibular hypofunction and age-matched controls to further our
understanding of hearing loss and vestibular dysfunction and the implications they may have on balance performance
among young adults.
Number of Subjects:
Participants in this pilot study included 9 healthy young adults (C; 5 males, Mean Age= 26.2, SD=0.97), 4 individuals
with vestibular hypofunction (V; 3 males, Mean Age=25.0, SD=2.9), 7 individuals with unilateral hearing loss (HL; 4
males, Mean Age=27.9, SD=2.0), due to conductive and mixed hearing loss on either side.
Materials and Methods:
Participants were recruited and tested at the Ear Institute of Mount Sinai. They performed the TUG at a comfortable
walking speed, and the FSST as fast as possible. The best score of 2 trials was used for analysis.
Participants in both HL and V groups tended to be slower on the TUG than controls, (HL; M= 7.09, SD= 2.06) (V;
M= 6.34, SD=0.89) (C; M=5.26, SD=1.3) but this difference was not statistically significant. Participants in both HL
and V groups demonstrated significantly slower performance on the FSST than group C (Main effect of group on the
Kruskal-Wallis test, p = 0.043) (HL; M=8.24, SD=1.89) (V; M=7.05, SD=0.95) (C; M=6.26, SD=1.4). Pairwise
Comparisons with Bonferroni correction demonstrated that the difference in FSST scores between C and HL was
statistically significant (p = 0.037) while V and C were not significantly different from each other.
Young adults with HL were the slowest among the 3 groups despite having no complaints of dizziness or imbalance.
This study is limited by the small sample size and the varying types of HL included. However, findings suggest that
hearing loss has implications for individuals’ balance, even among young adults. Future research should investigate the
independent relationship between hearing loss and balance dysfunction, regardless of age and vestibular function.
Clinical Relevance:
Participants with Unilateral Vestibular Hypofunction were already participating in rehabilitation but individuals with
HL were seen for their hearing and not for their balance. Clinicians should be encouraged to screen individuals with
hearing loss for balance deficits and refer to balance rehabilitation as needed to minimize their risk of falls and
maximize their function.
TITLE: Long-Term Retention of Overground Gait-Slip Perturbation Training in People with Chronic Stroke: A
Randomized-Controlled Trial
AUTHORS: Tanvi Bhatt, Tanvi Bhatt, Shamali Dusane, Shuaijie Wang, Rudri Milind Purohit
Purpose/Hypothesis: Preliminary evidence from perturbation-based training studies demonstrate the ability of people
with chronic stroke (PwCS) to acquire fall-resisting skills1, 2. However, most of the studies are in standing and the
relative contributions from paretic and non-paretic limb have not been examined. Thus, this study examined if PwCS
could demonstrate motor adaptation, immediate retention and 6-month retention after a single session of bilateral
overground gait-slip training.
Number of Subjects: 65 PwCS
Materials and Methods: 65 PwCS were randomly assigned to either the training group, which first received blocks of
non-paretic and paretic slips and then a mixed block of random non-paretic and paretic slips mixed with unperturbed
walking trials during overground walking, or the control group, which received a single non-paretic and paretic slip
each in a random order. Immediate and longer-term retention was tested respectively after 30 minutes 6-month 6
months post-training. Slip outcome, recovery strategies, center of mass (CoM) state stability, slipping kinematics and
compensatory stride length were analyzed.
Results: The training group demonstrated lower falls and balance losses associated with improved post-slip stability,
stride length and slipping kinematics on non-paretic and paretic slip blocks; however, improvement in pre-slip stability
was seen only on the non-paretic slip block (p
TITLE: Predicting Fall Risk in Persons with Multiple Sclerosis Utilizing the Msws-12
AUTHORS: Caterina Marie Abate, Elizabeth S. Gromisch, Marc A. Campo, Jennifer A. Ruiz, Heather M.
Purpose/Hypothesis: Aim 1) to determine the predictive ability and cut-off score of the self-reported 12-item Multiple
Sclerosis Walking Scale (MSWS-12) outcome measure in identifying persons with multiple sclerosis (PwMS) at a
greater risk of falling. It is hypothesized that PwMS with higher MSWS-12 scores are at greater risk of falling. Aim 2)
to analyze participant demographics and disease characteristics as contributing factors in predicting fall risk in PwMS.
It is hypothesized that greater disease duration, disability, and age would also predict increased fall risk.
Number of Subjects: 171
Materials and Methods: A convenience sample of PwMS that responded to recruitment materials and met the study
criteria participated in a one-time research visit. Individuals were eligible if they had a clinical diagnosis of MS, were
aged 18-99, no relapse within the past two months, no recent surgeries or injury of the lower extremity, and no
contraindications to physical activity. Demographics (age, gender, body mass index [BMI], race, and ethnicity) and
disease characteristics (disease duration and disability level [ Patient Determined Disease Steps; PDDS]) were
collected along with the outcome variables: the MSWS-12 and number of falls in the last six months. Fallers for the
purpose of this study were defined as individuals that had one or more falls in the past six months. Receiver-operating-
characteristic (ROC) curves were performed to estimate the classification accuracy. Optimal cut-off scores were
calculated using the Youden Index. The sensitivity, specificity, and area under the curve (AUC) were reported. Then,
a hierarchal logistic regression was performed in which demographic and disease characteristics were entered in the
first step, with the dichotomized MSWS-12 cut-off score entered in the second step.
Results: Of the 171 participants, 53.8% (n = 92) reported a fall within the last six months. The MSWS-12 had a fair
classification accuracy of identifying fallers (AUC = 0.735), with the cut-off score of 45.83 having a sensitivity of 76.1%
and specificity of 64.6%. After accounting for demographic and disease characteristics, the MSWS-12 cut-off score was
a significant predictor of increased fall risk, with an adjusted odds ratio of 4.12 (95% CI: 1.75, 9.71, p =0.001). None of
the other variables in the model were significant (p ≥0.186).
Conclusions: PwMS with MSWS-12 scores greater than or equal to 45.83 are 4.12 times more likely to be fallers. This
cutoff score can be helpful in determining fall risk in the MS population.
Clinical Relevance: PwMS are at an increased risk for falling due to dysfunction in mobility and gait, which are
common self-reported impairments. Falls in this population can be detrimental due to increased risk of injury, need
for medical care, deconditioning, and decreased activity. Therefore, identifying tools to assess the risk of falling within
this population would aid clinicians in determining which patients could benefit from targeted physical therapy to
reduce fall risks.
TITLE: Exploring Vestibular/Ocular Motor Screen (VOMS) in Adults As a Potential Outcome after Concussion
Vestibular Rehabilitation
AUTHORS: Jennifer Louise Wilhelm, Josh Koch, Natalie C Pettigrew, Kody Campbell, Laurie Anne King
Purpose/Hypothesis: The Vestibular/Ocular Motor Screen (VOMS) is a tool used to aid in the diagnosis of
concussion. Although not designed as an outcome measure after rehabilitation, recent research is utilizing VOMS to
track recovery. However, it is unknown if changes on VOMS relate to functional improvement. We examined 3
measures looking at global concussion symptoms, dizziness and personal perception of improvement and
hypothesized that dizziness symptoms would correlate with improvement in VOMS scores. The goal of this abstract is
to 1) characterize the recovery of VOMS performance in adults with subacute concussion treated with physical therapy
and 2) determine if a change in VOMS correlates to subjective outcome measures.
Number of Subjects: Fifty-five subjects (mean age 32.8(±11.7); 46 F) with subacute concussion (84.5(±40.5) days since
injury) were enrolled. Subjects were symptomatic based on the Neurobehavioral Symptom Inventory (NSI)(mean
Materials and Methods: Subjects attended 8, 60-min physical therapy (PT) visits over 6 weeks with a daily home
exercise program as part of a larger clinical trial (King W81XWH-17-1-0424). PT included cervical therapy,
cardiovascular exercise (based on the Buffalo protocol), and vestibular rehabilitation (oculomotor exercises, gaze
stabilization, static and dynamic balance). Exercises were progressed based on tolerance. Subjects completed symptom
scales (NSI and Dizziness Handicapped Inventory (DHI)) and VOMS testing pre- and post-PT. Patient Global
Impression of Change (PGIC) was rated post-PT. A change score on VOMS was calculated by subtracting the total
baseline symptoms from the total symptoms in each subtest and then summed for total change scores. Wilcoxon
ranked sum tests were used to compare differences pre-to-post-PT on total change scores. Spearman rank correlations
(rs) evaluated the association between total change scores with change in subjective measures of overall function (NSI,
DHI) and PGIC after PT.
Results: Subjects had significantly lower VOMS total change scores post-PT (median and [1st and 3rd quartiles]: 2 [0,5])
compared to pre-PT (10 [3,21]; p < 0.0001). Lower VOMS total change scores following PT weakly related with
improvement on DHI post-PT (rs=0.28, p=0.04) and higher PGIC (rs= -0.30, p=0.03). Lower NSI severity after PT
had no relationship with total change scores (rs=0.11, p=0.43).
Conclusions: VOMS change scores improved after rehabilitation in this population. Improvements weakly correlated
to a validated clinical assessment of dizziness and subjective overall improvement with PT. VOMS did not correlate to
overall concussive symptom burden.
Clinical Relevance: Although VOMS total change scores improved with PT, caution should be used as improvements
were not strongly related to a broad range of subjective outcome measures. Future research should address minimally
clinically important difference and minimal detectable change if the VOMS is to be used as an outcome measure
within rehabilitation.
TITLE: Deep Brain Stimulation to Globus Pallidus Internus and Its Effects on Balance in Parkinson’s Disease
CURRENT SUB-CATEGORY: Degenerative Diseases SIG
AUTHORS: Daisy Perez Buenrostro, Kathleen Therese Scanlan, Jennifer Louise Wilhelm, Angelina M. Ciavarella,
Shannon Anderson, Edla da Silva
Purpose/Hypothesis: It has been well established that the motor symptoms of Parkinson’s disease (PD) including
rigidity, bradykinesia and tremor as well as motor fluctuations and dyskinesias from levodopa can effectively be treated
with deep brain stimulation (DBS). The effect of DBS on gait and balance are not as well understood. The globus
pallidus internus (GPi) target for DBS is becoming more common though it is still less frequently used than the
subthalamic nucleus. Presently little research has been done exploring the effects of GPi DBS electrode placement on
gait and balance. The purpose of this retrospective study is to evaluate the effects of GPi DBS for PD on gait and
balance and assess the relationship to changes in motor symptoms.
Number of Subjects: Subjects were identified through an IRB-approved database of patients who had received DBS at
Oregon Health and Science University using imaging for electrode placement and intraoperative target confirmation.
Subjects were included if they had GPi electrode placement and a pre-surgical and post-operative assessment including
United Parkinson’s Disease Rating Scale Motor Subscale (UPDRS-III) and Mini-BESTest. Subjects were excluded if
there was >1.5 years between pre-and post-operative evaluations to minimize the effect of disease progression. 14
subjects (8 F), age (mean(SD)) 65.0(6.3) at time of pre-operative assessment, disease duration 11.6(4.3) y, Hoehn and
Yahr stage 3.1(0.6) and average time between evaluations 0.9(0.3) y were included.
Materials and Methods: To minimize the effects of levodopa on gait and balance, patients were assessed with UPDRS-
III and Mini-BESTest outcome measures in the OFF state (> 12 hrs since PD medications). Post-operative evaluations
were at least 6 months after surgery when programming had been optimized. Statistical analysis was performed using
SPSS. A 2 tailed paired t-test (p) was used for the UPDRS-III, Wilcoxon Signed Ranks test was used for the Mini-
BESTest, and Spearman’s rho (ρ) was used for correlations.
Results: There was a significant improvement in OFF UPDRS scores (35.9(13.2) vs 27.1(7.1), p
TITLE: Consultative Coaching Model for Long-Term Exercise Engagement in People with Huntington’s Disease
CURRENT SUB-CATEGORY: Degenerative Diseases SIG
AUTHORS: Lori Quinn, Hai-Jung Steffi Shih, Rebecca Playle, Cheney Drew, Katie Taiyari, Rhys Williams-Thomas,
Lisa Mary Muratori, Ciaran Friel, Philippa Morgan-Jones, Anne Rosser, Monica Busse, PT PhD
Purpose/Hypothesis: Exercise and physical activity are important in the management of disease-related symptoms and
functional decline in people with Huntington’s disease (HD). A new physical therapy model of care with ongoing
consultation starting in early disease stages may be needed for effective disease management and to facilitate exercise
uptake. Here we describe PACE-HD, a 12-month physical therapist-led intervention to promote exercise and physical
activity uptake, and its implementation in a randomized controlled trial. The primary outcome was feasibility including
retention, adherence, fidelity and safety. Secondary objectives included exploration of effect estimates for the
intervention compared to usual activity.
Number of Subjects: RCT n=53: Intervention n=26; Control n=27
Materials and Methods: Persons enrolled in the Enroll-HD cohort study were invited to participate in the PACE-HD
trial across 6 sites in the U.S. and Europe. The 1-year intervention consisted of 18 physical therapist-led coaching
sessions that facilitated exercise goal setting and incorporated the use of a wearable activity monitor and educational
workbook. The activity monitor provided a means of self-monitoring to enhance autonomy. Participants were also
provided with their choice of exercise equipment, gym membership, and online exercise resources. Feasibility was
evaluated in terms of retention, adherence, fidelity and safety. Preliminary efficacy was evaluated with effect estimates.
Results: Retention rate was similar between intervention and control at 84% and 85%. Adherence to the intervention
(defined as sessions attended) was 81%. Prespecified intervention fidelity criteria were met; therapist questionnaires
confirm therapist/participant interactions were guided by the intervention logic model supporting self-determination
and collaborative regulation. No serious adverse events were reported. Number of falls was similar between groups (42
falls in control and 43 in intervention). Effect estimates suggest the intervention group improved in predicted VO2 max,
6-minute walk test, and self-reported physical activity (International Physical Activity Questionnaire) compared to the
control group.
Conclusions: A 12-month physical therapist-led exercise coaching program had good retention, adherence and fidelity,
and was safe compared to usual care. The intervention showed promising results for future trials to examine efficacy
and implementation.
Clinical Relevance: Physical therapists possess expertise in exercise and the management of neurodegenerative
diseases and can play an important role in guiding patients through long-term self-management strategies. A new
model of care that incorporates early exercise engagement with sustained consultation with physical therapists may be
useful for managing functional decline in patients with Huntington’s disease.
TITLE: Community-Based Cycling Class Promotes Exercise Adherence and Improves Disease Symptoms in
Individuals with Parkinson’s Disease
CURRENT SUB-CATEGORY: Degenerative Diseases SIG
AUTHORS: Anson Brennan Rosenfeldt, Mandy Miller-Koop, Amanda Penko, Karissa Hastilow, Jay Alberts
Purpose/Hypothesis: Corroborating results from several clinical trials indicate that habitual aerobic exercise mitigates
motor symptoms and potentially alters the trajectory of the disease in people with Parkinson’s disease (PwPD). Results
from well-controlled supervised laboratory studies are encouraging; however, a gap remains in understanding the
effectiveness of laboratory-based exercise protocols that are translated to community-based exercise environments. A
community-based, PD-specific cycling program, Pedaling for Parkinson’s (PFP), is grounded in an effective high
intensity laboratory-based protocol that stresses high cadence cycling. The PFP classes are offered year-round in 150+
fitness centers throughout the USA, offering a uniform protocol promoting high intensity aerobic exercise.
The aim of this project was to monitor real-world exercise adherence (i.e. attendance) and compliance (i.e. heart rate
(HR) and cadence) and its effect on disease progression in a group of community-dwelling PwPD participating in a
PFP program over 12 months. It was hypothesized that PwPD would be compliant with the protocol and that high
intensity exercise would have a positive impact on disease progression.
Number of Subjects: Forty-nine (n=30 males) mild to moderate PwPD from five diverse community fitness facilities
Materials and Methods: Pragmatic studies evaluate the effectiveness of an intervention under the typical conditions that
it will be or is intended to be applied. Motor and non-motor performance was evaluated at enrollment, 6, and 12
months. In the interim, participants attended PFP classes in their local gym, supervised by a group fitness instructor.
Exercise performance variables (cadence and HR) were continuously monitored and recorded for all participants for
each exercise session.
Results: Participants completed 69.1±29.4 out of 130 available sessions during the 12-month period (53.%). Average
pedaling cadence was 74.1±9.6 rpms while average percentage of HR max was 68.9±12.0%. There were no significant
differences between cycling adherence or intensity variables based on disease severity, age, or sex.
MDS-UPDRS III scores improved from 35[29, 45] to 33[25.8, 39] from enrollment to 6-month follow up (p=0.003).
Results from other motor tests (6MWT and an upper extremity manual dexterity test), cognitive tests (processing
speed and visual memory), and the Neuro-QoL were not statistically different from enrollment to 6-months. The
COVID-19 pandemic prevented collection of data at the 12-month time point.
Conclusions: Attendance and intensity data support the feasibility of translating an effective laboratory exercise
protocol for PwPD to a community setting. The lack of motor and non-motor symptom progression over the 6-month
observational period provides initial evidence that a community-based intervention may have disease altering
Clinical Relevance: The development of effective community-based exercise programs for PwPD can provide a
supportive and effective exercise environment that complements individualized physical therapy services. High-
intensity aerobic exercise continues to hold promise as a disease-modifying intervention for PwPD.
TITLE: Steps Don’t Tell the Whole Story: Walking Intensity Matters in Parkinson Disease
CURRENT SUB-CATEGORY: Degenerative Diseases SIG
AUTHORS: Jaimie Girnis, James Terrence Cavanaugh, Tamara Rork DeAngelis, Ryan Duncan, Martha J Hessler,
Michael Lawrence, Timothy Nordahl, Kerri S. Rawson, PhD, Jenna Zajac, Gammon M. Earhart, Theresa D. Ellis
Purpose/Hypothesis: Parkinson disease (PD) is a neurodegenerative disorder characterized by motor and non-motor
symptoms that contribute to decreased levels of walking activity.1 Decline in walking activity has been suggested to
precede worsening of disability and subsequently reduce community participation.2-4 Although daily step count is a
common target of health promotion intervention, steps alone do not convey information about natural walking
intensity. Public health guidelines suggest that adults should regularly engage in moderate to vigorous physical activity
and previous studies have proposed that walking at higher intensities may produce greater health benefits.5,6
Unfortunately, little is known about natural daily walking intensity in PD. The purpose of this study, therefore, was to
describe the extent to which persons with PD naturally walk at various intensities in their customary environments.
Number of Subjects: 69
Materials and Methods: This was a secondary, cross-sectional analysis of baseline walking activity data collected from
persons with idiopathic PD participating in a multi-center randomized controlled trial.7 Participants wore a StepWatch
Activity Monitor for 7 consecutive days. Mean daily values for the number of (1) steps taken and (2) minutes of
walking at various levels of intensity were calculated for each participant. The level of walking intensity occurring
during each active minute was categorized according to the number of steps it contained (i.e., 1-19, 20-39, 40-59, 60-
79, 80-99, or >100 steps). Descriptive statistics were used to characterize sample demographics, disease severity,
walking capacity (10 Meter Walk Test; 6 Minute Walk Test), daily steps, and daily walking intensity.
Results: The sample had a mean age of 67.9±8.6 years, was 55.1% male, and included individuals with mild to
moderate PD (Hoehn and Yahr 2: n=28; 2.5: n=31; 3: n=10). Most participants (73.9%) were not employed. Walking
capacity was relatively high (self-selected walking speed = 1.12±0.2 m/s; 6 Minute Walk distance = 437.7±99.3 m) and
many participants were relatively active (7739.9±3715.7 steps/day). Most active minutes of walking were spent at lower
intensity levels (149.9±65.1 min of 1-19 steps; 75.1±36.7 min of 20-39 steps; 34.4±21.5 min of 40-59 steps; 13.9±10.5
min of 60-79 steps; 7.1±7.1 min of 80-99 steps; 6.7±8.9 min of 100+ steps).
Conclusions: Despite relatively mild disease severity, high walking capacity, and being somewhat active, participants
tended to spend very few minutes each day walking at higher intensities. These findings highlighted an apparent
disconnect between walking amount, capacity, and intensity in people with PD.
Clinical Relevance: Although useful, clinical measures of daily step counts and walking capacity may not accurately
indicate the intensity of real-world walking activity. Given the importance of routine moderate to vigorous physical
activity, measures of and targets for real-world walking intensity are needed to advance the physical therapy
management of persons with PD.
TITLE: Immediate Effects of Forced Exercise Cycling on a Core Outcomes in Individuals with Parkinson’s Disease
CURRENT SUB-CATEGORY: Degenerative Diseases SIG
AUTHORS: Daniel Miner, Greg Crotser, Joseph Charles Joyce, Madison Noel, Jane Everett
Purpose/Hypothesis: Motor fluctuation due to wearing off of carbidopa/levodopa therapy in people with Parkinson’s
Disease (PwPD) is associated with a “change from mobility to disability,” due to worsening of rest tremor,
bradykinesia, rigidity, and increased difficulty with mobility and balance. Treatment of motor fluctuations is focused on
pharmacologic therapy. Evidence is lacking for non-pharmacologic management of motor fluctuations; however,
recent evidence suggests forced exercise cycling (FEC) may improve the motor symptoms of PD to a similar degree as
dopaminergic therapy. The purpose of this study was to examine immediate effects of a single bout of FEC on
performance on core outcomes in PwPD. It was hypothesized that performance on core outcomes would improve
immediately following FEC regardless of “ON-OFF” medication status.
Number of Subjects: 4 males, 4 females; Age 73.1±5.9 years; Years Since PD Diagnosis 6.6±3.2; Hoehn & Yahr
2.5±0.5; “ON” medication (n= 3), “OFF” medication (n=5)
Materials and Methods: Baseline Testing: Unified Parkinson’s Disease Rating Scale- Motor Score (UPDRS-III), 9
Hole Peg Test (9HPT), miniBESTest (MBT), 10m Walk Test (10mWT)- self-selected speed and fast speed.
Intervention: 48 hours later, subjects completed a single FEC session (30 min. (active-assisted cycling at 80 rpm) with a
5 min. warmup/cooldown at 50 rpm) on a Motomed Viva2 Parkinson cycle. Heart rate (HR) and Borg Rating of
Perceived Exertion (RPE) were monitored throughout. Post-test: All outcome measures above assessed immediately
following FEC intervention. Time of day and time from last dose of levodopa/carbidopa was kept consistent for
baseline and post-test to control for differences in performance attributable to medication effects. Dependent t-tests
analyzed differences in baseline vs post-test for all outcomes, Cohen’s d for effect size was calculated. Independent T-
Tests evaluated differences in performance based on “ON” vs “OFF” medication status. Statistical analyses completed
with IBM SPSS, version 27.
Results: FE Cycling: RPEmax= 13.9±1.2; %HRmax= 60.4±4.3%. Significant improvements (t ≥ 1.895) were observed in the
following outcomes: UPDRS-III (t= 11.8, p= 0.000, d= 5.1); UPDRS-Bradykinesia (t= 11.4, p=0.000, d= 1.5); UPDRS-
Tremor (t= 5.287, p= 0.001, d= 2.9); UPDRS-Rigidity (t= 11.906, p= 0.000, d= 1.1); MBT-Total (t= 5.494, p= 0.001,
d= 2.2); MBT-Dynamic Gait (t= 7.202, p= 0.000, d= 0.84); 9HPT-dominant hand ( t= 3.311, p= 0.007, d= 4.0); and
10mWT-Fast (t= 2.382, p= 0.025, d= 0.2). Cohens d value of ≥0.8 was interpreted as a large effect size.
Conclusions: A single bout of FEC resulted in immediate improvements in motor symptoms of PD (bradykinesia,
rigidity, and tremor) and performance across multiple balance systems, dynamic gait, fast walking speed, and upper
extremity coordination. No significant differences were observed based on “ON” vs “OFF” medication status.
Clinical Relevance: Regardless of medication status, PwPD demonstrate immediate improvements in performance on
core outcomes across multiple domains of function following FEC intervention. FEC may be a powerful adjunctive
therapy for management of motor symptoms/fluctuations affecting PwPD.
TITLE: Does ZIP Code Influence Daily Steps in Individuals with Parkinson Disease?
CURRENT SUB-CATEGORY: Degenerative Diseases SIG
AUTHORS: Kristen Koch, Norah Sweeney, James Terrence Cavanaugh, Tamara Rork DeAngelis, Ryan Patrick
Duncan, Jaimie Girnis, Martha Hessler, PhD, Mary Beth A. Holmes, Timothy Jon Nordahl, Kerri S. Rawson, PhD,
Jenna Zajac, Gammon M. Earhart, Theresa D. Ellis
Purpose/Hypothesis: Despite the known benefits of physical activity (PA) in the management of Parkinson Disease
(PD),1 many do not meet recommended PA guidelines.2 Prior research has explored the relationship between PA and
various ICF-Model domains in PD;2 however, there is a paucity of research evaluating the relationship between PA and
the environmental factor domain. In other populations, evidence suggests that environmental factors influence PA.3-6
The purpose of this study was to examine the relationship between PA and the environmental factors of neighborhood
socioeconomic disadvantage and walkability in persons with PD. We hypothesized lower neighborhood deprivation
and higher walkability would have a positive correlation with daily steps in PD.
Number of Subjects: n=68
Materials and Methods: This was a cross-sectional analysis of baseline data from a multi-center randomized controlled
trial.7 To measure PA, participants wore a StepWatch Activity MonitorTM for seven consecutive days. Mean values were
calculated for daily steps. Walk Score®(WS) was used to measure neighborhood walkability. The scale (0-100, 0=Car
Dependent, 100=Walker’s Paradise) is based on proximity to amenities, population density, intersection density, and
block length. Area Deprivation Index (ADI) was used to measure neighborhood socioeconomic disadvantage. This
scale (0-100, 0=Low Deprivation, 100=High Deprivation) ranks census blocks based on domains of income,
employment, housing quality and education. WS and ADI were obtained from participant zip codes. Descriptive
statistics were used to characterize baseline WS, ADI, and daily steps. Assumptions of normality were met and
Pearson correlation coefficients were used to examine bivariate relationships between (1) WS and daily steps and (2)
ADI and daily steps (α = 0.05).
Results: Participants (n=68) had a mean age of 66.69 ± 8.02 years with mild to moderate PD (Hoehn and Yahr: 2:
n=30; 2.5 n=27 ; 3 n=11). Participants had an average of 7,818.77 ± 3,634.74 daily steps. Participants’ environments
were relatively car dependent (WS: mean (SD)=30.68 ± 31.51; range= 0-96) and socioeconomically advantaged (ADI:
mean (SD) 31.87 ± 23.64); range=1-99). No significant correlations were found between participants’ daily steps and
WS (r=.224, p=.066) or daily steps and ADI (r=-.173, p=.157).
Conclusions: In this sample, WS and ADI were not related to daily steps in persons with PD. This may be due to the
characteristics of the sample which was highly educated and predominantly white with a low ADI. It is possible that
participants were not reliant on neighborhood walking to achieve daily steps. Future studies should examine the impact
of the environment on PA in a more diverse sample with a wider variety of neighborhood deprivation and walkability.
Clinical Relevance: Neighborhood walkability and socioeconomic status are potentially important considerations for
physical activity health promotion in people with PD. Environmental factors may play a role for some individuals and
should be considered when developing an individualized plan of care.
TITLE: Self-Report Measures of Fatigue in MS: Recommendations Following Systematic Review of Psychometrics
and Usability
CURRENT SUB-CATEGORY: Degenerative Diseases SIG
AUTHORS: Kirsten A. Potter, Nora Elizabeth Fritz, Patricia Noritake Matsuda, Diane Dameron Allen, Amy M.
Yorke, Gail L. Widener, Evan T. Cohen
Purpose/Hypothesis: Fatigue is a common, debilitating impairment in multiple sclerosis (MS). Clinicians rely on
individuals' self-report to assess their experience of fatigue and its impact. However, choosing appropriate standardized
self-report measures of fatigue in MS can be challenging. The Academy of Neurologic Physical Therapy appointed the
MS Outcome Measures Task Force to systematically review fatigue measures and provide recommendations. The
purpose of this report is to document the psychometrics and usability of fatigue measures tested in people with MS
using a modified COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) rating
Number of Subjects: NA
Materials and Methods: PubMed, CINAHL, and Embase databases were searched through January 2020 using search
terms related to fatigue and MS. Studies were included if they reported on a self-report fatigue measure in at least 30
people with MS and included information on reliability, content validity, responsiveness, interpretability, or
generalizability of the measure. Data were extracted by two independent reviewers; discrepancies remaining after
discussion were resolved by a third reviewer. Risk of bias and quality were appraised within the relevant COSMIN
sections. Usability was assessed based on information retrieved for each measure.
Results: 45 studies met eligibility criteria, with information on 17 fatigue measures used in people with MS. Data were
available for all psychometric properties of interest for five measures: Fatigue Impact Scale (FIS), Fatigue Severity
Scale, Modified Fatigue Impact Scale (MFIS), Neurological Fatigue Index for MS, and Unidimensional-FIS. Final
recommendations were based on positive and complete information, plus positive usability factors.
Conclusions: Few fatigue measures have evidence across all COSMIN items. Additional research on promising
measures is needed. Based on the literature available to date, the Task Force recommends the MFIS for both research
and clinical practice due to psychometrics, ease-of-use, and inclusion of physical, cognitive, and psychosocial domains
of fatigue.
Clinical Relevance: Many self-report measures of fatigue exist, yet data are lacking to support the use of many
measures. The MFIS is an in-depth yet clinically feasible measure of fatigue that provides a comprehensive view of the
impact of the patient’s fatigue. Total MFIS and subscale scores (physical, cognitive, and psychosocial) can be
computed to assist with treatment planning, including making appropriate referrals to other health care professionals.
TITLE: Step Activity and Fall Risk Assessment in Persons with Parkinson’s Disease
CURRENT SUB-CATEGORY: Degenerative Diseases SIG
AUTHORS: Savannah Henry, Amethyst DeNeal, Crystal Renee Ramsey, Srikant Vallabhajosula
Purpose/Hypothesis: Step activity has been shown to be a predictor of falls in community dwelling older adults.1
However, there is limited research on step activity and fall prediction for persons with Parkinson’s disease (PD). The
risk of a person with PD falling is 45-68% according to prospective studies with a repeat fall occurring 50-86% of the
time.2 The purpose of this study was to determine the associations between step activity, fall history, and functional
outcomes with fall risk in persons with PD.
Number of Subjects: 18 persons with PD, mean age of 71.4 (9.1) years. The average UPDRS score was 38.6 (15.4).
Materials and Methods: Subjects were divided into fallers (7) and non-fallers (11) by self-reported falls in the past year.
The Step Activity Monitor was worn by subjects for 7 days. Self-selected backward and forward gait speed were
measured using the Zeno Walkway. Falls Efficacy Scale-International (FES-I) survey assessed fear of falling. Clinical
balance was evaluated with the miniBESTest. An independent samples t-test comparing the step activity between the
groups and Pearson correlations for associations between clinical assessments were performed.
Results: Step activity was similar between both groups (Non-fallers=4246.1 steps, Fallers=3334.03 steps, p=.424). FES-I
had a strong negative correlation (r=-.720, p=.001) with step activity. MiniBESTest had a moderate positive correlation
(r=.545, p=.019) with step activity. Forward gait speed had a moderate positive correlation (r=.660, p=.003) with step
activity. Backward gait speed had a strong positive correlation (r=.760, p
TITLE: Overground Locomotor Training in Parkinson’s Disease: Effects on Walking Distance, Perceived Fatigability,
and V̇O2 on-Kinetics
AUTHORS: Andrew Eric Pechstein, Jared M. Gollie, Randall E. Keyser, Kerry B. Rosen, Lobna S. Elsarafy, R. Jamil
Pugh, Emily M. Leonard, Andrew A. Guccione
Walking endurance is compromised in individuals with Parkinson’s disease (PD).1 Although the pathophysiology of
PD affects both gait quality and autonomic function,1,2 evidence of the mutability of walking endurance in response to
task-specific locomotor training performed exclusively overground in people with PD is currently limited as
cardiorespiratory factors have been addressed less frequently in this population.3,4 The primary objectives of this study
were to examine the effects of overground locomotor training5 (OLT) on walking endurance in individuals with mild-
to-moderate PD, and to further explore the understudied potential functional impacts of cardiorespiratory
impairments that may impede individuals with PD during sustained walking.2
Number of Subjects:
Twelve subjects with PD (7 male, 5 female); Hoehn and Yahr stage 1-3; age 68.5±6.4 years).
Materials and Methods: Pre- and post-test design. Subjects underwent 24 bi-weekly OLT sessions. During each
session, training volume was recorded using a step tracker worn on the ankle and training intensity was monitored
using a chest-strap heart rate (HR) monitor. Walking endurance was measured as total distance walked (m) during a
ten-minute walk test (10MWT). Perceived fatigability was assessed after the 10MWT using a seven-point self-report
scale. Walking economy (V̇O2·kg-1·m-1) was calculated by dividing oxygen consumption (V̇O2) by walking velocity.6 V̇O2
on-kinetics profiles were determined by fitting a mono-exponential function to V̇O2 data during the first 6 minutes of
the 10MWT.7 Cohen’s d(unbiased) effect sizes were calculated for all pre-to-post outcomes.
The average OLT session featured 3036±297 steps completed in 56.9±2.5 minutes. Average intensity of OLT sessions
were performed at 65.5%±8% age predicted HR-maximum. Training volume increased over the 24 sessions of OLT
by approximately 25 steps per session on average, while training intensity remained stable. Moderate effects for total
distance walked (Cohen’s d(unbiased) = 0.54) and phase-II time-constant of the V̇O2 on-kinetic profile (Cohen’s d(unbiased) =
0.54) were observed following OLT. Subjects’ perceptual response to walking remained relatively unchanged after
training (Cohen’s d(unbiased) = 0.11). Small effects were observed for walking economy following OLT (Cohen’s d(unbiased) =
These findings provide preliminary data supporting the potential for improved walking endurance and faster
cardiorespiratory adjustments to walking activity following OLT. Smaller magnitude changes in walking economy were
found, but the interpretation of the physiological impact of this change requires additional investigation.
Clinical Relevance: The co-occurrence of increased step volume per session as well as increased walking distance and
a faster phase-II time-constant in response to OLT suggests improved fitness in our subjects that enabled individuals
with mild-to-moderate PD to perform a greater amount of work for the same level of perceived fatigability following
the OLT used in this study.
TITLE: Locomotor Training Using Adaptive Robotics in Adults with Spinal Cord Injury: Preliminary Feasibility and
AUTHORS: Louis Anthony DeMark, Jessica Dunn, Meghan Kettles, Hannah Snyder, Gina Brunetti, Kathryn L.
Cavka, Christy L. Conroy, Clayton Wauneka, Bob McIver, Geneva Tonuzi, Emily Jane Fox
Background and Purpose:
Locomotor training (LT) is an established rehabilitation approach that emphasizes repetitive practice and appropriate
kinematics to improve walking in individuals with spinal cord injuries (SCIs). Physical assistance is often provided but
can be costly or difficult to deliver. Robotic devices are an alternative approach but often lack natural movement
variations and promote passivity and reliance on the device. The Hybrid Assistive Limb (HAL) is a novel robotic
device used during treadmill (TM) walking that provides ‘as-needed’ assistance. The device adjusts assistance levels
based on surface electromyogram activity from lower limb muscles. The safety and feasibility of intense LT with the
HAL are not established and are critical to determine if randomized clinical trials and adoption of this technology are
warranted. The purpose of this case series is to describe preliminary outcomes and feasibility of LT using the HAL in
adults with SCI.
Case Description:
Five adults with incomplete SCI, >1 year post injury (4 male; 41.6 ± 18.4 years; 12.6 ± 18.9 years post-SCI; 4 cervical
and 1 thoracic; 4 AIS D) completed 60 sessions (5x/week for 12 weeks) of LT that included 30 minutes of TM
walking at approximately 70-80 %HRmax with HAL followed by 10 minutes of overground walking without HAL.
Daily monitoring of skin integrity, pain, spasticity and other adverse responses was conducted. For each session
outcome measures included step count, max TM speed, rating of perceived exertion (RPE; scale 6-20), and
overground walking distances. Walking function was assessed pre and post training using the 10-Meter Walk Test
(10MWT) and the 6-Minute Walk Test (6MWT).
All participants completed the 60-session protocol with no adverse responses. The group’s average outcomes per
session included: 1814 steps, 1.1mph TM speed, 582ft overground distance, 17 RPE, and 68.2 %HRmax. The group’s
average walking speed and endurance improved by 0.10 ± 0.30m/s and 31.8 ± 63.21m, respectively. Three participants
demonstrated clinically important differences in both speed (>0.06m/s) and distance (22% change). A 4th participant
displayed decreased walking speed (-0.34m/s) and endurance (-59.4m). The 5th participant achieved the fewest steps,
TM speed, %HRmax, but highest RPE per session.
Outcomes in five participants suggest use of the HAL device to deliver intense LT is safe and feasible. The training
protocol was completed without adverse responses and walking outcomes exceeded clinically important cut-offs in
three of five individuals. The two individuals who did not demonstrate speed and endurance gains had vastly different
presentations. The 4th participant had a more severe injury and moderate spasticity which limited his ability to stand
and walk. The 5th individual had a pre-training walking speed of 1.15m/s and throughout training, adjusted her gait
pattern to be more symmetrical and less compensated. These changes in walking pattern appeared to decrease her
10MWT and 6MWT outcomes. Overall, the HAL device may be a useful method to deliver intense LT.
TITLE: Trunk Strength Is Associated with Maximal Respiratory Pressure Generation in Individuals with Spinal Cord
AUTHORS: Gina Brunetti, Kelly Ann Hawkins, Kathryn L. Cavka, Hannah Snyder, Tinuade Olarewaju, Emily Jane
Purpose/Hypothesis: Trunk motor function contributes to sitting and respiratory function. Spinal cord injury (SCI)
disrupts descending neural inputs to trunk muscles. Therefore, trunk assessment and recovery of trunk function is a
common rehabilitation goal after SCI. Despite its importance, rehabilitation to promote respiratory recovery after SCI
is inconsistent and respiratory impairment remains a leading cause of illness and rehospitalization. Since trunk strength
and respiratory function rely on trunk motor output, measures of trunk and respiratory function may be associated and
understanding of this relationship may inform clinical practice and advance insights into SCI impairments. Thus, the
purpose of this study was to test the hypothesis that trunk strength is positively associated with respiratory function in
adults with SCI.
Number of Subjects: Eight individuals with chronic incomplete SCI participated (47.3 ± 18.6 age in years; male=6;
11.1±13.8 years post-SCI; C1-T7 AIS C/D; cervical=7). All participants demonstrated respiratory impairment at
baseline assessment (8/8 with MEP 24-88% of age and sex matched normative values; 5/8 with MIP 54-77%).
Materials and Methods: Seated trunk strength was assessed with hand-held dynamometry to quantify isometric force
generation in the anterior and posterior directions. Respiratory function was assessed with standard assessments:
maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), forced vital capacity (FVC) and forced
expiratory volume in one second (FEV1). Spearman correlation coefficients were calculated to assess the strength of
association between the trunk and respiratory outcomes.
Results: There was a strong positive correlation between posterior trunk strength and maximal pressure generation
(MEP: rho=.762, p=.028; MIP: rho=.714, p=.047) and a strong positive correlation between anterior trunk strength
and MEP (rho=.905, p=.002). The relationships between trunk strength and forced spirometry outcomes were not
significant (FVC and FEV1: rho≤0.15, p≥0.7).
Conclusions: Outcomes suggest that isometric seated trunk strength in the anterior and posterior directions is
associated with respiratory strength based on maximal pressure generation, which is performed against an occluded
airway. While forced spirometry measures require maximal inhalation and expiration, these maneuvers are not
resisted (occluded) which may explain why outcomes are not associated with trunk muscle strength. These outcomes
suggest that seated trunk strength may be indicative of respiratory function.
Clinical Relevance: Since respiratory impairment remains a leading cause of illness after SCI, greater focus is needed
to identify deficits and provide effective treatments. Seated trunk strength measures may provide insight into
respiratory deficits and suggest the need for more specific respiratory assessment and treatment. Given that assessment
of trunk function is a common aspect of SCI rehabilitation, understanding the relationship between these assessments
and respiratory function may promote greater awareness and development of respiratory recovery strategies.
TITLE: Relationships Among Environmental Variables, Balance Self-Efficacy, and Real-World Walking Activity Post-
AUTHORS: Allison Elizabeth Miller, Ryan T. Pohlig, Darcy Schwartz Reisman
Purpose/Hypothesis: The social and physical environment affect real-world walking activity in individuals with stroke.
However, environmental variables are often difficult or impossible to modify in clinical practice. Examining the
potential mechanisms by which the environment affects real-world walking may help clinicians understand
opportunities for intervention to overcome environmental barriers. Therefore, the purpose of this study was to
investigate the potential mechanisms by which the social and physical environment influence real-world walking activity
in individuals with stroke. Based on prior work, we hypothesized that balance self-efficacy would mediate the
relationship between the social and physical environment and real-world walking activity. If this were the case, this
would suggest that targeting balance self-efficacy may be an effective approach to overcoming environmental barriers in
individuals with stroke.
Number of Subjects: n = 283 individuals with chronic (≥6 months) stroke, mean age 63.5 years (SD 12.6), 146 males
Materials and Methods: Individuals completed an evaluation that included measures of balance self-efficacy (Activities
Specific Balance Confidence Scale, ABC), social environment (living situation and work status), and physical
environment (Area Deprivation Index (ADI), Walk Score, and residential density). Real-world walking activity was
measured using a commercially available step activity monitor. In our analysis, the social environment was a latent
construct measured using work status and living situation, and the physical environment was a latent construct
measured using ADI, Walk Score, and residential density. Balance self-efficacy (ABC) was the mediator. Structural
equation modeling was used to test our hypothesis.
Results: Analysis revealed that balance self-efficacy does not mediate the relationship between the environment and
real-world walking (physical environment: indirect effect = -0.02, p=0.36, direct effect = -0.06, p = 0.37; social
environment: indirect effect = -0.05, p=0.12, direct effect = -0.04, p = 0.70).
Conclusions: Balance self-efficacy does not mediate the relationship between the social and physical environment and
real-world walking activity in our sample of stroke survivors. This suggests that targeting solely balance self-efficacy may
not be an effective approach for overcoming environmental barriers to walking activity after stroke. Future work
should consider alternative models to understand potential approaches to overcoming environmental barriers to
improve real-world walking activity in individuals with stroke.
Clinical Relevance: The results of this study help clinicians understand if we can target balance self-efficacy to
overcome environmental barriers in individuals with chronic stroke.
TITLE: Development and Results of a Successful Implementation Plan for High-Intensity Gait Training
AUTHORS: Jennifer Lynn Moore, Elisabeth Bø, Anne Spendrup Erichsen, Ingvild Kristina Hurum Rosseland,
Joakim Moestue Halvorsen, Hanne Bratlie, T. George George Hornby, Jan Egil Nordvik
Purpose/Hypothesis: High-intensity gait training (HIT) is a recommended intervention for individuals with stroke who
are undergoing gait rehabilitation. Research indicates that effectively implementing interventions into clinical practice is
a challenge. This presentation will describe an overview of the development of an implementation plan for HIT,
present implementation results, and identify the impact of implementing this intervention on clinicians and the health
Number of Subjects: Two inpatient rehabilitation facilities, including nine physical therapists, collaborated with a
knowledge translation center to implement this program. Clinical and fidelity data were collected during stroke
rehabilitation usual care (n=56) and after implementation of HIT (n=54).
Materials and Methods: We developed an implementation plan using the Knowledge-to-Action Framework. The
Consolidated Framework for Implementation Research was used to identify barriers and select implementation
strategies. Using mix-methods research, including surveys and informal discussions, we evaluated current practice,
barriers, outcomes, and the sustainability of high-intensity gait training in practice. Fidelity measures included stepping
amounts, peak heart rate, and time in the target heart rate zone.
Results: A multi-component implementation plan with 26 implementation strategies to target barriers was developed.
Clinicians reported that usual care interventions to improve walking included a combination of balance, strength
training, and gait interventions. Barriers to using HIT in routine practice included knowledge, beliefs, HIT
adaptability, resources, and culture. Surveys and informal discussions identified significant changes in perceived
practice, HIT adoption, and positive impacts on the health system. Following implementation, the average steps/day
(5777±2784) was significantly greater than during usual care (3917±2656, p
TITLE: Paretic Limb Gait Propulsion Does Not Contribute to Perceived Quality of Life in Chronic Stroke
AUTHORS: David Matthew Rowland, Michael David Lewek
Purpose/Hypothesis: Gait performance (speed and endurance) is related to quality of life following stroke. The
biomechanical mechanisms underlying gait dysfunction post-stroke may reveal a suitable target to enhance perceived
quality of life. Given the known relationship between paretic limb propulsion (i.e., anteriorly directed ground reaction
forces during late stance) and gait performance, we hypothesized that greater paretic limb propulsion would be
associated with higher quality of life measures. Additionally, we hypothesized that increase in paretic limb propulsion
following gait training would be related to increase in quality of life.
Number of Subjects: 40 subjects with chronic stroke (>6 months), gait speed < 1.0 m/s, and evidence of spatiotemporal
gait asymmetry.
Materials and Methods: Using an RCT design, participants completed 18 gait training sessions in one of three motor
learning groups for spatiotemporal gait asymmetry: error augmentation, error minimization, or conventional gait
training. We analyzed all groups together given our lack of differences between groups in prior analyses. Quality of life
measures (Stroke Impact Scale [SIS] domains reflective of gait performance) were collected one week before and after
training. Propulsive peaks and integrals were measured during treadmill walking during the first and last session. Cross-
sectional (pre; N = 40) and longitudinal analyses (pre and post; N=31) were performed using Pearson and Spearman
correlations. We assessed for potential relationships between propulsive measures (peak, impulse, and side to side
ratios), gait performance (speed, endurance), and quality of life.
Results: In the cross-sectional analysis, we observed significant correlations between all paretic limb propulsion metrics
and gait performance measures (all r≥.533, p
TITLE: Stroke Upper and Lower Extremity Physical Function Patient-Reported Outcome Measures Were Reliable,
Valid, and Efficient
AUTHORS: Daniel Deutscher, Deanna Hayes, Michael Kallen, Mark William Werneke, Carole A. Tucker, Jerome
E Mioduski, Theresa M. Toczylowski, Jessica Petitti, Karon F. Cook
Calibrate newly developed items to create independent item banks for Stroke-Upper and Stroke-Lower Extremity
Physical Function (S-UEPF; S-LEPF) patient-reported outcome measures (PROMs). Assess the newly developed
PROMs for reliability, validity, and efficiency using computerized adaptive test (CAT) and short form (SF)
administration modes.
Number of Subjects:
Two retrospective cohorts of stroke survivors treated in outpatient rehabilitation clinics for the S-UEPF and S-LEPF
included 2017 and 2107 patients aged 14 to 89 years; mean ages (SDs) of the cohorts were 62 (14) and 63 (14),
Materials and Methods:
Each cohort responded to a set of candidate items at intake that addressed tasks related to upper (28 items) or lower
(25 items) extremity function. Item response theory (IRT) model assumptions of local independence,
unidimensionality, item fit, and absence of differential item functioning (DIF) were evaluated. Computed CAT and SF
scores were assessed for each PROM. Known-groups validity was assessed for change scores (intake vs. discharge) for
their ability to discriminate among patient groups by demonstrating expected differing levels of functional change
during the episode of care.
For the S-UEPF and S-LEPF, 28 and 24-item banks were established, respectively: Each item set demonstrated
unidimensionality; individual items fit the employed IRT model. Ten-item SFs were selected per measure based on
clinical content and score-level item information (reliability). Reliability estimates were >0.93 for both measures’ CAT
and SF administration modes. No items demonstrated DIF. Higher scores represented better perceived physical
function. At intake, the S-UEPF and S-LEPF had 1% and 0.3% of scores between 0 and 5 (floor effect); 4.3% and
1.1% were between 95 and 100 (ceiling effect). At discharge, the S-UEPF and S-LEPF had 0.4% and 0% score floor
effects and 12.4% and 3.8% score ceiling effects, respectively. Change-score effect sizes for S-UEPF and S-LEPF were
medium (0.47 and 0.64, respectively). Simulated CAT scores for S-UEPF and S-LEPF were obtained using an average
of 6 and 5.6 items (median=5, range 5-12), respectively. Change scores (intake to discharge) discriminated between
patient groups in clinically logical ways: Greater change (better outcomes) was observed for patients who were younger,
had less chronicity, and had fewer comorbidities, after controlling for intake scores.
The S-UEPF and S-LEPF PROMs were reliable, valid, moderately responsive to change, and efficient, with negligible
floor and acceptable ceiling effects for assessing physical function as perceived by stroke survivors with upper and/or
lower extremity impairments; thus, they are suitable for research and routine clinical administration.
Clinical Relevance:
The newly developed S-UEPF and S-LEPF PROMs provide IRT measurement advantages including improved score
precision and administration efficiency using CAT and SF administration modes. They can be used for research and
clinical care in outpatient rehabilitation settings.
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