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Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke.

INTRODUCTION

The process by which neuronal circuits are modified by experience, learning, or injury is referred to as neuroplasticity [1]. Knowledge of this process has greatly expanded in recent years, with important implications for rehabilitation. Both the brain and body need to relearn how to function following neurological injury, and harnessing this inherent ability for neuronal circuit change in the brain may be essential to maximize the benefit of rehabilitation. Motor-learning research in nondisabled subjects and subjects with neurological compromise has suggested that high numbers of repetitions (reps) of task-specific activity may be required to promote neuroplastic change. Animal studies in neuroplasticity have shown that 400 to 600 reps per day of a challenging functional task (fine-motor grasping) can lead to structural neurological changes following an induced stroke to the hand area in nonhuman primates

[2-4]. In nondisabled humans, repeated practice of specific thumb movements can alter the transcranial magnetic stimulation evoked responses toward the trained direction [5]. This change required 15 to 30 minutes of continuous effort of one movement and extinguished after approximately 20 to 30 minutes. After stroke, increased amounts of task repetition have been shown to cause cortical changes and functional improvement [6-8]. As a specific example, in Carey et al., subjects with impaired grasp-and-release secondary to stroke performed more than 100 reps per day (1,200 total) of a finger-tracking exercise and demonstrated significant cortical reorganization and functional improvement compared with control subjects [6]. In the lower limb (LL), gait evidence in animal models suggests that approximately 1,000 to 2,000 steps per session are required to improve hind-limb stepping and step quality [9-11].

While task repetition is not the only important feature, it is becoming clear that neuroplastic change and functional improvement occur after large numbers of a specific task are performed but do not occur with fewer numbers [12-13]. Thus, one item of focus for rehabilitation professionals should be the number of reps and type of activity performed. However, very little research is available that quantifies the amount and type of movement practice that occurs during a clinical rehabilitation session [14-16]. In a pilot study [16] and a larger multi-center study across North America [17], practice of task-specific functional upper-limb (UL) movement occurred in only 51 percent of sessions that addressed the UL and the average number of reps per session was 32. The average number of gait steps performed per session was 357. These findings are an order of magnitude lower than the number of reps documented in neuroplasticity research.

As with stroke, patients with traumatic brain injury (TBI) also require cortical reorganization to overcome neurological damage. Occupational and physical therapy settings are experiencing increasing numbers of patients with TBI on their caseloads because of advances in medical technology that allow more people to survive brain injury. According to Rutland-Brown et al., of the approximately 1.57 million Americans who sustained TBI in 2003, 97 percent survived [18]. TBI is also noted as the "signature injury" of Operation Iraqi Freedom and Operation Enduring Freedom. More than 12,000 members of the armed forces reported TBI from March 2003 to March 2007 [19], thereby increasing the prevalence of TBI in the United States and the number of patients requiring rehabilitation. Limited research describes and quantifies the rehabilitation of patients with this diagnosis.

Patients with TBI have been shown to have positive rehabilitation outcomes as a result of high numbers of functional reps, such as is required in constraint-induced movement therapy (CIMT) [20]. Patients with TBI who received additional functional reps (+160 reps of sit-to-stand and step-ups) had a larger functional improvement compared with a group who did not receive the additional reps, suggesting that the dose of rehabilitation is also important in TBI [21]. No studies to date have documented the number of reps typically performed by patients with TBI during a clinical therapy session. Similarly, the extent to which patient diagnosis or therapist characteristics affect number of reps performed by patients is unknown.

The purposes of this study were to quantify the number and type of activities performed by patients with TBI and stroke in physical and occupational therapy sessions to determine whether (1) the number of reps approaches the numbers in neuroplasticity research, (2) there were differences based on patient diagnosis, and (3) patient or therapist characteristics affected the type or amount of activities. This comparison between diagnoses allows insight into whether this limited repetition number is unique to stroke or whether it occurs in another major diagnostic category as well.

METHODS

Subjects

This observational study was conducted at two metropolitan-area hospital settings: an acute hospital and a long-term acute rehabilitation facility. Both the rehabilitation providers and patients were considered subjects and both diagnoses were seen at each facility. The rehabilitation providers were referred to as "provider subjects" and the patients were referred to as "patient subjects." Provider subjects were included in the study if they were a licensed physical therapist (n = 17), physical therapist assistant (n = 7), occupational therapist (n = 13), or certified occupational therapist assistant (n = 3). A total of 50 provider subjects consented, 40 of whom (3 male, 37 female) were observed. Provider subjects were divided into five groups based on their years of neurorehabilitation experience: <1 year (n = 3), 1 to <5 years (n = 13), 5 to <10 years (n = 7), 10 to <15 years (n = 6), and >15 years (n = 11).

A total of 48 patient subjects (29 male, 19 female) participated in the study. All patient subjects were referred for physical or occupational therapy. Patients with unilateral or bilateral paresis due to stroke or TBI met inclusion criteria. Patient subjects were excluded if they or a family member could not provide informed consent or if the functional level of the patient prevented any active limb movement. Patient subjects were then divided into two groups based on diagnosis. There were 24 patient subjects in the TBI group and 24 patient subjects in the stroke group.

The stroke group in this study was part of a larger multicenter study, and observers were trained to correctly classify each therapy exercise through written materials and videos that were developed for use in the pilot study by Lang et al. [16]. Each observer was then tested for reliability, requiring a score of at least 90 percent in order to collect study data. Previous use of this method resulted in an interrater reliability intraclass correlation coefficient of 0.99 (p < 0.001). The observer obtained the data by recording each repetition within a therapy session and placing the count in its designated category. Observers positioned themselves so they did not interfere with the therapy session yet could still hear and see what took place. Observers had no direct contact with the subjects during the treatment sessions but could approach the therapist after the session in order to clarify the purpose of an activity to ensure correct classification and documentation. The same observation procedure was used during all observations, regardless of patient subject diagnosis.

Three trained observers conducted a total of 107 observations (53 stroke, 54 TBI; range, mean age [+ or -] standard deviation [SD] = stroke: 31-88 yr, 64 [+ or -] 16 yr, TBI: 19-90 yr, 49 [+ or -] 20.5 yr) over 9 months at both facilities. Each patient subject was allowed to be observed for a maximum of three therapy sessions. Observations occurred during the patient subject's regularly scheduled occupational or physical therapy sessions, which addressed motor impairments related to the patient's diagnosis (not evaluations or discharge planning). Initial contact with the patient subject was made through the patient's primary therapist (provider subject). After initial contact was made, the observer explained the study to the patient subject and obtained informed consent before the observation. Neither the patient subjects nor the provider subjects knew that number of reps was being counted. Provider and patient subjects were told that the observers were "recording what happened during a therapy session."

Categories

Data were collected by the counting of reps of a particular activity according to the following categories: UL, LL, and mobility. The UL and LL categories were further divided into the following subcategories: (1) active exercise, (2) passive exercise, (3) sensory, and (4) functional activity. Mobility was divided into the following subcategories: gait, transfers, stairs, wheelchair mobility, and balance (see Table 1 for complete description and examples; also see Lang et al. [17]). If during an instructed task more than one type of activity was performed, then each was counted, such as might occur when a patient performs a balance task that incorporates a UL functional movement. In addition, a repetition was counted if a clear attempt was made at the task; the task did not have to be completed in its entirety. We also documented duration of therapy session, patient diagnosis, side affected, age, and sex (Table 2). Each patient subject's Functional Independence Measure (FIM) score [22] on admission was documented when available. However, the entire FIM was not completed in the majority of cases and therefore could not be used in any statistical analysis. Thus, scores on FIM items were used but mean values for the total FIM score could not be calculated for each group. Range and mean of the documented FIM locomotor scores are reported in Table 2 to provide an example of locomotor skills at the baseline. Provider subject information was collected and included age, sex, years of experience, years of neurological rehabilitation experience, and degree earned. Of the 107 session observations, 6 were conducted by providers in the <1-year group, 40 by the 1 to <5-year group, 20 by the 5 to <10-year group, 13 by the 10 to <15-year group, and 28 by the >15-year group.

Data Reduction

Sessions that contained no entries in a given category or subcategory were eliminated from that category or subcategory for analyses. For example, if no UL exercises in any subcategory (active, passive, sensory, or functional) were instructed within a therapy session, we assumed that UL function was not the focus of the session and, thus, should not be included in the statistical comparison. Thus, different n values (observed sessions) are assigned for some subcategories (Tables 2-4). Additionally, if <10 percent of the observed sessions contained a particular subcategory of intervention, this subcategory was eliminated from the comparison between groups. This was the case for sensory, passive exercise, and wheelchair mobility. These data are reported in the results tables but were not compared between groups because of the very low observed frequency. Though data were collected from providers with four different licenses, the distribution of categories did not allow for comparisons between licensure. This is because, in the investigated settings, occupational therapy tended to focus more on UL issues and physical therapy more on LL. Thus, we pooled all provider subjects into one group.

Statistical Analysis

Data were assessed for normality. We used two metrics to examine the amounts of practice. First, we compared the number of reps per session between groups in each category and subcategory. We also computed and compared the reps per minute by dividing the total reps by the therapy time for each session. This second metric controlled for differences in total therapy time across patients and groups. For comparisons between the stroke and TBI groups, either parametric two-tailed t-tests or Mann-Whitney U independent two-tailed t-tests were conducted, as appropriate. Because of nonnormal distribution, Kruskal-Wallis one-way analysis of variance was applied to compare therapist years of experience and number of reps. For all data, an alpha level of 0.05 was used and results are presented as mean [+ or -] SD unless otherwise indicated. Lastly, correlation and regression analyses were used to determine whether any relationships existed between the number of reps performed and specific patient demographics and characteristics (e.g., age, FIM UL item scores, FIM locomotor score, time since onset) in each of the categories and subcategories.

RESULTS

Overview of Data from Both Groups

Pooling the data from both groups, the average total number of UL reps across all four subcategories (active exercise, passive exercise, sensory, and functional activity) in those sessions that included UL rehabilitation (n = 55) was 50.56 [+ or -] 44.11. The average total number of reps for each of the subcategories was 18.34 [+ or -] 31.43 for UL functional activity, 21.89 [+ or -] 37.48 for UL active exercise, 8.62 [+ or -] 23.84 for UL passive exercise, and 1.64 [+ or -] 6.92 for UL sensory. With both groups pooled, the average total number of LL reps across all four subcategories in those sessions that included LL rehabilitation (n = 52) was 61.04 [+ or -] 102.75. The average total number of reps for the subcategories was 0.25 [+ or -] 0.95 for LL functional activity, 59.08 [+ or -] 103.58 for LL active exercise, 1.42 [+ or -] 3.28 for LL passive exercise, and 0.29 [+ or -] 1.16 for LE sensory. The average number of gait reps in those sessions that included gait (n = 58) was 249.28 [+ or -] 254.47. Therapy sessions lasted on average 29.11 [+ or -] 12.14 minutes.

Comparison between TBI and Stroke Groups

Upper and Lower Limbs

Tables 3 and 4 provide the number of reps per session and the number of reps per minute for each UL and LL category and subcategory. No differences in reps per session were found between groups (p-values > 0.05) for any of the UL and LL categories and subcategories. In comparisons of reps per minute, the TBI group had more total UL reps per minute than the stroke group (p < 0.05). No other differences in reps per minute were found.

Mobility

Numbers of reps per session and per minute for the mobility categories are provided in Table 5. When examining the mobility categories with the reps per session metric, we found no differences between groups (p-values > 0.05). When examining the mobility categories with the reps per minute metric, we found that reps per minute were higher in the TBI group than the stroke group for the gait steps and transfers categories (p-values < 0.05).

Patient Characteristics

To examine the effects of patient age and functional status on the number of reps per session, correlation and regression analyses were performed for each category. Correlation coefficients ranged from -0.0019 to 0.0256 (p-values > 0.05). The regression model indicated that patient factors predicted little variance in the number of reps performed ([R.sup.2] = 0.06,p > 0.05).

Therapist Experience

A statistically significant difference was found for years of neurorehabilitation experience of therapists for two comparisons (p = 0.02). Therapists in the 5 to <10-year and 10 to <15-year groups instructed patients in significantly more functional reps per minute than did therapists in the <1-year group (z = 1.96 and z = 3.00). Therapists in the 10 to <15-year group also instructed patients in significantly more functional reps per minute than did therapists in the >15-year group (z = 2.22) (Figure). No differences were found in the other categories and subcategories assessed.

DISCUSSION

Results of this study demonstrate that in the observed rehabilitation sessions, the number of reps performed per session (e.g., between 40-60 reps for all UL categories) did not approach that which neuroplasticity research has suggested is required for cortical reorganization. Though no specific amount has been established, the evidence across animal and human literature suggests that the number is in the hundreds for the UL [23] and in the thousands for gait steps [10]. Ours is the first report on this issue in patients with TBI, and our finding is consistent with results found in a multicenter study in subjects with stroke [17].

We also evaluated reps per minute to account for any differences in total treatment time and for differences in how a therapist may choose to distribute the activities performed in a given therapy session. When evaluated in this manner, the TBI group performed more total UL reps per minute, gait steps per minute, and transfers per minute than the stroke group. The variability in reps was quite high within groups, which may have accounted for different conclusions from the reps per session versus reps per minute data. Since observation often influences behavior, the number of reps counted here may overestimate "typical" rehabilitation if provider and patient subjects were hoping to favorably impress the observer.

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Is repetition a valid measure of practice? Though not fully understood, the number of reps appears to be an important issue for functional improvement and cortical reorganization [24]. We posit that comparison of reps across types of injury in the same species (humans), such as was done here, is reasonable. While the direct translation of exact numbers across species may not be valid, the translation of general estimates probably is valid. Our rationale is that (1) the relative contributions of various motor system structures, such as the rubrospinal tract [25], differ in humans compared with monkeys and rats (see also Nudo and Masterton for data [26] and Lang et al. for review [27]) and (2) monkey and rat models are not exact replications of the human experience of stroke and TBI. Thus, one could conclude that while the animal models indicate that large numbers of reps may be required, they do not specify what exactly those numbers need to be.

Other issues are also likely to be important, such as the effort required to perform a task and how meaningful the task is to the patient. This study did not attempt to answer these less measurable issues but did attempt to control for the issue of severity of motor impairment by counting a partial performance of a movement as a repetition. One interesting finding in our results and in the multisite study with stroke patients [17] was that motor function, as measured by FIM scores, was not related to reps. Thus, the clinical perception that people who are more severely affected do fewer reps was not supported. This finding may mean that the observed therapists were skilled at grading the activities to the capabilities of each patient. In a study specifically addressing the issue of simple repetitive movement versus repetitive movement requiring more active cognitive processing, two groups with stroke performed a finger-tracking task that was either an "easy" highly repetitive task or a "difficult" repetitive task that required visuospatial processing and motor learning [12]. Contrary to the authors' hypothesis, both groups improved on the functional tests. In fact, the group that performed the easy task had greater improvement on one of the functional tests. The authors speculated that the lack of advantage of the more difficult training was due to the "higher number of reps" performed by the group completing the easy task. Both groups trained for the same amount of time and at the same range of motion, but the group with the easy training was able to self-pace and performed at a statistically higher frequency of movement and, thus, performed a higher number of reps than the group with the difficult motor-learning task [12].

In the current study, no difference was found between groups when they were evaluated with the reps per session metric. This metric of amount is the most appropriate for comparison to the neuroplasticity research previously discussed. We did find, however, several differences between groups when they were evaluated with the reps per minute metric. While the design of the study did not allow specific investigation of the reasons for these differences between groups, several factors may have contributed, such as cognitive, behavioral, or age-related issues. Although no correlation was found between patient age and number of reps performed, generally, patients with TBI tend to be younger males and patients with stroke tend to be older. Patients with stroke are more likely to have comorbidities, such as concurrent vascular disease, that may affect their ability to perform the same number of reps or to perform at the same pace as TBI patients without vascular disease. Alternatively, therapists may be less likely to challenge older patients to the same degree as younger patients with similar levels of impairment.

Years of experience in the area of neurological rehabilitation significantly affected the amount of practice received. Providers with 5 to <15 years of experience instructed their patients in significantly more functional activities than did those with <1 year of experience. Providers with 10 to <15 years of experience instructed patients in significantly more functional reps than did providers with >15 years of experience. The differences in reps between providers suggest that those with less experience may have less confidence in how to best facilitate neuroplastic change through functional motor tasks or may lack the experience or "bag of tricks" needed to creatively facilitate the task in a functional way. With less experience, one may feel less comfortable challenging a patient to perform more reps or perform a more complex or cognitively challenging motor task. A new therapist may also have difficulty modifying traditional motor tasks to make them more functional yet still achievable by patients with limited abilities. Perhaps the more experienced therapists were able to devise exercises that addressed two components, such as a balance activity with a functional UL movement, which would increase the number of reps a given patient performed. Therapists with >15 years of experience in neurological rehabilitation may have been educated under a different model in which use of functional tasks during therapy was not emphasized.

The question in many clinicians' minds may be, Is it feasible to perform a high number of reps? Evidence that this can be successfully employed exists in CIMT literature (for a review, see Wolf et al. [28]) and in 1-hour therapy sessions in a recent cohort of people with chronic stroke [29]. Specific to TBI, Canning et al. documented the effects of additional therapeutic reps on functional performance [21]. The researchers required the experimental group to perform an average of 87 additional sit-to-stand reps and 42 additional step-up exercises per day compared with the standard-care control group. A 62 percent improvement in motor performance was reported in all 12 subjects in the experimental group compared with an 18 percent improvement in the control group (p = 0.05). These results demonstrate that increasing the number of reps during therapy sessions results in desirable outcomes. When specific treatment goals are used within each session, a much higher number of reps per session can be accomplished [29]. Indeed, other tools or models of therapy may need to be considered rather than the traditional one-on-one interaction. Group or robot-assisted therapies are areas currently under investigation that may support the goal of increased numbers of reps (for a review, see Kwakkel et al. [30]). Activities emphasizing changes to both the neuroplastic mechanism and the muscle must be considered for optimal effectiveness. Historically, strength training and range-of-motion exercises have been the focus of rehabilitation. For a deconditioned patient, increasing strength is an important goal; however, it has been shown in subjects with stroke that a significant increase in strength does not necessarily result in improved functional performance [31] or cortical change as measured by functional magnetic resonance imaging [32]. Physical and occupational therapists may need to reexamine the goal of therapy sessions to determine how to best facilitate muscle strengthening with motor learning, planning, and control.

Given the preliminary and observational nature of this study, results cannot be necessarily interpreted as representing the population at large. However, in the preliminary work by Lang et al., the results of a single site of observation [16] were supported by the larger international study [17], indicating that consistencies exist in rehabilitation practice regardless of region or setting. Another study limitation includes the lack of information regarding the functional status of each patient subject. Other than FIM score, which has been shown to be an insensitive predictor [33], functional status information is not typically collected during rehabilitation sessions and, thus, reflects a limitation of our rehabilitation system. In addition, this study documented the types and number of reps performed but did not address many other issues that may affect functional improvement, such as "quality" versus "quantity" of movement, duration, types of feedback or cues given, and the cognitive demand of the task. Nevertheless, our study presents a starting point for a more in-depth investigation into other critical issues, such as ideal therapy dose.

CONCLUSIONS

This study shows that in the rehabilitation of patients after TBI and stroke, (1) considerably fewer total reps are performed in any category compared with what neuroplasticity research suggests is required for neuroplastic change, (2) slight differences in reps per minute occur based on patient diagnosis, and (3) emphasis on reps of functional activity varies based on therapist experience. These findings are important for researchers in the field of neuroplasticity to consider in the general framework from which therapy is being provided and within the confines of the current clinical setting. In addition, rehabilitation professionals must examine other models of service delivery to find creative solutions for achieving more practice. These models may include group therapy, circuit training [34], or alterations in daily therapy schedules to allow longer sessions each day. If sessions are organized so as to maximize reps, the patient may be more likely to rebuild necessary cortical pathways through neuroplasticity and achieve greater functional improvement.

Abbreviations: CIMT = constraint-induced movement therapy, FIM = Functional Independence Measure, LL = lower limb, reps = repetitions, SD = standard deviation, TBI = traumatic brain injury, UL = upper limb.

JRRD at a Glance

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Rehabilitation, including repetitions of physical exercise, helps patients regain skills lost because of damage to the brain. Research suggests that hundreds of repetitions are needed for the brain to make new "connections." Our study reported how many repetitions of exercises are being done in rehabilitation sessions with patients who have had a stroke or traumatic brain injury. Results showed that the average number of repetitions being performed is less than what research suggests is needed to reorganize the brain and depends on the patient's diagnosis or the therapist's years of experience. This information invites discussion about how rehabilitation may need to be altered to maximize brain changes.

ACKNOWLEDGMENTS

Author Contributions:

Study concept and design: T. J. Kimberley, C. E. Lang.

Acquisition of data: S. Samargia, L. G. Moore, J. K. Shakya.

Analysis and interpretation of data: T. J. Kimberley, S. Samargia, L. G. Moore, J. K. Shakya, C. E. Lang.

Drafting of manuscript: T. J. Kimberley.

Critical revision of manuscript for important intellectual content: T. J. Kimberley, S. Samargia, L. G. Moore, J. K. Shakya, C. E. Lang. Statistical analysis: S. Samargia, L. G. Moore, J. K. Shakya, T. J. Kimberley.

Study supervision: T. J. Kimberley.

Financial Disclosures: The authors have declared that no competing interests exist. Parts of this work were presented at the Combined Sections Meeting of the American Physical Therapy Association, February 2009, Las Vegas, Nevada.

Funding/Support: This material was unfunded at the time of manuscript preparation. Salary support for Dr. Lang was provided by the National Institutes of Health (grant HD047669).

Additional Contributions: We would like to thank Amy Kieffer, PT; Carol McKenzie, OT; and Tricia Nichols, MS, PT, for their valuable assistance.

Institutional Review: This study was approved by the University of Minnesota Internal Review Board and the Health East Internal Review Board. All subjects gave informed written consent according to the Declaration of Helsinki.

Participant Follow-Up: The authors do not plan to inform participants of the publication of this study because contact information is unavailable.

Submitted for publication February 25, 2010. Accepted in revised form July 6, 2010.

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Teresa Jacobson Kimberley, PhD, PT; (1-2) * Sharyl Samargia, MA, CCC-SLP; (2) Lisa G. Moore, DPT; (1) Josefin K. Shakya, DPT; (1) Catherine E. Lang, PhD, PT (3)

(1) Program in Physical Therapy, Department of Physical Medicine and Rehabilitation, and (2) Program in Rehabilitation Science, University of Minnesota, Minneapolis, MN; (3) Program in Physical Therapy, Program in Occupational Therapy, Department of Neurology, Washington University, St. Louis, MO

* Address all correspondence to Teresa Jacobson Kimberley, PhD, PT; University of Minnesota, MMC 388, 420 Church St SE, Minneapolis, MN 55455; 612-626-4096.

Email: tjk@umn.edu

DOI: 10.1682/JRRD.2010.02.0019
Table 1. Description of activity within each subcategory.

Subcategory                              Description

Passive Exercise        Any joint movement that is done by therapist
                        or outside source without active participation
                        of patient. Examples include but are not
                        limited to stretching of wrist and finger
                        flexors, stretching of ankle muscles, and
                        passive shoulder range of motion.

Active Exercise         Any movement in which patient partially or
                        completely engages in moving limb from resting
                        position, through specific movement, and back
                        to resting position. Examples include but are
                        not limited to raising arm out in front and
                        returning it to side, flexing and extending
                        elbow, bending knee and hip up to chest and
                        then straightening out leg, adducting and
                        abducting leg, and flexing ankle.

Functional Activity     Any movement that produces end result or
                        contributes to productivity. Examples include
                        but are not limited to reaching or grasping
                        for target object and activities of daily
                        living, such as dressing, bathing, tooth
                        brushing, and cooking. Many of these tasks
                        were broken down into subunits for counting
                        purposes. (Although gait and stairs are
                        considered purposeful activities in clinical
                        setting, they were counted separately for
                        purposes of this study.)

Sensory                 Any activity that involves providing patient
                        stimulation for sensation or proprioception.
                        Examples include but are not limited to
                        vibratory stimulation to muscle.

Gait                    Ambulation with or without assistive device.
                        Recorded in episodes and individual steps
                        within each episode. If patient rested for >20
                        seconds, new episode was recorded.

Transfers               Any movement by patient from one place to
                        another or change in position. Examples
                        include but are not limited to sit to stand,
                        stand to sit, mat to chair, supine to sit,
                        chair to toilet, and stand to kneel. Transfers
                        were only counted if they were specifically
                        instructed by therapist.

Balance                 Any task instructed by therapist to maintain
                        balance. Examples include but are not limited
                        to standing or sitting with and without
                        assistance. One episode of balance was counted
                        for each balance task presented.

Wheelchair Propulsion   Any activity that requires patient to navigate
                        wheelchair independently. Recorded in episodes
                        and repetitions within that episode counted as
                        number of arm movements needed to propel
                        wheelchair. If patient rested for >20 seconds,
                        new episode was recorded.

Stairs                  Any activity that requires patient to navigate
                        single step-up or flight of stairs. Recorded
                        in episodes and individual stair steps within
                        each episode. If patient rested for >20
                        seconds, new episode was recorded.

Table 2. Demographics for stroke and traumatic brain injury (TBI)
patients.

Demographic                                        Stroke

Age, Mean [+ or -] SD (years)               63.00 [+ or -] 19.38

Duration Between Injury & Session (days)
  Range                                             5-300
  Mean 42                                  (3 outliers >100 days)

Side Affected (%)
  Right                                              42
  Left                                               50
  Bilateral                                           4
  Not Specified in Medical Chart                     --

Sex (%)
  Male                                               54
  Female                                             46

FIM Locomotor Score
  % Reported                                         50
  Range                                              1-7
  Mean                                              2.91

Demographic                                          TBI

Age, Mean [+ or -] SD (years)               51.34 [+ or -] 19.32

Duration Between Injury & Session (days)
  Range                                             10-86
  Mean 42                                            40

Side Affected (%)
  Right                                              12
  Left                                               16
  Bilateral                                          38
  Not Specified in Medical Chart                     29

Sex (%)
  Male                                               66
  Female                                             33

FIM Locomotor Score
  % Reported                                         80
  Range                                              1-5
  Mean                                              2.55

FIM = Functional Independence Measure, SD = standard deviation.

Table 3. Upper limb: Average total task repetitions (Reps) performed
each rehabilitation session and each minute by traumatic brain injury
(TBI) and stroke patients.

                                  TBI (n = 27)

                    Mean Reps/
Task                 Session        SD         95% CI

Active Exercise       26.44       46.40     8.09 to 44.80
Passive Exercise      11.93       32.10      0 to 24.63
Functional            22.33       33.92     8.91 to 35.75
Sensory                 0           0             0
Total                 60.85       52.47    40.10 to 81.61

                    Mean Reps/
                       Min

Active Exercise        1.29        2.55     0.28 to 2.29
Passive Exercise       0.60        1.81       0 to 1.31
Functional             1.00        1.44     0.42 to 1.57
Sensory                 0           0             0
Total *                2.88        2.83     1.76 to 4.00

                              Stroke (n = 28)

                    Mean Reps/
Task                 Session        SD         95% CI

Active Exercise       17.50       26.38     7.27 to 27.73
Passive Exercise       5.43       11.07     1.13 to 9.72
Functional            14.50       28.93     3.28 to 25.71
Sensory                3.21        9.52       0 to 6.90
Total                 40.64       32.14    28.18 to 53.10

                    Mean Reps/
                       Min

Active Exercise        0.52        0.90     0.17 to 0.87
Passive Exercise       0.19        0.42     2.82 to 0.36
Functional             0.43        0.95     5.98 to 0.80
Sensory                6.87        0.22       0 to 0.15
Total *                1.21        1.19     0.75 to 1.67

* Significant difference between groups (p < 0.05).

CI = confidence interval, n = number of observation sessions in which
these subcategories were included, SD = standard deviation.

Table 4. Lower limb: Average total task repetitions (Reps) performed
each rehabilitation session and each minute by traumatic brain injury
(TBI) and stroke patients.

                                TBI (n = 28)

                    Mean Reps/
Task                 Session        SD          95% CI

Active Exercise       77.79       132.50    26.41 to 129.64
Passive Exercise       1.46         3.13     0.25 to 2.68
Functional             0.14         0.52        0 to 0.35
Sensory                0.21         0.83        0 to 0.54
Total                 79.61       131.58    28.58 to 130.63

                    Mean Reps/
                       Min

Active Exercise        3.24        5.37      1.16 to 5.32
Passive Exercise       5.49        0.12      8.65 to 0.10
Functional             6.74        2.49         0 to 1.64
Sensory                8.04        2.97         0 to 0.02
Total                  3.31        5.34      1.24 to 5.38

                              Stroke (n = 24)

                    Mean Reps/
Task                 Session        SD          95% CI

Active Exercise       37.25        47.52    17.18 to 57.32
Passive Exercise       1.38        3.51         0 to 2.86
Functional             0.38        1.28         0 to 0.92
Sensory                0.38        1.47         0 to 1.00
Total                 39.39        46.63    19.69 to 59.65

                    Mean Reps/
                       Min

Active Exercise        0.99        1.50      0.31 to 1.62
Passive Exercise       4.87        0.14         0 to 0.11
Functional             1.34        0.05         0 to 3.44
Sensory                9.76        3.57         0 to 0.02
Total                  1.06        1.47      0.44 to 1.69

CI = confidence interval, n = number of observation sessions in which
these subcategories were included, SD = standard deviation.

Table 5. Mobility: Average total task repetitions (Reps) performed
each rehabilitation session and each minute by traumatic brain injury
(TBI) and stroke patients.

                                      TBI

Task             n      Mean Reps/       SD            95% CI
                         Session

Gait Steps       28       317.93       330.26     180.86 to 445.99
Transfers        31         9.32        15.02       3.81 to 14.83
Balance          23        46.70        64.62      18.75 to 74.64
Stairs            4        28.75        22.08            0
Wheelchair        0         0            0               0

                        Mean Reps/
                           Min

Gait Steps *     28       13.13        14.08       7.66 to 18.59
Transfers *      31        0.39         0.54       0.19 to 0.59
Balance          23        1.88         2.37       0.86 to 2.91
Stairs            4        1.21         0.79          0 to 2.48
Wheelchair        0         0            0               0

                                     Stroke

Task             n      Mean Reps/       SD            95% CI
                         Session

Gait Steps       30       185.20        130.1      136.63 to 233.77
Transfers        43         7.81         6.10      594.00 to 9.70
Balance          27        23.07        25.91       12.82 to 33.32
Stairs            9        37.60        33.04       13.97 to 61.23
Wheelchair        6       139.33       191.42           0 to 340.21

                        Mean Reps/
                           Min

Gait Steps *     30        4.97         3.50         3.67 to 6.28
Transfers *      43        0.22         0.14         0.18 to 0.26
Balance          27        0.67         0.85         0.35 to 1.03
Stairs            9        0.74         0.62         0.30 to 1.19
Wheelchair        6        2.91         3.65            0 to 6.74

* Significant difference between groups (p < 0.05).

CI = confidence interval, n = number of observation sessions in which
these subcategories were included, SD = standard deviation.
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Author:Kimberley, Teresa Jacobson; Samargia, Sharyl; Moore, Lisa G.; Shakya, Josefin K.; Lang, Catherine E.
Publication:Journal of Rehabilitation Research & Development
Article Type:Report
Geographic Code:1USA
Date:Dec 1, 2010
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