Functioning, the most important outcome of stroke interventions, is complex to characterize. Stroke survivors measure functioning compared to what they did in their prestroke lives; hence equating functioning with recovery. To optimize the recovery of functioning, research suggests that rehabilitation interventions should start early post-stroke. To quantify changes in function owing to different interventions, the average value on an index comprised of multiple items related to function is compared or the proportions of people categorized into different functional levels are compared. Currently, there is no agreed upon method of quantifying improvements in functioning and using multiple indices is problematic. This thesis examined combining a method of quantifying behaviours, Rasch analysis that produces measures with interval properties from ordinal observations, with the component of the International Classification of Functioning (ICF), to conceptualize, define, and quantify functioning in a single measure. The ensuing prototype measure was limited in scope. Therefore, using data from a longitudinal prognostic study involving people with acute stroke assessed at three days and followed up at three months, a Functioning measure at three months, the F3m, was developed. The F3m is a valid and reliable measure that amalgamates tests where performance is observed and self-report questionnaires where people rate their difficulties in performing physical activities. The F3m covers all ICF components and can be used to quantify recovery at three months. Interventions to improve early functioning post-stroke must impact favourably on the factors that affect early recovery. The most influential factor related to recovery, to date, has been early functioning. As a measure of such early functioning did not exist, a measure of functioning at three days, the FM, was constructed in a manner similar to the F3m. Univariate and multivariate analyses were then used to identify strong early factors collected 24-72 hours post-stroke, and link the factors to function at 3 months. A seven-variable predictive model of functioning was derived. The most important influential predictor of functioning in the model, the comprehensive FM measure, can now be used to evaluate and develop early interventions to enhance functioning, and to act as a covariate explaining the recovery of functioning.

Background and rationale. Cerebral palsy (CP) is one of the most common disabling disorders of childhood and constitutes a substantial portion of pediatric rehabilitation. This condition demands comprehensive rehabilitation using age-appropriate tasks and activities and encompassing aspects of body function and structure, activity and participation, and personal and environmental factors. Yet little is known regarding actual occupational therapy (OT) and physical therapy (PT) practices. / Objective. The primary objective of this doctoral thesis was to describe OT and PT practices for young children with CP in the Province of Quebec, Canada. / Methods. This was a cross-sectional, multi-centered survey. All eligible and consenting pediatric occupational therapists (OTs) and physical therapists (PTs) were interviewed using a structured telephone interview based on vignettes of two typical children with CP at two age points---18 months and 4 years. Reported practices were grouped according to the International Classification of Functioning, Disability, and Health (ICF). Literature review of pediatric assessments and interventions potentially used for CP was done to determine their level of evidence of effectiveness. In addition, two expert groups provided, for each vignette, a best practice problem identification list and a best practice intervention list. / Results. A total of 62 PTs (83.8% participation rate) and 85 OTs (91.4% participation rate) participated in the study. Overall, 91.9% of PTs and 67.1% of OTs reported using at least one standardized pediatric assessment for at least one vignette. OT and PT interventions focused primarily on impairments and primary function, with less attention to interventions related to play and recreation/leisure. Clinicians reported the need for more training and education specific to CP and to the use of research findings in clinical practice. Wide variations and gaps were identified in therapists' responses suggesting the need for a basic standard of PT and OT management as well as strategies to encourage knowledge dissemination regarding current best practice. Further, implementation of evidence-based practice necessitates more collaboration between researchers, clinicians and administrators.

Approximately one percent of the population in North America suffers from burns every year. However, information concerning the long-term functional recovery of burn survivors remains limited. Therefore, the main objective of this study was to examine the effects of burns on quadriceps muscle endurance and fatigue recovery by comparing healed major burn survivors with healthy matched individuals. Muscle endurance was measured by the number of intermittent submaximal isometric contractions completed during two standard fatigue protocols (SFPs). Recovery from fatigue was monitored for 10 minutes using the interpolated twitch technique. Parameters that were collected at baseline and post SFPs included maximum voluntary contraction (MVC) force, muscle activation level, twitch tension (Pt), compound muscle action potential (M-wave) amplitude, and activity of agonist (vastus medialis)/antagonist(biceps femoris) muscles. Results revealed a lower endurance level in major burn survivors than in matched individuals. The differential detrimental effects of fatigue on Pt and MVC force indicated excitation-contraction uncoupling as the major underlying cause of fatigue in both groups. In addition, neuromuscular propagation impairment, decreased muscle membrane excitability and increased antagonist activity may contribute to the decrease in force generating capacity in major burn survivors. Further research is needed to examine the residual physical limitations from major burn injuries and their effects on quality of life.

A series of studies were conducted to investigate differences in voluntary and evoked contractile properties of trained, untrained and previously immobilized ankle fracture subjects before and following fatigue. Measurements included twitch contractile properties, maximal voluntary contractions (MVC), electromyography (EMG) and muscle activation (interpolated twitch (IT) ratio and second order polynomials). Although second order polynomials were found to be a more precise measurement of muscle activation ($ sim$6% error) than the IT ratio (superimposed evoked torque/potentiated resting evoked torque), both techniques provided a general estimate of muscle activation before and following fatigue. Prior to fatigue, trained plantarflexor subjects exerted greater force (17.5%) and had significantly less antagonist activity (41.3%) than untrained subjects. Following fatigue, untrained subjects experienced greater deficits in excitation-contraction coupling and increased antagonist activity (58%) contributing to their tendency for increased fatiguability. The lower force output (45.8%) and muscle activation (20.4%) of previously immobilized non-fixated ankle fractures did not result in greater fatiguability than controls. Disuse adaptations such as potentiation of the muscle action potentials and twitch torque helped to maintain the fatiguing contractions. However the more severely fractured ankles of the internally-fixated subjects experienced increased agonist (13%) and antagonist (8.5%) EMG activity and similar changes in muscle activation and evoked contractile properties while performing fewer contractions. This would suggest that injuries of greater severity may result in an intrinsically more fatiguable muscle. To determine whether the findings could be generalized to other muscles and fatigue protocols, various contraction intensities were used to elicit short and long duration fatiguing contractions in the plantarflexors and quadriceps. Muscle activation, and t

This study aimed to determine whether the use of body weight (BWS) during overground ambulation leads to immediate improvements in the gait pattern. of stroke clients, and whether an overground support system is feasible for use as a gait training tool in this population. Fourteen subjects 3 to 18 weeks post stroke and with ambulatory capacity but mobility problem (timed-up-and-go score > 25 s) participated in the study. Subjects were instructed to walk over a distance of 7 m with 0% (full weight bearing), 15% or 30% BWS provided by an overhead suspension system. Ground reaction forces, body kinematics and temporal distance factors were recorded. Subjects demonstrated significant improvements in force generation during both the loading and push off phase of gait (p < 0.001) with increasing support. There were also significant improvements in trunk postural control as well as a decrease in cycle duration and total double support time. The results indicate that providing partial BWS during overground walking allows for the expression of an improved walking pattern in stroke clients. The system was well tolerated by all subjects during testing and indicates therefore that this system is feasible for use in retraining walking in stoke clients.

Non-synostotic occipital plagiocephaly (NSOP) is a term commonly used to describe asymmetry of the infant skull arising in the perinatal period. There is preliminary evidence in the literature suggesting that infants with NSOP may exhibit a motor delay. However, confirmation of this delay, as well as elucidation of the factors that may contribute to this delay have never been empirically determined using standard measures of motor performance. / The objective of this study was to compare motor skill acquisition of infants with NSOP to a matched group of normal healthy children. The results indicated that infants with NSOP are more likely to be delayed in the acquisition of early motor skills when compared to typically developing infants. This delay appears to be associated with a lack of exposure to the prone position while awake. Findings suggest that clinicians should assess the possibility of motor delays when evaluating these children.

The global objectives of this project were to refine and validate the content, and to obtain preliminary estimates of reliability for the STroke REhabilitation Assessment of Movement (STREAM). Two consensus panels, involving a total of twenty physical therapists, produced an intermediate test version of STREAM. Based on initial evaluations of internal consistency and reliability, items that were redundant, unrelated, and/or not reliably scored were eliminated. The final STREAM, with enhanced content validity, is made up of thirty items evaluating limb movements and basic mobility. Two reliability studies were conducted: (1) a direct observation of twenty stroke patients by pairs of raters in the clinical setting, and (2) two repeated ratings by twenty raters using videotaped assessments of four stroke patients. The STREAM demonstrated excellent internal consistency, inter- and intra-rater reliability, and is now ready for preliminary use in the clinical setting. The favorable results of this study indicate that further testing of the psychometric properties of the STREAM is warranted.

Idiopathic Parkinson's disease (IPD) is a severely disabling neurodegenerative disorder. The akinesia symptom dramatically alters the lifestyle of individuals with IPD. A within-subjects design was used to study the effects of sensory stimulation on akinesia. Twelve male, non-institutionalized parkinsonian subjects were tested. All demonstrated akinesia and were right-handed. Reaction time and movement time measures were recorded on an Apple 2e computer. The task entailed reached from a release switch to a target switch while three sensory stimuli (visual, auditory and concurrent visual and auditory) were used randomly during three different environmental conditions (open, physical constraint and stress). It was found that the concurrent use of visual and auditory stimuli in an open environmental condition significantly decreased the movement times and total reaction times. Therefore the use of sensory stimulation improves a reaching movement in subjects with IPD. The use of such stimuli would alter the person's disabilities and improve their functional status.

The purpose of the present study was to identify the muscle and kinematic parameters associated with the emergence of a skilled organization of landing from a jump in boys 7 years to 13 years of age. Jumps were videotaped (60Hz) in the right sagittal plane. The digitized coordinates of six landmarks were used to calculate the angular position, velocity, and acceleration parameters for the hip, knee, and ankle joints. Surface EMG signals were recorded for six muscles (Tibialis Anterior, Lateral Gastrocnemius, Soleus, Vastus Lateralis, Rectus Femoris, Biceps Femoris) to obtain the pattern of muscle onsets in anticipation for landing and the modulation of the muscle activity during the impact phase. / Subjects could be classified into three distinct groups based on the pattern of muscle onsets: the Proximal-distal group (PDS), the Transitional group (TS), and the Adult group (AS). The classification reflected a progression from a proximal-distal (PDS) to a distal-proximal (AS) organization of landing. At the muscular level, the progression was associated with: (1) an increased contribution of the ankle to the anticipatory control of landing; and (2) the modulation of muscle activity to reduce the impact ground reaction forces. The strongest kinematic correlates were associated with the increased ability: (1) to manage and organize motion-dependent torques; (2) to critically modulate the joint position in anticipation of landing, and (3) to utilize anticipatory muscle activity rather than biomechanical joint limits to manage the impact ground reaction forces.

The gait pattern during treadmill walking is comparable with overground walking in healthy subjects, but the effects due to the mode of walking in stroke subjects have not been established. Purpose. (1) To compare the maximum gait speed of stroke subjects walking on treadmill vs. the ground. (2) To estimate the temporal-distance determinants of the maximal gait speed. (3) To compare temporal distance factors and body kinematics of stroke subjects walking at comfortable vs. maximum speeds during the two modes of locomotion. Subjects. Ten subjects (aged 63 +/- 19 years) with a hemiparesis due to a stroke (<3 months) were tested. Methods. Subjects walked at comfortable and maximal speeds on the treadmill and overground, and gait outcomes were thus compared. Results. Overground walking resulted in higher maximal speeds, greater stride lengths and a lower cadence, as compared to treadmill. The comfortable gait speed and the maximum stride length proved to be strong determinants for the maximal speed on both modes of locomotion, but the maximum cadence was correlated to maximum speed only overground. At matched speed, the hip and knee joint demonstrated greater excursion overground for both the paretic and nonparetic sides. Conclusions. Stroke subjects walked slower on the treadmill as compared to overground. Furthermore, a different strategy was implemented to increase gait speed on each surface. A guarded gait pattern was evident in the lower extremity kinematic patterns during treadmill ambulation, perhaps due to muscle weakness, reduced stability and fear of falling on the treadmill.