Background and Purpose Hemiparesis resulting in functional limitation of an upper extremity is common among stroke survivors. Although existing evidence suggests that increasing intensity of stroke rehabilitation therapy results in better motor recovery, limited evidence is available on the efficacy of virtual reality for stroke rehabilitation. Methods In this pilot, randomized, single-blinded clinical trial with 2 parallel groups involving stroke patients within 2 months, we compared the feasibility, safety, and efficacy of virtual reality using the Nintendo Wii gaming system (VRWii) versus recreational therapy (playing cards, bingo, or “Jenga”) among those receiving standard rehabilitation to evaluate arm motor improvement. The primary feasibility outcome was the total time receiving the intervention. The primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period. Efficacy, a secondary outcome measure, was evaluated with the Wolf Motor Function Test, Box and Block Test, and Stroke Impact Scale at 4 weeks after intervention. Results Overall, 22 of 110 (20%) of screened patients were randomized. The mean age (range) was 61.3 (41 to 83) years. Two participants dropped out after a training session. The interventions were successfully delivered in 9 of 10 participants in the VRWii and 8 of 10 in the recreational therapy arm. The mean total session time was 388 minutes in the recreational therapy group compared with 364 minutes in the VRWii group (P=0.75). There were no serious adverse events in any group. Relative to the recreational therapy group, participants in the VRWii arm had a significant improvement in mean motor function of 7 seconds (Wolf Motor Function Test, 7.4 seconds; 95% CI, −14.5, −0.2) after adjustment for age, baseline functional status (Wolf Motor Function Test), and stroke severity. Conclusions VRWii gaming technology represents a safe, feasible, and potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke.

No abstract

No abstract

Change-in-support strategies, involving stepping or grasping movements of the limbs, are prevalent reactions to instability and appear to play a more important functional role in maintaining upright stance than has generally been appreciated. Contrary to traditional views, change-in-support reactions are not just strategies of last resort, but are often initiated well before the center of mass is near the stability limits of the base of support. Furthermore, it appears that subjects, when given the option, will select these reactions in preference to the fixed-support "hip strategy" that has been purported to be of functional importance. The rapid speed of compensatory change-in-support reactions distinguishes them from "volitional" arm and leg movements. In addition, compensatory stepping reactions often lack the anticipatory control elements that are invariably present in non-compensatory stepping, such as gait initiation. Even when present, these anticipatory adjustments appear to have little functional value during rapid compensatory movements. Lateral destabilization complicates the control of compensatory stepping, a finding that may be particularly relevant to the problem of falls and hip fractures in elderly people. Older adults appear to have problems in controlling lateral stability when stepping to recover balance, even when responding to anteroposterior perturbation. Increased understanding and awareness of change-in-support reactions should lead to development of new diagnostic and therapeutic approaches for detecting and treating specific causes of imbalance and falling in elderly people and in patients with balance impairments.

it is important for clinicians to assess compensatory stepping and reaching, in order to identify individuals who are at risk of falling and to pinpoint specific control problems to target for balance or strength training or other intervention. More effective use of stepping and reaching reactions can be promoted through improved design and appropriate use of sensory aids, mobility aids, footwear, handrails and grab-bars. It is particularly important to address the problems associated with the control of lateral stability because it is the lateral falls that are most likely to result in hip fracture.

IMPORTANCE Gait performance is affected by neurodegeneration in aging and has the potential to be used as a clinical marker for progression from mild cognitive impairment (MCI) to dementia. A dual-task gait test evaluating the cognitive-motor interface may predict dementia progression in older adults with MCI. OBJECTIVE To determine whether a dual-task gait test is associated with incident dementia in MCI. DESIGN, SETTING, AND PARTICIPANTS The Gait and Brain Study is an ongoing prospective cohort study of community-dwelling older adults that enrolled 112 older adults with MCI. Participants were followed up for 6 years, with biannual visits including neurologic, cognitive, and gait assessments. Data were collected from July 2007 to March 2016. MAIN OUTCOMES AND MEASURES Incident all-cause dementia was the main outcome measure, and single-and dual-task gait velocity and dual-task gait costs were the independent variables. A neuropsychological test battery was used to assess cognition. Gait velocity was recorded under single-task and 3 separate dual-task conditions using an electronic walkway. Dual-task gait cost was defined as the percentage change between single-and dual-task gait velocities: ([single-task gait velocity-dual-task gait velocity]/ single-task gait velocity) × 100. Cox proportional hazard models were used to estimate the association between risk of progression to dementia and the independent variables, adjusted for age, sex, education, comorbidities, and cognition. RESULTS Among 112 study participants with MCI, mean (SD) age was 76.6 (6.9) years, 55 were women (49.1%), and 27 progressed to dementia (24.1%), with an incidence rate of 121 per 1000 person-years. Slow single-task gait velocity (<0.8 m/second) was not associated with progression to dementia (hazard ratio [HR], 3.41; 95% CI, 0.99-11.71; P = .05) while high dual-task gait cost while counting backward (HR, 3.79; 95% CI, 1.57-9.15; P = .003) and naming animals (HR, 2.41; 95% CI, 1.04-5.59; P = .04) were associated with dementia progression (incidence rate, 155 per 1000 person-years). The models remained robust after adjusting by baseline cognition except for dual-task gait cost when dichotomized. CONCLUSIONS AND RELEVANCE Dual-task gait is associated with progression to dementia in patients with MCI. Dual-task gait testing is easy to administer and may be used by clinicians to decide further biomarker testing, preventive strategies, and follow-up planning in patients with MCI.

No abstract

423ences reflect a systematic bias against women and/or personal preferences on the part of individual faculty that align themselves by gender? Academic internal medicine needs to consider these results and scrutinize institutional and departmental policies towards women physicians. Women faculty, likewise, need to evaluate their careers and their priorities among different potential professional activities.