Assistive devices for balance and mobility: Benefits, demands, and adverse consequences

External cues benefit walking ability of ambulatory patients with spinal cord injury

BACKGROUND/OBJECTIVES

Sensorimotor dysfunction following spinal cord injury (SCI) reduces ability of the patients to perceive information and control movements. They may need alternative sources of input to optimize their walking ability. This study investigated effects of external cues on walking ability in 33 independent ambulatory participants with SCI.

METHODS

Participants' walking ability was cross-sectionally assessed under three conditions including self-determined fastest walking speed (uncued condition), and fastest walking speed with the use of external cues (visual cue and visuotemporal cue conditions). Walking ability was measured in terms of walking speed, stride length, cadence, and percent step symmetry. Findings of the three conditions were compared using the one-way analysis of variance with repeated measures.

RESULTS

When using external cues particularly the visuotemporal cue, participants showed a significant increase in walking speed, stride length, and cadence as compared with those of the uncued condition (P < 0.005). The increment of walking speed was demonstrated even in participants at a chronic stage of injury (post-injury time ≥ 12 months), with severe SCI (American Spinal Injury Association Impairment Scale C), or who required a walking device.

CONCLUSION

The results suggested the benefit of external cues, particularly the visuotemporal cues, as a potential rehabilitation tool to improve walking speed of individuals with SCI.

Ambulation and complications related to assistive devices after spinal cord injury

OBJECTIVE

To evaluate long-term health outcomes including pain intensity, pain interference, and fatigue among ambulatory persons with spinal cord injury (SCI).

DESIGN

Prospective cohort study.

SETTING

Data were analyzed at a major medical university in the southeast USA.

PARTICIPANTS

Participants included 783 ambulatory adults with SCI of traumatic origin, who were at least 1-year post-injury. Participants were identified through three sources of records at a large specialty hospital in the southeastern USA.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Pain intensity and interference (Brief Pain Inventory) and fatigue (Modified Fatigue Impact Scale Abbreviated Version 5).

RESULTS

Examining assistive devices used for ambulation, 66% of the population used at least one device. In the logistic model, wheelchair and cane usage were significantly related to the outcomes after controlling for age, gender, and race. Wheelchair usage 50% of the time or less was significantly related to pain intensity (odds ratio (OR) 2.05, 95% confidence interval (CI) = 1.39-3.03), pain interference (OR 2.11, 95% CI = 1.43-3.12), and fatigue (OR 1.99, 95% CI = 1.12-1.43). Additionally, unilateral cane use was significantly related to the outcomes; pain intensity (OR 1.86, 95% CI = 1.35-2.56), pain interference (OR 2.11, 95% CI = 1.52-2.93), and fatigue (OR 2.49, 95% CI = 1.52-4.08).

CONCLUSIONS

Among ambulatory persons with SCI, increased pain intensity, pain interference, and fatigue are associated with minimal wheelchair usage (50% or less) and less supportive assistive device (unilateral cane) usage.

Ambulatory assistive devices and walking performance in patients with incomplete spinal cord injury

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

To primarily explore types of ambulatory assistive device (AAD) used and secondarily describe walking performance in independent ambulatory patients with spinal cord injury (SCI) who walked without and with various AADs as determined using walking speed and distance walked in 6 min.

SETTING

A tertiary rehabilitation center and community hospitals, Thailand.

METHODS

The data of 195 independent ambulatory patients with SCI were used to describe the use of an AAD. Among these, only 140 subjects were assessed for their walking speed and distance walked in 6 min.

RESULTS

More than half of the subjects (64%) walked with an AAD in which most of them used a standard walker (45%), followed by a single-tip cane (11%) and bilateral crutches (8%), respectively. The walking speed and distance showed significant differences among the groups (P<0.001), except those who used walker versus crutches, and those who used crutches versus cane (P>0.05). Among the significant variables, types of AAD used had the greatest influence on walking speed and distance of the subjects.

CONCLUSION

More than half of ambulatory subjects with SCI walked with an AAD in which most of them used a standard walker. However, the non-significant differences of walking performance between the groups may suggest the heterogeneity of walking ability in subjects who used the same type of AAD. Therefore, a method to facilitate the use of an AAD with less supportive ability would increase levels of independence for the patients.

An exploration of risk for recurrent falls in two geriatric care settings

Background

Fall events were examined in two distinct geriatric populations to identify factors associated with repeat fallers, and to examine whether patients who use gait aids, specifically a walker, were more likely to experience repeat falls. Each unit already had a generic program for falls prevention in place.

Methods

Secondary data analysis was conducted on information collected during the pilot testing of a new quality assurance Incident Reporting Tool between October 2006 and September 2008. The study settings included an in-patient geriatric rehabilitation unit (GRU) and a long stay veterans’ unit (LSVU) in a rehabilitation and long-stay hospital in Ontario. Participants were two hundred and twenty three individuals, aged 65 years or older on these two units, who experienced one or more fall incidents during the study period.

Results

Logistic regression analyses showed that on the GRU age was significantly associated with repeat falls. On the LSVU first falls in the morning or late evening were associated with repeat falling. Walker as a gait aid listed at time of first fall was not associated with repeat falls.

Conclusions

This study suggests that different intervention may be necessary in different geriatric settings to identify, for secondary prevention, certain individuals for which the generic programs prove inadequate. Information collection with a specific focus on the issue of repeat falls may be necessary for greater insight.

The potential for technology to enhance independence for those aging with a disability

Technologies of all kinds can sustain and accelerate improvements in health and quality of life for an aging population, and enhance the independence of persons with disabilities. Assistive technologies are widely used to promote independent functioning, but the aging of users and their devices produces unique challenges to individuals, their families, and the health care system. The emergence of new "smart" technologies that integrate information technology with assistive technologies has opened a portal to the development of increasingly powerful, individualized tools to assist individuals with disabilities to meet their needs. Yet, issues of access and usability remain to be solved for their usefulness to be fully realized. New cohorts aging with disabilities will have more resources and more experience with integrated technologies than current elders. Attention to technological solutions that help them adapt to the challenges of later life is needed to improve quality of life for those living long lives with disabilities.

Improving Staff Reports of Falls in Assisted Living

This study examined falls data reported by staff to (a) describe characteristics of falls in this population and (b) analyze the quality and utility of the data available from incident reports (IRs) to improve fall prevention. Data from 34 incident reports were analyzed. Descriptive and frequency analyses were conducted to describe fall characteristics, use of assistive devices, high-risk medication use, and prevalence of omitted data on IRs. Thirty-four falls occurred among 15 residents (age, M = 84 years). More than half resulted in injury. Significant omissions of data were noted in the IRs, which may have limited full analysis of fall events and the ability to communicate about health outcomes of these events and the prevention of subsequent falls. This study provides data about falls in assisted living and recommendations for enhanced data collection to support the monitoring of falls risk and the prevention of future falls.

Sit-stand powered mechanical lifts in long-term care and resident quality indicators

OBJECTIVE

To determine associations between long-term care powered mechanical lift (PML) availability and mobility-related resident outcomes.

METHODS

Long-term care directors of nursing (N = 271) nationwide gave facility information on the PML availability and the lifting policy to which we linked data on mobility-related resident outcomes from the Centers for Medicare & Medicaid Services Minimum Data Set Quality Indicators.

RESULTS

Four of six Centers for Medicare & Medicaid Services-derived resident indicators improved with the PML number but were maximal for the sit-stand lift use. In facilities with the fewest lifts, 16% of residents had pressure ulcers and 4% were bedfast. In facilities with the maximum number of lifts, only 10% had pressure ulcers (P = 0.000) and 2% were bedfast (P = 0.002). Although falls were more frequent with more lift use, this risk was blunted by a comprehensive safe lift program.

CONCLUSION

The PML availability is associated with benefits to resident outcomes, and accompanying risks are mitigated by safe lift policies.

Assistive devices alter gait patterns in Parkinson disease: advantages of the four-wheeled walker

Gait abnormalities are a hallmark of Parkinson's disease (PD) and contribute to fall risk. Therapy and exercise are often encouraged to increase mobility and decrease falls. As disease symptoms progress, assistive devices are often prescribed. There are no guidelines for choosing appropriate ambulatory devices. This unique study systematically examined the impact of a broad range of assistive devices on gait measures during walking in both a straight path and around obstacles in individuals with PD. Quantitative gait measures, including velocity, stride length, percent swing and double support time, and coefficients of variation were assessed in 27 individuals with PD with or without one of six different devices including canes, standard and wheeled walkers (two, four or U-Step). Data were collected using the GAITRite and on a figure-of-eight course. All devices, with the exception of four-wheeled and U-Step walkers significantly decreased gait velocity. The four-wheeled walker resulted in less variability in gait measures and had less impact on spontaneous unassisted gait patterns. The U-Step walker exhibited the highest variability across all parameters followed by the two-wheeled and standard walkers. Higher variability has been correlated with increased falls. Though subjects performed better on a figure-of-eight course using either the four-wheeled or the U-Step walker, the four-wheeled walker resulted in the most consistent improvement in overall gait variables. Laser light use on a U-Step walker did not improve gait measures or safety in figure-of-eight compared to other devices. Of the devices tested, the four-wheeled-walker offered the most consistent advantages for improving mobility and safety.

Four-wheeled walker related injuries in older adults in the Netherlands

BACKGROUND

With ageing populations worldwide, mobility devices are used more than ever. In the current literature there is no consensus whether the available mobility devices safely improve the mobility of their users. Also, evidence is lacking concerning the risks and types of injuries sustained while using a four-wheeled walker.

OBJECTIVE

To assess injury risks and injury patterns in older adults (≥65 years) who presented at Emergency Departments (ED) in the Netherlands with an injury due to using a four-wheeled walker.

DESIGN AND SETTING

In this study, the Dutch Injury Surveillance System was used to obtain a national representative sample of annual ED visits in the Netherlands in the adult population (≥65 years) sustaining an injury while using a four-wheeled walker. The numbers of four-wheeled walker users in the Netherlands were obtained from the national insurance board. The numbers of ED visits were divided by the numbers of four-wheeled walker users to calculate age- and sex-specific injury risks.

RESULTS

Annually 1869 older adults visited an ED after sustaining an injury while using a four-wheeled walker. Falls were the main cause of injury (96%). The injury risk was 3.1 per 100 users of four-wheeled walkers. Women (3.5 per 100 users) had a higher risk than men (2.0 per 100 users). Injury risk was the highest in women aged 85 years and older (6.2 per 100 users). The majority of injuries were fractures (60%) with hip fracture (25%) being the most common injury. Nearly half of all four-wheeled walker related injuries required hospitalisation, mostly due to hip fractures. Healthcare costs per injury were approximately €12 000.

CONCLUSIONS

This study presents evidence that older adults experiencing a fall while using a four-wheeled walker are at high risk to suffer severe injuries.

Design and validation of GCH System 1.0 which measures the weight-bearing exerted on forearm crutches during aided gait

Normally, when the patient's functional recovery involves partial weight-bearing aided walking using forearm crutches, it is not possible to control the amount of weight-bearing objectively that the individuals carry out and its progression. This leads to significant errors in accuracy and, consequently, complications and after effects in pathologies. To compensate for this deficiency, we have set out to design and validate a measurement system and a computerized record of the loads exerted on Canadian crutches in aided walking as well as incorporating a mechanism for acoustic and visual biofeedback that will inform the subject if said charges are correct, so that they are able correct their errors and avoid problems in their recovery. We analyzed the validity and reliability of the system through a concordance study with the AMTI OR6-7-2000 force plate, extensively validated previously, while finding a correlation coefficient of 0.99 with a significance (p<0.001). We have designed and developed a measurement system with a computerized record, analysis and wireless graphical display of real-time data, incorporating a mechanism for acoustic and visual biofeedback to measure the loads exerted on forearm crutches during aided walking. The device, called "GCH System 1.0" is a reliable and valid instrument.

Risk factors for mortality after spinal cord injury in the USA

STUDY DESIGN

Cohort study.

OBJECTIVES

First, to examine three sets of risk and protective factors for mortality after spinal cord injury (SCI), with an emphasis on health and secondary conditions. Second, to extend earlier work with several methodologic enhancements and addition of new predictors.

SETTING

Twenty hospitals designated as SCI Model Systems (SCIMSs) of care in the United States.

METHODS

Altogether, 8183 adults with traumatic SCI who received at least one follow-up evaluation between November 1995 and October 2006 from one of the SCIMSs were included in the study. There were 76,262 person-years and 1381 deaths at the end of June 2011. Mortality status determined by National Death Index and Social Security Death Index searches. Three successive sets of risk factors were evaluated with a logistic regression model on person-year observations to estimate the chance of dying in any given year.

RESULTS

Several biographic and injury, socio-environmental and health factors were significantly related to the odds of mortality. A history of pneumonia or kidney calculus was associated with greater odds of mortality, whereas deep vein thrombosis was not. Poor general health, decline in health over the past year, hospitalization and a grade 3 or 4 pressure ulcer were also related to mortality. Consistent with a mediating effect, odds ratios declined with the addition of each successive set of factors.

CONCLUSION

The relationship of biographic and injury characteristics with mortality after SCI is mediated by socio-environmental and health factors. Assessment of these variables enhances our ability to identify individuals at risk for excess mortality.

Use of mobility aids reduces attentional demand in challenging walking conditions

While mobility aids (e.g., four-wheeled walkers) are designed to facilitate walking and prevent falls in individuals with gait and balance impairments, there is evidence indicating that walkers may increase attentional demands during walking. We propose that walkers may reduce attentional demands under conditions that challenge balance control. This study investigated the effect of walker use on walking performance and attentional demand under a challenged walking condition. Young healthy subjects walked along a straight pathway, or a narrow beam. Attentional demand was assessed with a concurrent voice reaction time (RT) task. Slower RTs, reduced gait speed, and increased number of missteps (>92% of all missteps) were observed during beam-walking. However, walker use reduced attentional demand (faster RTs) and was linked to improved walking performance (increased gait speed, reduced missteps). Data from two healthy older adult cases reveal similar trends. In conclusion, mobility aids can be beneficial by reducing attentional demands and increasing gait stability when balance is challenged. This finding has implications on the potential benefit of mobility aids for persons who rely on walkers to address balance impairments.

Assistive devices for ambulation

Interacting with other people and the environment is fundamental to quality of life. Canes, walkers, and crutches increase, maintain, or improve functional capabilities of many individuals with neurologic disorders. Canes offer a choice of handle, shaft, and base. Walkers have various types of base, uprights, handgrips, platforms, and accessories. Crutch designs include underarm, triceps, forearm, and platform. Orthoses, particularly ankle foot orthoses and knee ankle foot orthoses, are often used to stabilize or immobilize lower limb segments while walking. Studies have shown the benefits of traditional assistive devices on gait, when prescribed and used properly.

Individual differences and their impact on the safety and the efficiency of human-wheelchair systems

OBJECTIVE

The extent to which individual differences in fine motor abilities affect indoor safety and efficiency of human-wheelchair systems was examined.

BACKGROUND

To reduce the currently large number of indoor wheelchair accidents, assistance systems with a high level of automation were developed. It was proposed to adapt the wheelchair's level of automation to the user's ability to steer the device to avoid drawbacks of highly automated wheelchairs. The state of the art, however, lacks an empirical identification of those abilities.

METHOD

A study with 23 participants is described. The participants drove through various sections of a course with a powered wheelchair. Repeatedly measured criteria were safety (numbers of collisions) and efficiency (times required for reaching goals). As covariates, the participants' fine motor abilities were assessed.

RESULTS

A random coefficient modeling approach was conducted to analyze the data,which were available on two levels as course sections were nested within participants.The participants' aiming, precision, and armhand speed contributed significantly to both criteria: Participants with lower fine motor abilities had more collisions and required more time for reaching goals.

CONCLUSION

Adapting the wheelchair's level of automation to these fine motor abilities can improve indoor safety and efficiency. In addition, the results highlight the need to further examine the impact of individual differences on the design of automation features for powered wheelchairs as well as other applications of automation.

APPLICATION

The results facilitate the improvement of current wheelchair technology.

Age-related changes in speed and accuracy during rapid targeted center of pressure movements near the posterior limit of the base of support

BACKGROUND

Backward falls are often associated with injury, particularly among older women. An age-related increase occurs in center of pressure variability when standing and leaning. So, we hypothesized that, in comparison to young women, older women would display a disproportionate decrease of speed and accuracy in the primary center of pressure submovements as movement amplitude increases.

METHODS

Ground reaction forces were recorded from thirteen healthy young and twelve older women while performing rapid, targeted, center of pressure movements of small and large amplitude in upright stance. Measures included center of pressure speed, the number of center of pressure submovements, and the incidence rate of primary center of pressure submovements undershooting the target.

FINDINGS

In comparison to young women, older women used slower primary submovements, particularly as movement amplitude increased (P<0.01). Even though older women achieved similar endpoint accuracy, they demonstrated a 2 to 5-fold increase in the incidence of primary submovement undershooting for large-amplitude movements (P<0.01). Overall, posterior center of pressure movements of older women were 41% slower and exhibited 43% more secondary submovements than in young women (P<0.01).

INTERPRETATIONS

We conclude that the increased primary submovement undershoots and secondary center of pressure submovements in the older women reflect the use of a conservative control strategy near the posterior limit of their base of support.

Reliability and validity of three functional tests in ambulatory patients with spinal cord injury

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

To investigate reliability, discriminative ability and concurrent validity of three functional tests (including the 10-meter walk test (10MWT), timed up and go test (TUGT) and five times sit-to-stand test (FTSST)) using the Functional Independence Measure Locomotor (FIM-L) scores as a standard criterion.

SETTING

A tertiary rehabilitation center, Thailand.

METHODS

Subjects were 66 patients with spinal cord injury (SCI), who were able to walk at least 50 m unassisted with or without a walking device (FIM-L scores 6-7). They were tested for functional ability using the 10MWT, TUGT and FTSST. Sixteen subjects also assessed the ability using three assessors to evaluate the inter-tester reliability of the tools.

RESULTS

The three functional tests demonstrated excellent inter-tester reliability (intraclass correlation coefficient (3,3)=0.997-1.00) and could clearly distinguish between subjects who walked with and without a walking device. In addition, the tests showed significant correlation with walking categories or FIM-L scores (r(pb)=0.778, -0.692 and -0.595 for the 10MWT, TUGT and FTSST, respectively, P<0.001).

CONCLUSION

The findings support reliability and validity of the 10MWT, TUGT and FTSST to assess levels of independences in ambulatory subjects with SCI.

Assistive walking device use and knee osteoarthritis: results from the Health, Aging and Body Composition Study (Health ABC Study)

OBJECTIVES

To identify factors that predicted incident use of assistive walking devices (AWDs) and to explore whether AWD use was associated with changes in osteoarthritis of the knee.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

Older adults (N=2639) in the Health, Aging and Body Composition (Health ABC) Study including a subset of 874 patients with prevalent knee pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incident use of AWDs, mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores, and the frequency of joint space narrowing on knee radiographs over a 3-year time period.

RESULTS

AWD use was initiated by 9% of the entire Health ABC cohort and 12% of the knee pain subset. Factors that predicted use in both groups were age ≥73 (entire cohort: odds ratio [OR]=2.07; 95% confidence interval [CI], 1.43-3.01; knee pain subset: OR=1.87; 95% CI, 1.16-3.03), black race (entire cohort: OR=2.95; 95% CI, 2.09-4.16; knee pain subset: OR=3.21; 95% CI, 2.01-5.11), and lower balance ratios (entire cohort: OR=3.18; 95% CI, 2.21-4.59; knee pain subset: OR=3.77; 95% CI, 2.34-6.07). Mean WOMAC pain scores decreased slightly over time in both AWD and non-AWD users. Twenty percent of non-AWD users and 28% of AWD users had radiographic progression in joint space narrowing of the tibiofemoral joint in at least 1 knee. Fourteen percent of non-AWD users and 12% of AWD users had radiographic progression in joint space narrowing in the patellofemoral joint in at least 1 knee.

CONCLUSIONS

AWDs are frequently used by older adults. Knee pain and balance problems are significant reasons why older adults initiate use of an AWD. In an exploratory analysis, there was no consistent relation between the use or nonuse of an AWD and WOMAC pain scores or knee joint space narrowing progression. Further studies of the relation of use of AWDs to changes in knee osteoarthritis are needed.

A cane improves postural recovery from an unpracticed slip during walking in people with Parkinson disease

BACKGROUND

Little is known about the effects of use of a cane on balance during perturbed gait or whether people with Parkinson disease (PD) benefit from using a cane.

OBJECTIVES

The purpose of this study was to evaluate the effects of cane use on postural recovery from a slip due to repeated surface perturbations in individuals with PD compared with age- and sex-matched individuals who were healthy.

DESIGN

This was a prospective study with 2 groups of participants.

METHODS

Fourteen individuals with PD (PD group) and 11 individuals without PD (control group) walked across a platform that translated 15 cm rightward at 30 cm/s during the single-limb support phase of the right foot. Data from 15 trials in 2 conditions (ie, with and without an instrumented cane in the right hand) were collected in random order. Outcome measures included lateral displacement of body center of mass (COM) due to the slip and compensatory step width and length after the perturbation.

RESULTS

Cane use improved postural recovery from the first untrained slip, characterized by smaller lateral COM displacement, in the PD group but not in the control group. The beneficial effect of cane use, however, occurred only during the first perturbation, and those individuals in the PD group who demonstrated the largest COM displacement without a cane benefited the most from use of a cane. Both PD and control groups gradually decreased lateral COM displacement across slip exposures, but a slower learning rate was evident in the PD group participants, who required 6, rather than 3, trials for adapting balance recovery.

LIMITATIONS

Future studies are needed to examine the long-term effects of repeated slip training in people with PD.

CONCLUSIONS

Use of a cane improved postural recovery from an unpracticed slip in individuals with PD. Balance in people with PD can be improved by training with repeated exposures to perturbations.

Falls in multiple sclerosis

OBJECTIVE

To examine incidence, associated factors, and health care provider (HCP) response to falls in persons with multiple sclerosis (MS).

DESIGN

Cross-sectional retrospective design.

SETTING

Community setting.

PARTICIPANTS

Four hundred seventy-four persons with MS.

METHODS

Mailed survey questionnaire examined incidence, risk factors, and HCP response to falls in persons with MS who were dwelling in the community. Univariate and multiple ordinal regression analysis identified variables associated with single and multiple falls.

MAIN OUTCOME MEASUREMENTS

Falls, causes and perceived reasons for falls, and HCP response.

RESULTS

A total of 265 participants (58.2%) reported one or more falls in the previous 6 months, and 58.5% of falls were medically injurious. Trips/slips while walking accounted for 48% of falls. Factors associated with falls included use of a cane or walker (odds ratio [OR] 2.62; 95% confidence interval [CI] 1.66-4.14), income <$25,000 (OR 1.85; 95% CI 1.13-3.04), balance problems (OR 1.28; 95% CI 1.11-1.49), and leg weakness (OR 1.26; 95% CI 1.09-1.46). Fifty-one percent of those who fell (135/265) reported speaking to an HCP about their falls; recommended strategies included safety strategies (53.2%), use of gait assistive devices (42.1%), exercise/balance training (22.2%), and home modifications (16.6%).

CONCLUSIONS

Factors associated with falls in persons with MS are similar to those in other populations with neurologic diseases. Despite the high incidence of falls, fewer than 50% of people with MS receive information about prevention of falls from an HCP.

Reducing fall risk by improving balance control: development, evaluation and knowledge-translation of new approaches

PROBLEM

Falling is a leading cause of serious injury, loss of independence, and nursing-home admission in older adults. Impaired balance control is a major contributing factor.

METHODS

Results from our balance-control studies have been applied in the development of new and improved interventions and assessment tools. Initiatives to facilitate knowledge-translation of this work include setting up a new network of balance clinics, a research-user network and a research-user advisory board.

RESULTS

Our findings support the efficacy of the developed balance-training methods, balance-enhancing footwear, neuro-prosthesis, walker design, handrail-cueing system, and handrail-design recommendations in improving specific aspects of balance control. IMPACT ON KNOWLEDGE USERS: A new balance-assessment tool has been implemented in the first new balance clinic, a new balance-enhancing insole is available through pharmacies and other commercial outlets, and handrail design recommendations have been incorporated into 10 Canadian and American building codes. Work in progress is expected to have further impact.

Mobility, balance and falls in persons with multiple sclerosis

BACKGROUND

There is a lack of information concerning the relation between objective measures of gait and balance and fall history in persons with MS (PwMS). This investigation assessed the relation between demographic, clinical, mobility and balance metrics and falls history in persons with multiple sclerosis (MS).

METHODS

52 ambulatory persons with MS (PwMS) participated in the investigation. All persons provided demographic information including fall history over the last 12 months. Disease status was assessed with Expanded Disability Status Scale (EDSS). Walking speed, coordination, endurance and postural control were quantified with a multidimensional mobility battery.

RESULTS

Over 51% of the participants fell in the previous year with 79% of these people being suffering recurrent falls. Overall, fallers were older, had a greater prevalence of assistive devices use, worse disability, decreased walking endurance, and greater postural sway velocity with eyes closed compared to non-fallers. Additionally, fallers had greater impairment in cerebellar, sensory, pyramidal, and bladder/bowel subscales of the EDSS.

CONCLUSIONS

The current observations suggest that PwMS who are older, more disabled, utilize an assistive device, have decreased walking coordination and endurance and have diminished balance have fallen in the previous year. This suggests that individuals who meet these criteria need to be carefully monitored for future falls. Future research is needed to determine a prospective model of falls specific to PwMS. Additionally, the utility of interventions aimed at reducing falls and fall risk in PwMS needs to be established.

Gait changes with walking devices in persons with Parkinson's disease

PURPOSE

To study immediate gait changes in persons with PD when walking with different assistive walking devices.

METHODS

Ten individuals with idiopathic PD participated in the study. Gait parameters were recorded while walking with a cane and a wheeled walker, and were compared to a free walk without a walking device.

RESULTS

Persons with PD walked with slower gait speed when using a cane and a wheeled walker compared to walking without any device (p = 0.007, p = 0.002, respectively). Stride length reduced significantly when walking with a wheeled walker (p = 0.001). Walking with the assistive devices did not affect cadence, double support phase, heel to heel base of support, stride time, and stance period.

CONCLUSION

Persons with PD immediately walked with slower gait speed when using either a cane or a wheeled walker, and with shorter stride length when walking with a wheeled walker. The results may lead to more cautious clinical practice in gait rehabilitation using ambulatory assisted devices.

Use of a standard cane increases unipedal stance time during static testing

The records of 11 consecutive qualifying patients were reviewed to evaluate whether use of a cane increased unipedal balance time during static testing. Measured with a stopwatch, the maximum unipedal balance time increased significantly with use of a single-point cane, whether standing on the left (M = 14.4 sec.) or right (M = 16.7 sec.) lower limb. The results indicate that in clinical situations, sophisticated instruments are not needed to demonstrate the effects of a cane and that unipedal stance times obtained with a stopwatch can confirm the effectiveness of canes for increasing unipedal balance of patients and caregivers.

Why is walker-assisted gait metabolically expensive?

Walker-assisted gait is reported to be ∼200% more metabolically expensive than normal bipedal walking. However, previous studies compared different walking speeds. Here, we compared the metabolic power consumption and basic stride temporal-spatial parameters for 10 young, healthy adults walking without assistance and using 2-wheeled (2W), 4-wheeled (4W) and 4-footed (4F) walker devices, all at the same speed, 0.30m/s. We also measured the metabolic power demand for walking without any assistive device using a step-to gait at 0.30m/s, walking normally at 1.25m/s, and for repeated lifting of the 4F walker mimicking the lifting pattern used during 4F walker-assisted gait. Similar to previous studies, we found that the cost per distance walked was 217% greater with a 4F walker at 0.30m/s compared to unassisted, bipedal walking at 1.25m/s. Compared at the same speed, 0.30m/s, using a 4F walker was still 82%, 74%, and 55% energetically more expensive than walking unassisted, with a 4W walker and a 2W walker respectively. The sum of the metabolic cost of step-to walking plus the cost of lifting itself was equivalent to the cost of walking with a 4F walker. Thus, we deduce that the high cost of 4F walker assisted gait is due to three factors: the slow walking speed, the step-to gait pattern and the repeated lifting of the walker.

Older homebound women: negotiating reliance on a cane or walker

Canes and walkers are commonly characterized as assistive devices that serve the same purpose: as walking aides. These general views were reappraised and tempered in this descriptive phenomenological study with 40 older women (aged 85 to 98 years) who were unable to leave their homes without help. The purpose was to describe the phenomena of negotiating reliance on canes and walkers as walking devices and the lifeworld context underlying each phenomenon. Relative to lifeworld, there were differences between coming to terms with using a cane and coming to terms with using a walker. Data revealed similarities and distinctions between the basic intentions of relying on canes and walkers and the associated purposes served by canes and walkers. Participants did not view either device as consistently assistive. Findings evoke opportunities for dialogue among older persons, scholars, practitioners, and designers of these devices about coming to terms with such devices and relying on them.

Determinants for the use of ambulation AIDS in a geriatric rehabilitation care unit: a retrospective study

OBJECTIVES

This study aimed at assessing the profile of ambulation aid users among patients admitted for geriatric rehabilitation care.

DESIGN

Retrospective chart review.

SETTING

Geriatric Rehabilitation Department of the Hôpital Albert Chenevier, Créteil, France.

PARTICIPANTS

The sample comprised 206 records of patients aged 65 or older with no previous use of assistive device before admission and length of stay longer than 7 days.

MEASUREMENTS

Ambulation levels were classified as independent ambulators (IA, reference category), ambulation aid users (AA), or nonambulatory patients (NA). we explored age, gender, purpose of initial admission, comorbidities, and past medical history as factors potentially associated with ambulation levels, using multinomial logistic regression.

RESULTS

The study population (mean age 84 years [6.1 standard deviation], 68.5 % women) comprised 110 IA (53.4% of the overall population), 72 AA (34.9%), and 24 NA (11.6%). Factors independently associated with AA use were the following: older age (odds ratio = 1.17; [95% confidence interval 1.09-1.25]), previous history of lower limb surgery (2.15; [1.0-4.73]), and admission for hip surgery (8.14; [2.60-25.53]). Factors independently associated with NA were the following: older age (1.12 [1.02-1.23]) and low Mini-Mental State Exam score (0.77 [0.70-0.85]). A borderline association was observed for visual impairment (3.36 [0.93-12.95]). Cardiac disease, respiratory disease, falls, and dementia were not associated with ambulation aid use.

CONCLUSIONS

History of lower-limb surgery, particularly recent hip surgery, and old age are the primary predictive factors of ambulation aid use in a geriatric rehabilitation hospital.

Walking aid use after discharge following hip fracture is rarely reviewed and often inappropriate: an observational study

QUESTIONS

What walking aid prescription occurs at discharge after hip fracture? What changes in walking aid use occur in the following six months? Who initiates changes in walking aids and why?

DESIGN

Prospective longitudinal observational study.

PARTICIPANTS

95 community-dwelling older adults who had undergone surgical treatment of a hip fracture.

OUTCOME MEASURES

Range of walking aids prescribed at discharge and participants' recall of advice about progression were recorded. Progression of walking aids was observed fortnightly over 6 months. With any change in walking aid use, an independent physiotherapist determined if it was appropriate and participants reported the reason for the change.

RESULTS

Most participants were discharged from their final inpatient setting with a wheeled frame (92%). Eighty-two (86%) participants were not aware of any goals set by the physiotherapist for the first 6 months and 89 (94%) stated that a review time had not been set. Despite this, 78 (82%) participants changed their walking aid, on average 8 weeks (SD 6) after discharge. However, 32% of those who changed their walking aids were using an inappropriate aid or using it incorrectly. Six months after discharge, 40% of participants had not returned to using their pre-morbid indoor aid and 50% their outdoor aid.

CONCLUSION

A review of walking aid by a physiotherapist is rare within six months after discharge following hip fracture. Most patients make their own decision about what walking aid is most appropriate. This has safety implications in a group at high risk of falls.

The effect of cane use method on center of mass displacement during stair ascent

The aim of the study was to examine the effect of forward and lateral cane placement on displacement of whole body center of mass (COM) and spatial relationship between COM and the cane during stair ascent (SA) in healthy adults. The data were obtained using three-dimensional motion analysis while ascending stairs non-reciprocally with following methods: (1) dominant foot stepped up first, then the opposite foot without a cane (NC); (2) forward placement of a quadricane followed by the ipsilateral foot, then contralateral foot (FCI); (3) forward cane placement followed by the contralateral foot, then ipsilateral foot (FCC); (4) ipsilateral foot stepping up first, followed by the contralateral foot, then the cane (LCI); (5) contralateral foot stepping up, followed by the ipsilateral foot, then the cane (LCC). The results indicated that the cane placement had significant effect on the medial-lateral (ML) COM displacement and the kinematics of the trunk. Lateral cane placement requires greater trunk extension and side-flexion. The major differences between ipsilateral and contralateral cane use are the motions at frontal and transverse planes in which the COM displacement in ML direction is larger in ipsilateral cane use. The COM displacement in ML direction is larger in ipsilateral use of cane (LCI and FCI). The results of this study may help clinicians better understand the possible nature of balance control in patients who ascend stairs with a cane, and suggest that the method of cane placement should be taken into consideration by clinicians when teaching the cane user to ascend stairs.

Impact of different types of walking aids on the physiological energy cost during gait for elderly individuals with several pathologies and dependent on a technical aid for walking

In elderly individuals balance disorders and muscle weakness can lead to prescribing a walker. There are several different models. According to the very poor effort tolerance in this population, the energy cost necessary to operate walking technical aids should be taken into account when making a choice.

OBJECTIVE

Compare two types of walker in regards to energy cost produced during gait in weakened elderly individuals.

METHOD

Thirty subjects over the age of 65 (six men and 24 women, mean age 81.9 years) were admitted in geriatrics care. They all required a walker and performed the same 10-m course with a fixed walker, then with a model bearing front wheels. The walking speed (S) was computed, heart rate at rest (HRrest) and maximum heart rate (HRmax) were recorded during the test. The physiological cost index (PCI=HRmax-HRrest/S) was calculated. Finally a timed get-up-and-go (TGUG) test was performed with each of these technical aids.

RESULTS

With a rollator walker, HRmax was lower (P<0.05) and S higher (P<0.001). It was 2.01 with a fixed walker versus 1.23 with a rollator walker (P<0.01). We found this speed difference during the TGUG test (72.26 sec vs. 82.93 sec, P=0.001).

DISCUSSION AND CONCLUSION

There are very little studies on the evaluation of physiological energy cost produced during gait with a walker. The characteristics of our population did not allow us to conduct our test without a technical aid. The use of a fixed walker leads to a major increase in gait PCI, probably due to the required repeated efforts for lifting the walker. This model must be avoided in case of cardiac or respiratory disorders.

Pediatric mobility aid-related injuries treated in US emergency departments from 1991 to 2008

OBJECTIVES

Although mobility aids such as crutches, walkers, and wheelchairs are typically beneficial, they can be associated with injury. The objective of this study was to describe the incidence, patterns, and trends of pediatric mobility aid-related injuries to children and adolescents who were aged < or = 19 years and treated in US emergency departments between 1991 and 2008.

METHODS

A retrospective analysis was conducted by using data from the National Electronic Injury Surveillance System database for children and adolescents who were aged < or = 19 years. Sample weights were used to calculate national estimates of mobility aid-related injuries on the basis of 2301 actual cases.

RESULTS

An estimated 63 309 cases of children and adolescents who were aged < or = 19 years were treated in US emergency departments for mobility aid-related injuries. Approximately 70% of mobility aid- related injuries occurred while patients were using wheelchairs. Children who were aged 2 to 10 years were more likely to sustain injuries while using walkers and wheelchairs, injure their heads, and sustain traumatic brain injuries. Children who were aged 11 to 19 years were more likely to sustain injuries while using crutches, injure their lower extremities, and sustain sprains and strains. Injuries involving wheelchairs were more likely to be traumatic brain injuries and result in hospitalization. Injuries involving crutches were more likely to involve misuse and be triggered by stairs or curbs.

CONCLUSIONS

Injuries related to crutches, walkers, and wheelchairs have distinct injury patterns, mechanisms of injury, and trigger factors. Injury patterns between younger and older children were different. Additional research is needed to identify effective injury prevention strategies for the pediatric population.

Mechanisms involved in treadmill walking improvements in Parkinson's disease

Patients with Parkinson's disease (PD) improve gait after treadmill training and while they are walking over the treadmill. However, the mechanisms of these improvements have not been addressed. We designed a treadmill simulator without a belt that could move on a walkway in a constant speed, in order to explore the mechanism underlying treadmill walking improvements in PD. All subjects were tested in three different sessions (treadmill, simulator(assisted) and simulator(not assisted)). In each session, subjects first walked overground and then walked using the treadmill or simulator with the hands over the handrails (simulator(assisted)) or with the hands free (simulator(not assisted)). Step length, cadence, double support time, swing time, support time and the coefficient of variation (CV) of step time and double support time were recorded. Over the treadmill PD patients increased their step length and reduced significantly their cadence and CV of double support time in comparison with overground walking. In the simulator(assisted) condition PD patients reduced significantly the CV of double support time in comparison with overground walking. With the simulator(not assisted) both groups decreased their step length and increased their cadence and CV of double support time, compared with walking overground. These findings suggest that the step length improvement observed in PD patients, walking over a treadmill, is due to the proprioceptive information generated by the belt movement, since no improvement was reported when patients using a treadmill simulator.

Assessment of canes used by older adults in senior living communities

The purpose of this cross-sectional study is to provide basic but essential information about how older cane users obtain their canes and how they use these canes for their daily mobility, since there is still lack of information on these areas. Ninety-three older (≥65 years old) subjects who use canes for daily activities were recruited from four assisted living facilities and five retirement centers for this cross-sectional study. The assessment involved interviewing cane users with a questionnaire, examining their canes, and investigating how these canes were used by their owners during ambulation. The commonly used canes are (from most to least): adjustable single-tip, un-adjustable (wooden), small quad, and large quad. Five major problems from data analysis were identified: lack of medical consultation for device selection/use, incorrect cane height/maintenance, placement of cane in improper hand, inability to maintain the proper reciprocal gait pattern, and improper posture during ambulation. Only forward-leaning posture during ambulation might be associated with increased falls among the older cane users. Knowledge of these problems could assist health professionals to implement appropriate interventions in clinical settings and to provide community service to address all problems related to cane use.

Factors related to obstacle crossing in independent ambulatory patients with spinal cord injury

BACKGROUND/OBJECTIVES

To evaluate factors related to the ability of ambulatory patients with spinal cord injury (SCI) to walk over small obstacles.

STUDY DESIGN

Cross-sectional study.

METHODS

Thirty-four patients with SCI (ASIA impairment scale [AIS] D) who were able to walk independently at least 10 m with or without walking devices were recruited for the study. Participants were required to walk over small obstacles (1, 4, and 8 cm in height or width; total of 6 conditions). A "fail" was recorded when either the lower limbs or the walking device contacted the obstacle. Multiple logistic regression models were applied to determine the effects of walking devices (presence or absence), SCI levels (tetraparesis or paraparesis), and SCI stages (acute or chronic) on the ability of obstacle crossing.

RESULTS

Fifteen participants (44%) failed to adequately clear the foot or walking device over obstacles in at least one condition (range 1-3 conditions). After adjusting for covariates, the chance of failure on obstacle crossing was greatly increased with the use of walking devices (odds ratio = 8.50; 95% CI = 0.85-75.03)

CONCLUSIONS

Gait safety in independent ambulatory participants with SCI remains threatened. Participants who walked with walking devices encountered a greater chance of failing to walk over obstacles as a result of inefficiently moving the foot or walking device over small obstacles. Thus, instead of training in an empty/ quiet room, rehabilitation procedures should incorporate contextual conditions that patients encounter at home and in the community in order to minimize risk of injury and prepare patients to be more independent after discharge.