Speed and distance requirements for community ambulation: a systematic review

The Importance of Racially and Ethnically Inclusive Gait Speed Reference Values in Individuals 90 Years and Older: LifeAfter90

BACKGROUND AND PURPOSE

Clinicians use reference values to contextualize physical performance scores, but data are sparse in individuals 90 years and older and racial/ethnic diversity is limited in existing studies. Gait speed provides valuable information about an individual's health status. Slow gait speed is associated with falls, cognitive decline, and mortality. Here, we report gait speed reference values in a racially/ethnically diverse oldest-old cohort.

METHODS

LifeAfter90 is a multiethnic cohort study of individuals 90 years and older. Participants are long-term members of an integrated healthcare delivery system without a dementia diagnosis at enrollment. We assessed gait speed using the 4-m walk test and calculated means, standard deviations, and percentiles by age, sex, assistive device use, and device type. We used linear regression to compare means by sex, age, device use and type, living situation and arrangement, and race/ethnicity.

RESULTS AND DISCUSSION

The mean age of the 502 participants was 92.9 (range 90.1-102.8) years. Of these, 62.6% were women, 34.7% were college educated, 90.8% lived in a private residence, 20.9% self-reported as Asian, 22.5% as Black, 11.8% as Hispanic, 35.7% as White, and 9.2% as multiple, "other," or declined to state. The overall mean gait speed was 0.54 m/s (women = 0.51 m/s, men = 0.58 m/s). Mean gait speeds were 0.58 m/s, 0.53 m/s, and 0.48 m/s in the 90 to 91, 92 to 93, and 94+ age categories, respectively. In those without a device, mean gait speed was 0.63 m/s compared to 0.40 m/s in those with a device (cane = 0.44 m/s, walker = 0.37 m/s). Mean gait speed was significantly slower in women compared to men, age category 94+ compared to 90 to 91, participants with a device compared to those without, participants with a walker compared to a cane, and Black participants compared to Asian and White participants. However, differences by race/ethnicity were attenuated when chronic health conditions were considered.

CONCLUSIONS

Reference values developed from this multiethnic 90+ cohort will help clinicians interpret gait speed measures and tailor recommendations toward a 90+ population that is growing in number and in racial/ethnic diversity.

Weak grip strength among persons with multiple sclerosis having minimal disability is not related to agility or integrity of the corticospinal tract

INTRODUCTION

Mobility impairment is common in multiple sclerosis (MS); however, agility has received less attention. Agility requires strength and neuromuscular coordination to elicit controlled propulsive rapid whole-body movement. Grip strength is a common method to assess whole body force production, but also reflects neuromuscular integrity and global brain health. Impaired agility may be linked to loss of neuromuscular integrity (reflected by grip strength or corticospinal excitability).

OBJECTIVES

We aimed to determine whether grip strength would be associated with agility and transcranial magnetic stimulation (TMS)-based indices of corticospinal excitability and inhibition in persons with MS having low disability. We hypothesized that low grip strength would predict impaired agility and reflect low corticospinal excitability.

METHODS

We recruited 34 persons with relapsing MS (27 females; median [range] age 45.5 [21.0-65.0] years) and mild disability (median [range] Expanded Disability Status Scale 2.0 [0-3.0]), as well as a convenience sample of age- and sex-matched apparently healthy controls. Agility was tested by measuring hop length during bipedal hopping on an instrumented walkway. Grip strength was measured using a calibrated dynamometer. Corticospinal excitability and inhibition were examined using TMS-based motor evoked potential (MEP) and corticospinal silent period (CSP) recruitment curves, respectively.

RESULTS

MS participants had significantly lower grip strength than controls independent of sex. Females with and without MS had weaker grip strength than males. There were no statistically significant sex or group differences in agility. After controlling for sex, weaker grip strength was associated with shorter hop length in controls only (r = 0.645, p < .05). Grip strength did not significantly predict agility in persons with MS, nor was grip strength predicted by corticospinal excitability or inhibition.

CONCLUSIONS

In persons with MS having low disability, grip strength (normalized to body mass) was reduced despite having intact agility and walking performance. Grip strength was not associated with corticospinal excitability or inhibition, suggesting peripheral neuromuscular function, low physical activity or fitness, or other psychosocial factors may be related to weakness. Low grip strength is a putative indicator of early neuromuscular aging in persons with MS having mild disability and normal mobility.

High Intensity Functional Training for People with Parkinson's & Their Care Partners: A Feasibility Study

PURPOSE

Various forms of exercise have proven health benefits for people with Parkinson's (pwPD) yet high intensity functional training (HIFT) has yet to be studied. The purpose of this study was to examine the feasibility, physical and psychosocial impacts of a HIFT program for pwPD and their care partners (CPs).

DESIGN

A single group, pre-post design with assessments before, in the middle (13 weeks), and after the 25-week intervention.

SETTING

Community fitness facility.

PARTICIPANTS

Fourteen pwPD (10 at Hoehn Yahr Stage ≤2, 4 females) and 10 CPs (5 females) were included (mean age = 71.5 (6.1)).

INTERVENTION

A 25-week HIFT program (≤49 exercise sessions, ≤75 min long).

MEASURES

Recruitment, retention, attendance, safety and exercise intensity (measured via session-Rating of Perceived Exertion (RPE)) was assessed in addition to cardiovascular endurance, lower extremity strength, walking speed, balance, exercise self-efficacy, balance confidence, social support for exercise and health-related quality of life.

ANALYSIS

Descriptive data was used to describe feasibility measures. Wilcoxon signed-rank test was used to compare pre- and post-program data. Effect size, r, was calculated.

RESULTS

Recruitment rates were ≥40% for pwPD and CPs and retention rates were 80% for pwPD and 62.5% for CPs. Average session attendance was 71.2% with 15 adverse events reported, including 7 non-injurious falls. Median session-RPE was 5 (IQR = 1) out of 10. PwPD demonstrated significant improvements in cardiovascular endurance, self-selected and fast walking speeds, balance and social support for exercise. CPs demonstrated significant improvements in cardiovascular endurance and lower extremity strength. Exercise self-efficacy, balance confidence and health-related quality of life did not significantly change for pwPD or CPs.

CONCLUSION

High intensity functional training appears feasible for pwPD and their CPs and may lead to health benefits. Healthcare providers should consider HIFT as another option to engage pwPD in community-based exercise.

Combining specific task-oriented training with manual therapy to improve balance and mobility in patients after stroke: a mixed methods pilot randomised controlled trial

PURPOSE

In absence of existing studies, to describe changes in balance and mobility, following specific task-oriented training (TOT), its combination with talocrural manual therapy (MT-TOT) or no intervention, in chronic stroke patients. To explore the feasibility of a full-scale randomised controlled trial (RCT) based on criteria of recruitment, retention and adherence rates, adverse events, falls and acceptability of the intervention.

MATERIALS AND METHODS

Using an assessor-blinded pilot RCT, 36 stroke patients were allocated to either MT-TOT, TOT, or controls. Supervised interventions were performed 45 min, 2×/weekly, for 4 weeks, and home-based practice 20 min, 4x/weekly for 4 weeks. Qualitative interviews evaluated intervention acceptability. Outcomes of balance, mobility, ankle dorsiflexion range of motion (ROM), falls and health-related quality of life (HRQoL) were assessed at baseline, post-intervention and 4-week follow-up.

RESULTS

Preliminary efficacy of MT-TOT and TOT was shown in improving balance (effect size 0.714), walking speed (0.683), mobility (0.265), dual-tasking mobility (0.595), falls (0.037), active and passive talocrural ROM (0.603; 0.751) and activities and social participation related HRQoL domains (0.332-0.784) in stroke patients. The feasibility of a larger RCT was confirmed.

CONCLUSIONS

Specific MT-TOT and TOT appeared effective and are feasible in stroke patients. A larger RCT is needed to validate the results.Trial Registration: German Clinical Trials Register, DRKS00023068. Registered on 21.09.2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023068.

Feasibility of an Application-Based Outpatient Rehabilitation Program for Stroke Survivors: Acceptability and Preliminary Results for Patient-Reported Outcomes

BACKGROUND

The majority of stroke survivors experience long-term impairments. Regular physical activity and other lifestyle modifications play an important role in rehabilitation. Outpatient rehabilitation using telemedicine might be suitable to improve functional ability and long-term secondary prevention. The Strokecoach Intervention Program (SIP, Strokecoach GmbH, Cologne, Germany) comprises training, coaching and monitoring with the aim of improving or at least maintaining functional independence and preventing further stroke through more targeted physical activity. The SIP is provided as blended care, which refers to the integrated and coordinated delivery of healthcare services that combines traditional in-person interactions with technology-mediated interventions, optimizing the use of both face-to-face and virtual modalities to enhance patient outcomes.

OBJECTIVE

The aim of this study was to evaluate the acceptance of the SIP by the participants and its practical application, as well as to obtain initial indications of effects of the SIP on the basis of patient-related outcome measures, blood pressure measurements and recording of physical activity in parallel with the intervention.

METHODS

Data from individuals with stroke participating in the SIP were analyzed retrospectively. Within the SIP, participants received an application-based training program, were instructed to measure their blood pressure daily and to wear an activity tracker (pedometer). During the intervention period of either 6 or 12 weeks, the participants were supported and motivated by a personal coach via a messenger application. The primary outcomes of the analysis were recruitment, acceptance of and satisfaction with the SIP. Secondary outcomes included functional measures, mobility and health-related quality of life.

RESULTS

A total of 122 individuals with stroke could be recruited for the SIP. A total of 96 out of 122 were able to start the program (54% female, mean age 54.8 (SD = 13.1), 6.1 (SD = 6.6) years after stroke onset) and 88 completed the SIP. Participants wore the activity tracker on 66% and tracked their blood pressure on 72% of their intervention days. A further analyzed subgroup of 38 participants showed small improvements in patient-reported outcomes such as health-related quality of life (SF-36) with an increase of 12 points in the subdomain mental health, vitality (12.6) and physical functioning (9.1). However, no statistically significant improvements were found in other performance-based measures (Timed Up and Go test, gait speed).

CONCLUSIONS

This study showed that a blended therapy approach for stroke survivors with mild to moderate impairments in the chronic phase is feasible and was highly accepted by participants, who benefitted from the additional coaching.

Feasibility of using the NewGait assistive device for correcting gait deviations in individuals with various neurological disorders: Case study

PURPOSE

Impaired gait is one of the earliest, most devastating, and long-lasting symptoms associated with neurological disorders. This study tested the feasibility of wearing the NewGait rehabilitative device in individuals with gait impairments due to the most common neurological disorders.

METHODS

Seven participants with gait impairments due to strokes, Multiple Sclerosis, peripheral neuropathies, Cerebral Palsy (CP) and Parkinson's Disease (PD) were included in the study. Their walking with and without wearing the NewGait was analyzed and compared using the Vicon T160 system for motion analysis. Gait velocity, step length, foot clearance, lateral displacement of the Center of Mass, gait deviation and symmetry indexes were compared using two standard deviation band method for each participant.

RESULTS

Participants subjectively assessed the NewGait as a comfortable device to wear and showed immediate gait improvements to varying degrees. Most improvements were observed in participants with muscle weakness due to peripheral neuropathies, stroke, MS, and CP. These participants improved their foot clearance, gait velocity, and step length. Participants with cerebellar stroke and PD increased their gait stability. All participants demonstrated a reduction in composite gait deviation indexes. Not all gait parameters, though, showed immediate changes.

CONCLUSION

The results suggest that the NewGait rehabilitative device is feasible and useful for correcting gait impairments caused by neurological deficits. Participants may need to wear this device for longer periods of time in order to achieve long lasting changes in the gait pattern, rather than an immediate correction.

The C-Brace® microprocessor controlled stance and swing orthosis improves safety, mobility, and quality of life at one year: Interim results from a prospective registry

Introduction

The C-Brace microprocessor-controlled stance and swing control orthosis has been shown to improve function, mobility, and quality of life. A systematic registry to gather long-term, real-world safety and effectiveness data in patients fit with a C-Brace has not been performed.

Methods

International multicenter registry. Patients undergoing routine C-Brace fittings were assessed at baseline and 1 year after fitting. Primary outcomes were fast walking speed (FWS) measured by 25-foot or 10-meter walk test, Timed Up and Go (TUG) and the Activity-specific Balance Confidence (ABC) Scale. Secondary and exploratory outcomes included the Patient-specific Functional Scale (PSFS), falls, pain, PROMIS Pain Interference (PI), and quality of life.

Results

48 subjects with 1-year baseline and follow up data were analyzed. With the C-Brace, FWS improved by + 0.26 ± 0.33 m/s (p < .0001), TUG by -8.1 ± 14.6 sec (p < .0001), and ABC by + 24.9 ± 25.8% (p < .0001). Mean falls reduced from 33 ± 77 to 3.0 ± 5.6 (p = .0005). PSFS increased by 3.60 ± 2.34 points (p < .0001). Outcomes for pain, PI and quality of life showed significant improvements with the C-Brace.

Conclusion

The C-Brace is an effective option to improve safety, mobility, and quality of life for patients needing a KAFO for ambulation.

Concurrent validity of walking speed measured by a wearable sensor and a stopwatch during the 10-meter walk test in individuals with stroke

BACKGROUND

Walking speed is often measured with a stopwatch throughout stroke recovery. Wearable sensors also have been used recently to measure walking speed and provide information about spatiotemporal characteristics of walking.

RESEARCH QUESTION

Do walking speeds measured with stopwatch and APDM wearable sensors have concurrent validity?

METHODS

Individuals with chronic stroke (n = 62) performed the 10-meter walk test at comfortable and maximal speeds. Walking speeds were measured with a stopwatch and APDM Opal wireless wearable sensors (3-unit). Tests of concurrent validity between stopwatch and APDM (Bland-Altman plots, systematic and proportional bias, and intraclass correlations) and test-retest reliability between trials (intraclass correlations, standard error of measurement, and minimal detectable change) were performed.

RESULTS

Walking speeds measured with APDM were ∼0.07 m/s slower than those measured with stopwatch (systematic bias; t ≥ 13.1, p < 0.001). Intraclass correlations ranged from poor to excellent. There were greater differences in walking speeds between APDM and stopwatch for individuals with faster walking speeds (proportional bias). Test-retest reliability was excellent for both APDM and stopwatch (intraclass correlation≥0.94). Standard error of measurement ranged from 0.04 to 0.07 m/s and minimal detectable change ranged from 0.10 to 0.19 m/s.

SIGNIFICANCE

It may be inappropriate to use walking speed measurements from APDM sensors and stopwatch interchangeably in individuals with chronic stroke. Differences in walking speeds may reflect stopwatch error or the derivation of walking speed from wearable sensors. Test-retest reliability was excellent for both stopwatch and APDM, but minimal detectable change values were large. Large changes in walking speed may be required to be confident that the change is a true and clinically meaningful change and not measurement error. The validity and reliability of measuring walking speed with wearable sensors in individuals with chronic stroke has important implications for determining community ambulation, assessing improvements after rehabilitation, and developing exercise prescriptions.

Characterising gait in paediatric neuromuscular disorders: an observational study of spatio-temporal gait in a clinical cohort

AIM

Few studies have characterised the relationship between disease and gait function in children and young people with rare neuromuscular disorders (NMDs). This study aimed to describe the relationship between disease and gait in a large paediatric cohort from a neuromuscular outpatient clinic.

METHODS

A prospective, cross-sectional study of gait in independently ambulant children and young people aged 4-21 years with a clinical or genetically confirmed NMD. Participants traversed an electronic walkway barefoot and in footwear at self-selected and fast pace. Analysis of disease included a typically developing (TD) reference group.

RESULTS

A sample of 113 participants with NMD, mean age 9.5 years (SD 3.1), 28% female, grouped into nine diagnostic subgroups. Eighty percent reported limitations to functional mobility. Children with NMD walked slower, with a shorter and wider step compared to a TD reference group, with moderate to large effect sizes for each of these gait parameters indicative of the clinical significance of these gait deviations. Children with Duchenne muscular dystrophy (DMD) walked slowest with a markedly wide gait pattern. Footwear had little overall effect on gait in children with NMDs. All children could accelerate over short distances.

CONCLUSIONS

Gait, notably speed, step length, and width are clinically significant biomarkers of disease in paediatric NMDs, affording objective functional measures in clinical settings and research.Implications for rehabilitationGait should be considered a functional biomarker of disease in children and young people with neuromuscular disorders (NMDs).Comparison of gait in a paediatric neuromuscular cohort indicates that children with Duchenne muscular dystrophy (DMD) walk slowest with a shorter step length and a wider step width which increases with age and disease progression.Measurement of gait speed is a simple, pragmatic tool to monitor disease progression in the outpatient clinical environment and relates to everyday function.In clinical research, gait can be measured as a functional outcome to demonstrate change from disease-modifying interventions and treatments in NMDs.

Assessment of Walking Speed and Distance Post-Stroke Increases After Providing a Theory-Based Toolkit

BACKGROUND AND PURPOSE

While underutilized, poststroke administration of the 10-m walk test (10mWT) and 6-minute walk test (6MWT) can improve care and is considered best practice. We aimed to evaluate provision of a toolkit designed to increase use of these tests by physical therapists (PTs).

METHODS

In a before-and-after study, 54 PTs and professional leaders in 9 hospitals were provided a toolkit and access to a clinical expert over a 5-month period. The toolkit comprised a guide, smartphone app, and video, and described how to set up walkways, implement learning sessions, administer walk tests, and interpret and apply test results clinically. The proportion of hospital visits for which each walk test score was documented at least once (based on abstracted health records of ambulatory patients) were compared over 8-month periods pre- and post-intervention using generalized mixed models.

RESULTS

Data from 347 and 375 pre- and postintervention hospital visits, respectively, were analyzed. Compared with preintervention, the odds of implementing the 10mWT were 12 times greater (odds ratio [OR] = 12.4, 95% confidence interval [CI] 5.8, 26.3), and of implementing the 6MWT were approximately 4 times greater (OR = 3.9, 95% CI 2.3, 6.7), post-intervention, after adjusting for hospital setting, ambulation ability, presence of aphasia and cognitive impairment, and provider-level clustering. Unadjusted change in the percentage of visits for which the 10mWT/6MWT was documented at least once was smallest in acute care settings (2.0/3.8%), and largest in inpatient and outpatient rehabilitation settings (28.0/19.9% and 29.4/23.4%, respectively).

DISCUSSION AND CONCLUSIONS

Providing a comprehensive toolkit to hospitals with professional leaders likely contributed to increasing 10mWT and 6MWT administration during inpatient and outpatient stroke rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A390 ).

Walking speed at the acute and subacute stroke stage: A descriptive meta-analysis

Gait disorders are one of the leading patient complaints at the sub-acute stroke stage (SSS) and a main determinant of disability. Walking speed (WS) is a major vital and functional index, and the Ten-Meter Walk Test is considered the gold standard after stroke. Based on a systematic review of the literature, studies published between January 2000 and November 2021 were selected when WS was reported (ten-meter walk test for short distance and/or 6-min walking distance for long distance) within 6 months following a first ischemic and/or hemorrhagic stroke (SSS) in adults prior to receiving specific walking rehabilitation. Following PRISMA guidelines, a meta-analysis was conducted on two kinds of WS: the principal criterion focused on short-distance WS (ten-meter walking test) and the secondary criteria focused on long-distance WS (6-min test) and meta-regressions to study the association of WS with balance, cognitive disorders and autonomy. Nine studies comprising a total of 939 data on post-stroke patients were selected. The weighted average age was 61 years [95% IC [55-67] and males represented 62% ± 2.7 of patients [57-67]. Average short-distance WS was 0.36 ± 0.06 m.s⁻¹ [95% CI (0.23–0.49)]. Average long-distance WS was 0.46 ± 0.1 m.s⁻¹ [95% CI (0.26–0.66)]. The funnel plot revealed asymmetry of publication bias and high heterogeneity of the nine studies (I² index 98.7% and Q-test p < 0.0001). Meta-regressions of secondary endpoints could not be performed due to a lack of study data. At the SSS, WS would be lower than data in general population published in literature, but above all, lower than the WS required for safe daily autonomy and community ambulation after stroke. WS must be a priority objective of stroke rehabilitation to increase walking function but also for survival, autonomy, social participation and health-related quality of life.

Cognitive and gait outcomes after primary endoscopic third ventriculostomy in adults with chronic obstructive hydrocephalus

OBJECTIVE

The object of this study was to determine the short- and long-term efficacy of primary endoscopic third ventriculostomy (ETV) on cognition and gait in adults with chronic obstructive hydrocephalus.

METHODS

Patients were prospectively accrued through the Adult Hydrocephalus Clinical Research Network patient registry. Patients with previously untreated congenital or acquired obstructive hydrocephalus were included in this study. Gait velocity was assessed using a 10-m walk test. Global cognition was assessed with the Montreal Cognitive Assessment (MoCA). Only patients with documented pre- and post-ETV gait analysis and/or pre- and post-ETV MoCA were included.

RESULTS

A total of 74 patients had undergone primary ETV, 42 of whom were analyzed. The remaining 32 patients were excluded, as they could not complete both pre- and post-ETV assessments. The mean age of the 42 patients, 19 (45.2%) of whom were female, was 51.9 ± 17.1 years (range 19-79 years). Most patients were White (37 [88.1%]), and the remainder were Asian. Surgical complications were minor. Congenital etiologies occurred in 31 patients (73.8%), with aqueductal stenosis in 23 of those patients (54.8%). The remaining 11 patients (26.2%) had acquired cases. The gait short-term follow-up cohort (mean 4.7 ± 4.1 months, 35 patients) had a baseline median gait velocity of 0.9 m/sec (IQR 0.7-1.3 m/sec) and a post-ETV median velocity of 1.3 m/sec (IQR 1.1-1.4 m/sec). Gait velocity significantly improved post-ETV with a median within-patient change of 0.3 m/sec (IQR 0.0-0.6 m/sec, p < 0.001). Gait velocity improvements were sustained in the long term (mean 14 ± 2.8 months, 12 patients) with a baseline median velocity of 0.7 m/sec (IQR 0.6-1.3 m/sec), post-ETV median of 1.3 m/sec (IQR 1.1-1.7 m/sec), and median within-patient change of 0.4 m/sec (IQR 0.2-0.6 m/sec, p < 0.001). The cognitive short-term follow-up cohort (mean 4.6 ± 4.0 months, 38 patients) had a baseline median MoCA total score (MoCA TS) of 24/30 (IQR 23-27) that improved to 26/30 (IQR 24-28) post-ETV. The median within-patient change was +1 point (IQR 0-2 points, p < 0.001). However, this change is not clinically significant. The cognitive long-term follow-up cohort (mean 14 ± 3.1 months, 15 patients) had a baseline median MoCA TS of 23/30 (IQR 22-27), which improved to 26/30 (IQR 25-28) post-ETV. The median within-patient change was +2 points (IQR 1-3 points, p = 0.007), which is both statistically and clinically significant.

CONCLUSIONS

Primary ETV can safely improve symptoms of gait and cognitive dysfunction in adults with chronic obstructive hydrocephalus. Gait velocity and global cognition were significantly improved, and the worsening of either was rare following ETV.

Do older adults present altered pelvic and trunk movement pattern during gait? A systematic review with meta-analysis and GRADE recommendations

BACKGROUND

Cognitive, sensory, and biomechanical factors may affect gait of older adults. Among biomechanical factors, reduced pelvis and trunk range of motion (ROM) were associated with slower gait speed, shorter step length, and increased susceptibility to fall in older adults.

OBJECTIVE

To systematically review the studies that compared trunk and pelvic movement during gait among adults and older adults.

METHODS

Electronic search was conducted on MEDLINE, EMBASE, and Cinahl from inception until May 2020. Studies that compared trunk and/or pelvis kinematics during gait between adults and older adults were included. The following data were extracted from studies: gait speed, walking surface, and pelvis trunk ROM during gait in the three planes of motion. Meta-analyses were calculated for slow, comfortable, and fast gait speeds using random effects models. GRADE determined the strength of evidence.

RESULTS

Twelve studies were included in this review. There was moderate-quality evidence that older adults have reduced pelvic rotation ROM at comfortable speed (SMD = -0.90 [-1.35, -0.45]) and high-quality evidence that older adults also have reduced pelvic rotation ROM at fast walking speed (SMD = -1.55 [-3.43, -0.33]). In addition, there was low-quality evidence that older adults have reduced trunk rotation at fast walking speed (SMD = -0.63 [-1.23, -0.03]). There were no differences for pelvic and trunk movement in the sagittal and frontal planes.

CONCLUSION

There is low to high quality of evidence that older adults walk with less pelvic rotation ROM in comfortable and fast walking speeds, and less trunk rotation ROM during fast walking speed.

Catechol-O-methyltransferase (COMT) polymorphism predicts rapid gait speed changes in healthy older adults

IMPORTANCE

Adapting one's gait speed to external circumstances is critical for safe ambulation. Dopamine (DA), critical for adapting to increased task demands, predicts usual gait speed and may exert a greater role in complex tasks like rapid gait speed.

OBJECTIVE

We hypothesized that a genotypic proxy indicator of greater prefrontal DA signaling would predict significantly faster rapid gait.

DESIGN

Longitudinal cohort study over 8 years.

SETTING

Community-dwelling adults with no baseline mobility disability.

PARTICIPANTS

N = 2353 participants from the Health ABC Study.

MEASUREMENTS

Repeated measures of walking speed (meters/sec) were obtained in response to: "walk as fast as possible… (rapid gait) or "walk at your usual pace (usual gait)." Catechol-O-methyltransferase (COMT) val158met polymorphism indicated DA signaling (val/val = higher metabolism, lower DA signaling; met/met = lower metabolism, higher DA signaling).

RESULTS

Participants declined in rapid gait from 1.55 (SD = 0.33) to 1.35 m/s (SD = 0.34). Across the full follow-up period, the met/met genotype was associated with significantly greater rapid gait slowing. In mixed effect models, between-group differences were independent of covariates, and remained similar after adjustment for sensorimotor function, cognition, depressive symptoms, and energy. Follow-up analyses indicated the met/met genotype had a significantly faster rapid gait speed compared to the val/val genotype for the first 3 years (p < 0.01) but not years 4-8 (p > 0.05).

CONCLUSION

Greater prefrontal DA measured with COMT polymorphism may facilitate short-term adaptation to rapid walking demands that are lost over time. Studies should examine whether these effects are long-term and the underlying mechanistic pathways.

Ankle Power Generation Has a Greater Influence on Walking Speed Reserve Than Balance Following Traumatic Brain Injury

OBJECTIVE

Reduced walking speed is common following traumatic brain injury (TBI). Walking speed reserve (WSR) refers to the ability to increase walking speed on demand and is calculated as the difference between self-selected and fast walking speeds. Walking speed reserve is important for adaptive functional mobility in the community. Predictors of WSR following TBI are yet to be determined. The aim of the study was to identify whether static balance or ankle power generation (APG) was a stronger predictor of WSR following TBI.

SETTING

A major metropolitan rehabilitation hospital.

PARTICIPANTS

A total of 92 individuals receiving inpatient physiotherapy for mobility limitations following TBI were recruited.

DESIGN

A cross-sectional study.

METHODS

Walking speed (self-selected and fast), APG, and a summed single-leg stance scores were measured. The ability to increase walking speed on demand by 0.20 m/s or more defined WSR. Correlations, logistic regression, and receiver operating characteristic (ROC) curve analyses were performed to investigate independent relationships between WSR, APG, and static balance.

RESULTS

Fifty participants (54.3%) had a WSR of 0.20 m/s or more. The strongest predictor of WSR was APG (odds ratio [OR] = 3.34; 95% CI, 1.50-7.43) when compared with static balance (OR = 1.03; 95% CI, 1.01-1.06). The ROC curve demonstrated that APG could accurately discriminate between individuals with a WSR from those without (AUC [area under the ROC curve] = 0.79; 95% CI, 0.70-0.88). The APG cutoff score identified on the curve that maximized combined sensitivity (92.0%) and specificity (54.8%) was 0.75 W/kg.

CONCLUSION

Following TBI, APG was a stronger predictor of WSR than static balance. Clinicians should consider interventions that preferentially target APG in order to increase WSR for community mobility.

Changes in Walking Speed After High-Intensity Treadmill Training Are Independent of Changes in Spatiotemporal Symmetry After Stroke

Objectives: Decreased walking speeds and spatiotemporal asymmetry both occur after stroke, but it is unclear whether and how they are related. It is also unclear whether rehabilitation-induced improvements in walking speed are associated with improvements in symmetry or greater asymmetry. High-intensity speed-based treadmill training (HISTT) is a recent rehabilitative strategy whose effects on symmetry are unclear. The purpose of this study was to: (1) assess whether walking speed is cross-sectionally associated with spatiotemporal symmetry in chronic stroke, (2) determine whether HISTT leads to changes in the spatiotemporal symmetry of walking, and (3) evaluate whether HISTT-induced changes in walking speed are associated with changes in spatiotemporal symmetry.

Methods: Eighty-one participants with chronic stroke performed 4 weeks of HISTT. At pre, post, and 3-month follow-up assessments, comfortable and maximal walking speed were measured with the 10-meter walk test, and spatiotemporal characteristics of walking were measured with the GAITRite mat. Step length and swing time were expressed as symmetry ratios (paretic/non-paretic). Changes in walking speed and symmetry were calculated and the association was determined.

Results: At pre-assessment, step length and swing time asymmetries were present (p < 0.001). Greater temporal symmetry was associated with faster walking speeds (p ≤ 0.001). After HISTT, walking speeds increased from pre-assessment to post-assessment and follow-up (p ≤ 0.002). There were no changes in spatiotemporal symmetry (p ≥ 0.10). Change in walking speed was not associated with change in spatial or temporal symmetry from pre- to post-assessment or from post-assessment to follow-up (R² ≤ 0.01, p ≥ 0.37).

Conclusions: HISTT improves walking speed but does not systematically improve or worsen spatiotemporal symmetry. Clinicians may need to pair walking interventions like HISTT with another intervention designed to improve walking symmetry simultaneously. The cross-sectional relation between temporal symmetry and walking speed may be mediated by other factors, and not be causative.

A comprehensive, open-source dataset of lower limb biomechanics in multiple conditions of stairs, ramps, and level-ground ambulation and transitions

We introduce a novel dataset containing 3-dimensional biomechanical and wearable sensor data from 22 able-bodied adults for multiple locomotion modes (level-ground/treadmill walking, stair ascent/descent, and ramp ascent/descent) and multiple terrain conditions of each mode (walking speed, stair height, and ramp inclination). In this paper, we present the data collection methods, explain the structure of the open dataset, and report the sensor data along with the kinematic and kinetic profiles of joint biomechanics as a function of the gait phase. This dataset offers a comprehensive source of locomotion information for the same set of subjects to motivate applications in locomotion recognition, developments in robotic assistive devices, and improvement of biomimetic controllers that better adapt to terrain conditions. With such a dataset, models for these applications can be either subject-dependent or subject-independent, allowing greater flexibility for researchers to advance the field.

The role of theory to develop and evaluate a toolkit to increase clinical measurement and interpretation of walking speed and distance in adults post-stroke

PURPOSE

The iWalk study showed that 10-meter walk test (10mWT) and 6-minute walk test (6MWT) administration post-stroke increased among physical therapists (PTs) following introduction of a toolkit comprising an educational guide, mobile app, and video. We describe the use of theory guiding toolkit development and a process evaluation.

MATERIALS AND METHODS

We used the knowledge-to-action framework to identify research steps; and a guideline implementability framework, self-efficacy theory, and the transtheoretical model to design and evaluate the toolkit and implementation process (three learning sessions). In a before-and-after study, 37 of the 49 participating PTs completed online questionnaires to evaluate engagement with learning sessions, and rate self-efficacy to perform recommended practices pre- and post-intervention. Thirty-three PTs and 7 professional leaders participated in post-intervention focus groups and interviews, respectively.

RESULTS

All sites conducted learning sessions; attendance was 50-78%. Self-efficacy ratings for recommended practices increased and were significant for the 10mWT (p ≤ 0.004). Qualitative findings highlighted that theory-based toolkit features and implementation strategies likely facilitated engagement with toolkit components, contributing to observed improvements in PTs' knowledge, attitudes, skill, self-efficacy, and clinical practice.

CONCLUSIONS

The approach may help to inform toolkit development to advance other rehabilitation practices of similar complexity.Implications for RehabilitationToolkits are an emerging knowledge translation intervention used to support widespread implementation of clinical practice guideline recommendations.Although experts recommend using theory to inform the development of knowledge translation interventions, there is little guidance on a suitable approach.This study describes an approach to using theories, models and frameworks to design a toolkit and implementation strategy, and a process evaluation of toolkit implementation.Theory-based features of the toolkit and implementation strategy may have facilitated toolkit implementation and practice change to increase clinical measurement and interpretation of walking speed and distance in adults post-stroke.

Distance-limited walk tests post-stroke: A systematic review of measurement properties

BACKGROUND

Improving walking capacity is a key objective of post-stroke rehabilitation. Evidence describing the quality and protocols of standardized tools for assessing walking capacity can facilitate their implementation.

OBJECTIVE

To synthesize existing literature describing test protocols and measurement properties of distance-limited walk tests in people post-stroke.

METHODS

Electronic database searches were completed in 2017. Records were screened and appraised for quality.

RESULTS

Data were extracted from 43 eligible articles. Among the 12 walk tests identified, the 10-metre walk test (10mWT) at a comfortable pace was most commonly evaluated. Sixty-three unique protocols at comfortable and fast paces were identified. Walking pace and walkway surface, but not walkway length, influenced walking speed. Intraclass correlation coefficients for test-retest reliability ranged from 0.80-0.99 across walk tests. Measurement error values ranged from 0.04-0.40 and 0.06 to 0.20 for the 10mWT at comfortable and fast and paces, respectively. Across walk tests, performance was most frequently correlated with measures of strength, balance, and physical activity (r = 0.26-0.8, p < 0.05).

CONCLUSIONS

The 10mWT has the most evidence of reliability and validity. Findings indicate that studies that include people with severe walking deficits, in acute and subacute phases of recovery, with improved quality of reporting, are needed.

Feasibility of motor-assisted elliptical to improve walking, fitness and balance following pediatric acquired brain injury: A case series

PURPOSE

Walking, fitness, and balance deficits are common following acquired brain injury (ABI). This study assessed feasibility, acceptability, and usefulness of a modified motor-assisted elliptical (ICARE) in addressing walking, fitness, and balance deficits in children with chronic ABIs.

METHODS

Three children (> 5 years post-ABI) completed 24 ICARE exercise sessions (exercise time, speed, and time overriding motor-assistance gradually increased) to promote mass repetition of gait-like movements and challenge cardiorespiratory fitness. Parents' and children's perceptions of ICARE's safety, comfort, workout, and usability were assessed. Cardiovascular response, gait and balance outcomes were assessed.

RESULTS

No adverse events occurred. Parent's Visual Analogue Scale (VAS) scores of perceived device safety (range 80-99), workout (range 99-100), and usability (range 75-100) were high, while comfort were 76-80 given commercial harness fit and arm support. Children's VAS scores all exceeded 89. Comfortable walking velocity, 2-Minute Walk Test, fitness, and Pediatric Balance Scale scores improved post-training, with many outcomes surpassing established minimal clinically important differences.

CONCLUSION

Following engagement in moderate- to vigorous-intensity exercise promoting repetitive step-like movements on a specially adapted motor-assisted elliptical, three children with chronic ABI demonstrated improvements in walking, fitness and balance. Future research in community-based environments with a larger cohort of children with ABI is needed.

Kinetic Gait Changes after Robotic Exoskeleton Training in Adolescents and Young Adults with Acquired Brain Injury

Background

Acquired brain injury (ABI) is one of the leading causes of motor deficits in children and adults and often results in motor control and balance impairments. Motor deficits include abnormal loading and unloading, increased double support time, decreased walking speed, control, and coordination. These deficits lead to diminished functional ambulation and reduced quality of life. Robotic exoskeletons (RE) for motor rehabilitation can provide the user with consistent, symmetrical, goal-directed repetition of movement, as well as balance and stability.

Purpose

The goal of this preliminary prospective before and after study is to evaluate the therapeutic effect of RE training on the loading/unloading and spatial-temporal characteristics in adolescents and young adults with chronic ABI.

Method

Seven participants diagnosed with ABI between the ages of 14 and 27 years participated in the study. All participants received twelve 45 minute sessions of RE gait training. The bilateral loading (linearity of loading and rate of loading), speed, step length, swing time, stance time, and total time were collected using Zeno™ walkway (ProtoKinetics, Havertown, PA, USA) before and after RE training.

Results

Results from the study showed improved step length, speed, and an overall progression towards healthy bilateral loading, with linearity of loading showing a significant therapeutic effect (p < 0.05).

Conclusion

These preliminary results suggest that high dose, repetitive, consistent gait training using RE has the potential to induce recovery of function in adolescents and young adults diagnosed with ABI.

Development and Validation of Person-Centered Cut-Points for the Figure-of-8-Walk Test of Mobility in Community-Dwelling Older Adults

BACKGROUND

The Figure-of-8-Walk test (F8WT) is a performance measure of the motor skill of walking. Unlike walking speed over a straight path, it captures curved path walking, which is essential to real-world activity, but meaningful cut-points have yet to be developed for the F8WT.

METHODS

A secondary analysis of 421 community-dwelling older adults (mean age 80.7 ± 7.8), who participated in a community-based exercise clinical trial, was performed. Area under receiver operating characteristic curves (AUROCC) were calculated using baseline data, with F8WT performance discriminating different self-reported global mobility and balance dichotomies. Cut-points for the F8WT were chosen to optimize sensitivity and specificity. For validation, F8WT cut-points were applied to postintervention F8WT data. Participants were called monthly for 12 months after intervention completion to record self-reported incident falls, emergency department visits, and hospitalizations; risks of the outcomes were compared between those who performed well and poorly on the F8WT.

RESULTS

F8WT performance times of ≤9.09 seconds and ≤9.27 seconds can discriminate those with excellent (sensitivity = 0.647; specificity = 0.654) and excellent/very good global mobility (sensitivity = 0.649; specificity = 0.648), respectively. A total number of steps ≤17 on the F8WT can discriminate those with excellent/very good/good global balance (sensitivity = 0.646; specificity = 0.608). Compared to those who performed poorly, those who performed well had a lower incidence of negative outcomes: F8WT time ≤9.09 seconds = 46%-59% lower; F8WT time ≤9.27 seconds = 46%-56% lower; F8WT steps ≤17 = 44%-50% lower.

CONCLUSIONS

Clinicians may consider these preliminary cut-points to aid in their clinical decision making, but further study is needed for definitive recommendations.

Effects of an Overground Walking Program With a Robotic Exoskeleton on Long-Term Manual Wheelchair Users With a Chronic Spinal Cord Injury: Protocol for a Self-Controlled Interventional Study

BACKGROUND

In wheelchair users with a chronic spinal cord injury (WUSCI), prolonged nonactive sitting time and reduced physical activity-typically linked to this mode of mobility-contribute to the development or exacerbation of cardiorespiratory, musculoskeletal, and endocrine-metabolic health complications that are often linked to increased risks of chronic pain or psychological morbidity. Limited evidence suggests that engaging in a walking program with a wearable robotic exoskeleton may be a promising physical activity intervention to counter these detrimental health effects.

OBJECTIVE

This study's overall goals are as follows: (1) to determine the effects of a 16-week wearable robotic exoskeleton-assisted walking program on organic systems, functional capacities, and multifaceted psychosocial factors and (2) to determine self-reported satisfaction and perspectives with regard to the intervention and the device.

METHODS

A total of 20 WUSCI, who have had their injuries for more than 18 months, will complete an overground wearable robotic exoskeleton-assisted walking program (34 sessions; 60 min/session) supervised by a physiotherapist over a 16-week period (one to three sessions/week). Data will be collected 1 month prior to the program, at the beginning, and at the end as well as 2 months after completing the program. Assessments will characterize sociodemographic characteristics; anthropometric parameters; sensorimotor impairments; pain; lower extremity range of motion and spasticity; wheelchair abilities; cardiorespiratory fitness; upper extremity strength; bone architecture and mineral density at the femur, tibia, and radius; total and regional body composition; health-related quality of life; and psychological health. Interviews and an online questionnaire will be conducted to measure users' satisfaction levels and perspectives at the end of the program. Differences across measurement times will be verified using appropriate parametric or nonparametric analyses of variance for repeated measures.

RESULTS

This study is currently underway with active recruitment in Montréal, Québec, Canada. Results are expected in the spring of 2021.

CONCLUSIONS

The results from this study will be essential to guide the development, implementation, and evaluation of future evidence-based wearable robotic exoskeleton-assisted walking programs offered in the community, and to initiate a reflection regarding the use of wearable robotic exoskeletons during initial rehabilitation following a spinal cord injury.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03989752; https://clinicaltrials.gov/ct2/show/NCT03989752.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19251.

Cortical priming strategies for gait training after stroke: a controlled, stratified trial

BACKGROUND

Stroke survivors experience chronic gait impairments, so rehabilitation has focused on restoring ambulatory capacity. High-intensity speed-based treadmill training (HISTT) is one form of walking rehabilitation that can improve walking, but its effectiveness has not been thoroughly investigated. Additionally, cortical priming with transcranial direct current stimulation (tDCS) and movement may enhance HISTT-induced improvements in walking, but there have been no systematic investigations. The objective of this study was to determine if motor priming can augment the effects of HISTT on walking in chronic stroke survivors.

METHODS

Eighty-one chronic stroke survivors participated in a controlled trial with stratification into four groups: 1) control-15 min of rest (n = 20), 2) tDCS-15 min of stimulation-based priming with transcranial direct current stimulation (n = 21), 3) ankle motor tracking (AMT)-15 min of movement-based priming with targeted movements of the ankle and sham tDCS (n = 20), and 4) tDCS+AMT-15 min of concurrent tDCS and AMT (n = 20). Participants performed 12 sessions of HISTT (40 min/day, 3 days/week, 4 weeks). Primary outcome measure was walking speed. Secondary outcome measures included corticomotor excitability (CME). Outcomes were measured at pre, post, and 3-month follow-up assessments.

RESULTS

HISTT improved walking speed for all groups, which was partially maintained 3 months after training. No significant difference in walking speed was seen between groups. The tDCS+AMT group demonstrated greater changes in CME than other groups. Individuals who demonstrated up-regulation of CME after tDCS increased walking speed more than down-regulators.

CONCLUSIONS

Our results support the effectiveness of HISTT to improve walking; however, motor priming did not lead to additional improvements. Upregulation of CME in the tDCS+AMT group supports a potential role for priming in enhancing neural plasticity. Greater changes in walking were seen in tDCS up-regulators, suggesting that responsiveness to tDCS might play an important role in determining the capacity to respond to priming and HISTT.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03492229. Registered 10 April 2018 - retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03492229 .

An Investigation of the Predictors of Comfortable and Fast Gait Speed in Community-Dwelling Older Adults

BACKGROUND/PURPOSE

To identify the unique predictors of comfortable and fast gait speed in community-dwelling older adults using measures of physical performance (eg, lower extremity strength and balance), self-reported balance confidence, and global cognitive function.

METHODS

Demographic information was collected from 60 healthy, community-dwelling older adults older than 60 years. Participants completed the following assessments: Mini-Mental State Examination; Activities-Specific Balance Confidence Scale; 30-second Chair Stand (30-SCS); Functional Reach (FR); and gait speed (comfortable and fast) using the GAITRite system. Hierarchical linear regression was used to examine the relationship of both fast and comfortable gait speeds with functional performance (CST and FR), cognition (Mini-Mental State Examination), Activities-Specific Balance Confidence Scale, and demographic information (age, gender, and body mass index).

RESULTS AND DISCUSSION

Functional performance measures (30-SCS and FR) explained 55.4% and 64.7%, respectively, of the variance in comfortable and fast gait speed. Unique predictors for comfortable gait speed included 30-SCS, FR, and body mass index. Unique predictors of fast gait speed included 30-SCS, FR, gender, body mass index, and Activities-Specific Balance Confidence Scale score. These predictors explained 68.5% and 80.4% of the total variance in comfortable and fast gait speed, respectively. Global cognition was not a unique predictor of gait speed when performance measures were statistically controlled. However, the current study measured global cognitive status rather than the specific cognitive constructs, such as processing speed or executive function. Further research is needed to determine the role of cognition in the composition of gait speed.

CONCLUSIONS

Gait speed is an important indicator for many outcomes such as fall risk, mortality, and functional status. Understanding that key variables of strength and balance comprise a large portion of gait speed allows clinicians to better direct their care and optimize rehabilitation outcomes. This study specifically used functional measures of strength and balance that can be easily implemented in the clinical setting.

Balance and Gait After First Minor Ischemic Stroke in People 70 Years of Age or Younger: A Prospective Observational Cohort Study

BACKGROUND

Two-thirds of patients with stroke experience only mild impairments in the acute phase, and the proportion of patients <70 years is increasing. Knowledge about balance and gait and predictive factors are scarce for this group.

OBJECTIVE

The objective of this study was to explore balance and gait in the acute phase and after 3 and 12 months in patients ≤70 years with minor ischemic stroke (National Institutes of Health Stroke Scale score ≤3). This study also explored factors predicting impaired balance after 12 months.

DESIGN

This study was designed as an explorative longitudinal cohort study.

METHODS

Patients were recruited consecutively from 2 stroke units. Balance and gait were assessed with the Mini-Balance Evaluation Systems Test (Mini-BESTest), Timed Up and Go, and preferred gait speed. Predictors for impaired balance were explored using logistic regression.

RESULTS

This study included 101 patients. Mean (SD) age was 55.5 (11.4) years, 20% were female, and mean (SD) National Institutes of Health Stroke Scale score was 0.6 (0.9) points. The Mini-BESTest, gait speed, and Timed Up and Go improved significantly from the acute phase to 3 months, and gait speed also improved from 3 to 12 months. At 12 months, 26% had balance impairments and 33% walked slower than 1.0 m/s. Poor balance in the acute phase (odds ratio = 0.92, 95% confidence interval = 0.85-0.95) was the only predictor of balance impairments (Mini-BESTest score ≤22) at 12 months poststroke.

LIMITATIONS

Limitations include lack of information about pre-stroke balance and gait impairment and poststroke exercise. Few women limited the generalizability.

CONCLUSION

This study observed improvements in both balance and gait during the follow-up; still, about one-third had balance or gait impairments at 12 months poststroke. Balance in the acute phase predicted impaired balance at 12 months.

Wearable Sensors Quantify Mobility in People With Lower Limb Amputation During Daily Life

It is necessary to effectively assess functional mobility for appropriate prosthetic prescription and post-amputation rehabilitation. As part of this process, patients' ability for variable cadence and community ambulation are assessed in-clinic, often through visual assessments and without objective standards. The purpose of this study was to explore the clinical viability of using wearable sensors to characterize the functional mobility of people with lower limb amputation. We collected inertial measurement unit (IMU) and global positioning system (GPS) data over two weeks, from 17 individuals with lower limb amputation and 14 healthy non-amputee controls. We calculated stride-by-stride cadence, walking speed and stride lengths, along with whether they occurred in or out of the home. Self-selected walking speed was also assessed in the lab. Compared to the lab, both groups walked slower and with a lower cadence during their daily lives. There were no differences in cadence variability between groups or between strides taken in and out of the home. Both groups walked faster and with greater stride lengths away from the homes. The results suggest that functional capacity measured in the lab was not necessarily reflected in routine walking during daily life. The walking measures derived in this approach can be used to aid in the prosthetic prescription process or in the assessment of different interventions.

Relevance of medical comorbidities for functional mobility in people with limb loss: retrospective explanatory models for a clinical walking measure and a patient-reported functional outcome

OBJECTIVES

Various modifiable and non-modifiable factors affect functional mobility, but subjective patient-reported and objective performance-based measures are rarely combined in explanatory analyses of functional mobility in people with limb loss. This study determined separate explanatory models for patient-reported function using the Prosthetic Evaluation Questionnaire Mobility Subscale (PEQ-MS), and performance-based 2-Minute Walk Test (2MWT).

DESIGN

Retrospective cross-sectional observational analysis.

SETTING

Wellness-walking program.

PARTICIPANTS

Three hundred five volunteers with lower limb loss participated. Sixty nine percent were men, mean age 56 (15) years. Fifty two percent had vascular amputation causes, 42% had surgical levels above the knee, and 82% had medical comorbidities. Walking levels included limited-household (21%), limited-community (30%), and independent-community (49%). Outcome measures included patient-reported PEQ-MS, Activities-specific Balance Confidence (ABC) and Houghton scales; and performance-based balance and walking.

MAIN OUTCOMES

Separate PEQ-MS and 2MWT multiple regression models fit using backward deletion.

RESULTS

Modifiable (balance ability, ABC, Houghton score; P<0.05) and non-modifiable factors (sex, amputation cause, surgical level; P<0.05) explained the variance in 2MWT (adjusted R²=0.685). Patient-reported and performance-based modifiable factors (Houghton score, 2MWT; P<0.001) explained PEQ-MS variance (adjusted R²=0.660). Integumentary (P=0.022) and cardiopulmonary (P<0.001) comorbidities explained an additional 4% of PEQ-MS variance, while surgical level was insignificant.

CONCLUSIONS

Both modifiable and non-modifiable factors explained prosthetic functional mobility. Performance-based walking was explained by modifiable factors including balance ability and confidence, prosthesis and walking aid use. Patient-reported function was also explained by prosthesis and walking aid use, walking speed and medical comorbidities. Modifiable factors for objective and subjective prosthetic mobility may provide a clinical roadmap for rehabilitation.

Self-perceived functioning and disability after randomized conventional and electromechanically-assisted gait training in subacute stroke: A 6 months follow-up

BACKGROUND

Few previous studies have assessed self-perceived functioning, disability and recovery after electromechanically-assisted gait training (EAGT).

OBJECTIVE

To compare self-perceived functioning, disability and recovery after EAGT and after conventional gait training in the subacute stage after stroke, using the Stroke Impact Scale (SIS), and factors associated with self-perceived recovery, assessed at 6 months after stroke.

METHODS

Patients were randomized into two groups performing a 4-week intervention period of incorporated EAGT using the Hybrid Assistive Limb (HAL) or conventional physiotherapy only.

RESULTS

There were no significant differences in self-perceived strength, ADL, mobility, participation and percentage of recovery between intervention groups (p > 0.05). Self-perceived mobility was associated with improvements in objectively assessed walking speed/endurance and balance (R2 0.717, p = 0.002), and self-perceived recovery with self-perceived activities of daily living (ADL) ability (R2 0.34, p = 0.001).

CONCLUSIONS

This study indicates that EAGT and conventional gait training in the subacute stage after stroke have no differential impact on self-perceived functioning, disability and recovery at 6 months after stroke. Further, the study highlights the importance of interventions targeting ADL and self-care independence during stroke rehabilitation to enhance self-perceived recovery and clinical aspects to be targeted to enhance perceived mobility.

A new two square agility test for workplace health-reliability, validity and minimal detectable change

[Purpose] One promising strategy for workplace wellness programs is to emphasize functional mobility screening and coaching to promote suitable physical activity and reduce musculoskeletal risks. This study examined intra-rater reliability, test-retest reliability, concurrent validity, known-groups validity and minimal detectable change for a new Two Square Agility Test (TSAT) designed as a functional mobility measure to promote workplace health. [Participants and Methods] Two hundred forty eight non-disabled participants (ages 18-69) were measured for body size, physical activity and 3 trials of the Two Square Agility Test. 78 participants were tested a week later on the Two Square Agility Test and other functional mobility tests. [Results] Intra-rater reliability was excellent (ICC=0.94) and test-retest reliability was good (ICC=0.87). Two Square Agility Test correlated moderately with Timed Up and Go (r=0.63), Five Times Sit to Stand (r=0.62), and Maximum Step Length (r= -0.54), supporting its concurrent validity. Performances for Two Square Agility Test were better in males, younger age, higher physical activity, and non-obese groups. The minimal detectable change at a 95% confidence level (MDC₉₅) was 1.37 s. [Conclusion] Preliminary results supported reliability and validity of Two Square Agility Test as a functional mobility measure to promote workplace health.

Systematic review and meta-analysis of tick-borne disease risk factors in residential yards, neighborhoods, and beyond

BACKGROUND

Exposure to blacklegged ticks Ixodes scapularis that transmit pathogens is thought to occur peri-domestically. However, the locations where people most frequently encounter infected ticks are not well characterized, leading to mixed messages from public health officials about where risk is highest.

METHODS

We conducted a systematic review and meta-analysis on spatial risk factors for tick-borne disease and tick bites in eastern North America. We examined three scales: the residential yard, the neighborhood surrounding (but not including) the yard, and outside the neighborhood. Nineteen eligible studies represented 2741 cases of tick-borne illness and 1447 tick bites. Using random effects models, we derived pooled odds ratio (OR) estimates.

RESULTS

The meta-analysis revealed significant disease risk factors at the scale of the yard (OR 2.60 95% CI 1.96 - 3.46), the neighborhood (OR 4.08 95% CI 2.49 - 6.68), and outside the neighborhood (OR 2.03 95% CI 1.59 - 2.59). Although significant risk exists at each scale, neighborhood scale risk factors best explained disease exposure. Analysis of variance revealed risk at the neighborhood scale was 57% greater than risk at the yard scale and 101% greater than risk outside the neighborhood.

CONCLUSIONS

This analysis emphasizes the importance of understanding and reducing tick-borne disease risk at the neighborhood scale. Risk-reducing interventions applied at each scale could be effective, but interventions applied at the neighborhood scale are most likely to protect human health.

TRIAL REGISTRATION

The study was registered with PROSPERO: CRD42017079169 .

Outcome Measures of Free-Living Activity in Spinal Cord Injury Rehabilitation

PURPOSE OF REVIEW

The purpose of this article was to describe the utilization of body worn activity monitors in the SCI population and discuss the challenges of using body worn sensors in rehabilitation research.

RECENT FINDINGS

Many activity monitor-based measures have been used and validated in the SCI population including stroke number, push frequency, upper limb activity counts and wheelchair propulsion distance measured from a sensor attached to the wheelchair.

SUMMARY

The ability to accurately measure physical activity in the free-living environment using body-worn sensors has the potential to enhance the understanding of barriers to adequate activity and identify possible effective interventions. As the use of activity monitors used in SCI rehabilitation research continues to grow, care must be taken to overcome challenges related to participant adherence and data quality.

Associations of Usual Pace and Complex Task Gait Speeds With Incident Mobility Disability

BACKGROUND/OBJECTIVES

To assess whether gait speed under complex conditions predicts long-term risk for mobility disability as well as or better than usual-pace gait speed.

DESIGN

Longitudinal cohort study.

SETTING/PARTICIPANTS

Subsample of Health Aging and Body Composition study with follow-up from 2002 to 2003 to 2010 to 2011, including 337 community-dwelling adults (mean age = 78.5 years, 50.7% female, 26.1% black).

MEASUREMENTS

Associations of gait speed measured under usual-pace, fast-pace, dual-task, and narrow-path conditions with mobility disability, defined by any self-reported difficulty walking ¼ mile assessed annually, were tested by Cox proportional hazard models adjusted for demographic and health characteristics. Models were fitted for each walking condition, and R² statistics were used to compare predictive value across models. Models were repeated for persistent mobility disability, defined as at least two consecutive years of mobility disability.

RESULTS

Mobility disability occurred in 204 (60.5%) participants over the 8-year follow-up. There was a lower hazard of developing mobility disability with faster gait speed under all conditions. Hazard ratios, confidence intervals, and R² of gait speed predicting mobility disability were similar across all four walking conditions (R² range = 0.22-0.27), but were strongest for dual-task gait speed (hazard ratio [95% confidence interval], R² of fully adjusted models = 0.81 [0.75-0.88], 0.27). Results were comparable for persistent mobility disability (R² range = 0.26-0.28).

CONCLUSION

Slower gait speed under both usual-pace and complex conditions may be a clinical indicator of future risk of mobility disability. These results support the call for increased use of gait speed measures in routine geriatric care. J Am Geriatr Soc 67:2072-2076, 2019.

Exoskeletons for Personal Use After Spinal Cord Injury

Before the development of robotic exoskeletons, mobility options beyond a wheelchair were very limited for most people lacking leg movement due to spinal cord injury (SCI). Over the years, robotic exoskeletons have become more widely available and now have the potential to be successfully used for personal use at home and in the community. However, it is important that users set realistic expectations. The features and capabilities of each robotic exoskeleton differ, and how exoskeletons are used may vary greatly between individuals. Robotic exoskeletons can allow individuals with SCI with varying levels of injury to safely and functionally walk for personal mobility or exercise. The following special communication will discuss important considerations surrounding exoskeleton use including feasibility, safety, cost, speed, and potential health benefits of using an exoskeleton for everyday life for people with SCI.

Physical activity of children and adolescents with Charcot-Marie-Tooth neuropathies: A cross-sectional case-controlled study

BACKGROUND

Disability related to the progressive and degenerative neuropathies known collectively as Charcot-Marie-Tooth disease (CMT) affects gait and function, increasing with age and influencing physical activity in adults with CMT. The relationship between CMT-related disability, ambulatory function and physical activity in children and adolescents with CMT is unknown.

METHOD

A cross-sectional case-controlled study of physical activity in 50 children with CMT and age- and gender-matched typically developing (TD) controls [mean age 12.5 (SD 3.9) years]. A 7-day recall questionnaire assessed physical activity; CMT-related disability and gait-related function were measured to explore factors associated with physical activity.

RESULTS

Children with CMT were less active than TD controls (estimated weekly moderate to vigorous physical activity CMT 283.6 (SD 211.6) minutes, TD 315.8 (SD 204.0) minutes; p < 0.001). The children with CMT had moderate disability [CMT Pediatric Scale mean score 17 (SD 8) /44] and reduced ambulatory capacity in a six-minute walk test [CMT 507.7 (SD 137.3) metres, TD 643.3 (74.6) metres; p < 0.001]. Physical activity correlated with greater disability (ρ = -0.56, p < 0.001) and normalised six-minute walk distance (ρ = 0.74, p < 0.001).

CONCLUSIONS

CMT-related disability affects physical activity and gait-related function in children and adolescents with CMT compared to TD peers. Reduced physical activity adversely affects function across the timespan of childhood and adolescence into adulthood in people with CMT.

Validity of the Walked Distance Estimated by Wearable Devices in Stroke Individuals

Background: Health professionals need valid devices to assess a stroke individual’s ability to walk. The aim was to evaluate the validity of the estimation of the walked distance by wearable devices and the impact of the sensor’s position in stroke individuals. Methods: Post-stroke patients able to walk without human assistance were equipped with several wearable devices: pedometers, Actigraph, and Sensewear Armband placed according to the manufacturers' recommendations. Participants walked for 6 min at a comfortable speed wearing all sensors at the same time. We analyzed the validity of sensor-estimated distances according to their position using Bland–Altman analysis, root-mean-square error, and coefficient of correlation. Results: In total, 35 individuals were included (mean age = 65 ± 15 years). The best estimations were given by the Actigraph worn on the unaffected ankle (mean bias (MB) = 22.6 ± 32.4 m; p = 0.37) and by the pedometer worn on the unaffected hip (MB = 20.5 ± 24.6 m; p = 0.46). The other sensors and positions provided large estimation errors over 95 m (p < 0.05). Conclusion: This study led to a recommendation of a pedometer worn on the unaffected hip or an Actigraph worn on the unaffected ankle to get a valid estimation of the distance walked by stroke individuals.

Effects of high intensity speed-based treadmill training on ambulatory function in people with chronic stroke: A preliminary study with long-term follow-up

High intensity treadmill training has shown to be beneficial for stroke survivors, yet the feasibility and long-term effects remain unclear. In this study, we aimed to determine whether a 4-week high intensity speed-based treadmill training (HISTT) is feasible for chronic stroke survivors, and we examined its effects on ambulatory function, and long-term retention. Sixteen individuals post-stroke participated in 40 minutes of HISTT for four weeks at a frequency of three sessions per week. Gait speed was measured using the 10-meter walk test, endurance was measured using the 6-minute walk test, and quality of life was assessed using the Stroke Impact Scale (SIS) at baseline, post-training, and at 3-month follow-up. All participants successfully completed the training without any serious adverse events. Participants significantly increased fastest walking speed by 19%, self-selected walking speed by 18%, and walking endurance by 12% after the training. These improvements were maintained for 3 months after the intervention. Our results indicate that this modified speed-based high intensity walking program has the potential to be a feasible and effective method of gait training for stroke survivors. However, the small sample size and lack of a control group warrant caution in interpretation of results. Further studies are recommended to better understand effectiveness of this protocol in combination with other physical therapy interventions for functional recovery after stroke.

Physical Performance and Fall Risk in Persons With Traumatic Brain Injury

Injuries sustained from traumatic brain injury (TBI) culminate in both cognitive and neuromuscular deficits. Patients often progress to higher functioning on the Rancho continuum even while mobility deficits persist. Although prior studies have examined physical performance among persons with chronic symptoms of TBI, less is known about the relatively acute phase of TBI as patients prepare for rehabilitation discharge. The aims of this cross-sectional study were to (a) compare balance and gait performance in 20 ambulant persons with moderate to severe TBI who were nearing rehabilitation discharge with their age-matched controls and (b) describe performance with thresholds for fall risk and community navigation. During a designed task circuit, 40 participants (20 persons with TBI and 20 controls) performed the Timed Up and Go (TUG), gait velocity, and Walking and Remembering tests. Balance testing included the Fullerton Advanced Balance Scale (FABS) and instrumented Modified Clinical Test for Sensory Interaction in Balance (MCTSIB). Statistical analyses included analysis of covariance for group comparisons and a multivariate analysis of covariance for MCTSIB sway velocities with anthropometric controls. The TBI group (mean [ M] age = 42, standard deviation [ SD] =19.5 years; 70% males) performed significantly more poorly on all mobility tests ( p < .05) and their scores reflected a potential fall risk. Gait velocity was significantly slower for the TBI versus control group ( M = .96, SD = 2.6 vs. M = 1.5, SD = 2.2 m/s; p < .001), including TUG times ( M = 13.5, SD = 4.9 vs. M = 7.7, SD = 1.4; p < .001). TBI participants also demonstrated significantly greater sway velocity on all MCTSIB conditions ( p < .01) and lower performance on the FABS ( p < .001). Performance indices indicate potential fall risk and community navigation compromise for individuals with moderate to severe TBI. Physical performance scores support the need for continued interventions to optimize functional mobility upon discharge.

Strength of the lower limb and trunk muscles is associated with gait speed in individuals with sub-acute stroke: a cross-sectional study

OBJECTIVES

To investigate the association between measures of strength of the lower limb and trunk muscles and gait speed and to identify the muscle group that would best predict gait speed in individuals with sub-acute stroke.

METHODS

Using a cross-sectional observational study design, forty-four individuals with sub-acute stroke (62 years, SD=14; 4 months, SD=1 post-stroke) were assessed. The evaluations were performed at a university laboratory, participants' homes, or community-based settings. Bilateral maximum isometric strength (hip, knee, and ankle flexors/extensors, hip abductors, trunk flexors/extensors, and trunk lateral flexors and rotators) was measured using a portable dynamometer. Comfortable and maximum gait speeds were measured using the 10-m walk test.

RESULTS

Weak to moderate associations were found between measures of strength of the lower limb muscles and comfortable (0.36≤r≤0.53; p<0.05) and maximum (0.37≤r≤0.59; p<0.05) gait speeds, except for the non-paretic knee flexors and comfortable gait speed (p=0.06). Weak to moderate associations were also found between measures of strength of the trunk muscles and comfortable (0.39≤r≤0.50; p<0.05) and maximum (0.39≤r≤0.61; p<0.05) gait speeds. Stepwise multiple regression analyses revealed that the non-paretic dorsiflexors and the left lateral trunk flexors explained 29% and 42% of the variance in the maximum and comfortable gait speeds, respectively.

CONCLUSIONS

The strength of the lower limb and trunk muscles was positively associated with comfortable and maximum gait speeds. The muscle strength of the non-paretic dorsiflexors and the left lateral trunk flexors might have a role to play in determining comfortable and maximum gait speeds of individuals with sub-acute stroke.

One-Quarter of People Leave Inpatient Stroke Rehabilitation with Physical Capacity for Community Ambulation

BACKGROUND AND PURPOSE

Ability to walk in the community is important for independence and participation in life roles, but is difficult for many people following stroke. The purpose of this study was to determine the proportion of people with stroke with the physical capacity to be independent community ambulators at discharge from a publicly funded inpatient rehabilitation setting.

METHOD

Consecutive medical records were audited to collate walking outcome at discharge, and to clarify if people with stroke had potential to walk independently in the community as defined by 4 criteria: independence with stairs; ability to traverse slopes and inclines; walking speed of .8m/s or more; and walking distance 367 m or higher on 6-Minute Walk Test.

RESULTS

While 80% of the 124 persons with stroke could walk indoors, only 27% could perform 4 essential skills needed to walk independently in the community at discharge from hospital. The proportion that met each criterion was 52% for stairs, 39% for slopes and inclines, 58% for speed, and 40% for distance. For the overall sample, mean (standard deviation) walking speed was .90 (.33) m/s, and distance for 6-Minute Walk Test was 349.6 (146.5) m.

DISCUSSION AND CONCLUSION

A retrospective review found that three quarters of stroke survivors lacked physical capacity for 4 skills required to walk independently in the community at the time of discharge from a public inpatient rehabilitation. Our findings recommend that people with stroke have access to outpatient physical rehabilitation to optimize walking outcome.

Allogeneic Human Mesenchymal Stem Cell Infusions for Aging Frailty

Background

Impaired endogenous stem cell repair capacity is hypothesized to be a biologic basis of frailty. Therapies that restore regenerative capacity may therefore be beneficial. This Phase 1 study evaluated the safety and potential efficacy of intravenous, allogeneic, human mesenchymal stem cell (allo-hMSC)-based therapy in patients with aging frailty.

Methods

In this nonrandomized, dose-escalation study, patients received a single intravenous infusion of allo-hMSCs: 20-million (n = 5), 100-million (n = 5), or 200-million cells (n = 5). The primary endpoint was incidence of any treatment-emergent serious adverse events measured at 1 month postinfusion. The secondary endpoints were functional efficacy domains and inflammatory biomarkers, measured at 3 and 6 months, respectively.

Results

There were no treatment-emergent serious adverse events at 1-month postinfusion or significant donor-specific immune reactions during the first 6 months. There was one death at 258 days postinfusion in the 200-million group. In all treatment groups, 6-minute walk distance increased at 3 months (p = .02) and 6 months (p = .001) and TNF-α levels decreased at 6 months (p < .0001). Overall, the 100-million dose showed the best improvement in all parameters, with the exception of TNF-α, which showed an improvement in both the 100- and 200-million groups (p = .0001 and p = .0001, respectively). The 100-million cell-dose group also showed significant improvements in the physical component of the SF-36 quality of life assessment at all time points relative to baseline.

Conclusions

Allo-hMSCs are safe and immunologically tolerated in aging frailty patients. Improvements in functional and immunologic status suggest that ongoing clinical development of cell-based therapy is warranted for frailty.

How does wearable robotic exoskeleton affect overground walking performance measured with the 10-m and six-minute walk tests after a basic locomotor training in healthy individuals?

It is still unknown to what extent overground walking with a WRE is equivalent to natural overground walking without a WRE. Hence, the interpretability of the 10-m (10MWT) and six-minute (6MWT) walk tests during overground walking with a WRE against reference values collected during natural overground walking without a WRE is challenging. This study aimed to 1) compare walking performance across three different overground walking conditions: natural walking without a WRE, walking with a WRE providing minimal assistance (active walking), and walking with a WRE proving complete assistance (passive walking) and 2) assess the association and the agreement between the 10MWT and the 6MWT during passive and active walking with a WRE. Seventeen healthy individuals who underwent basic locomotor training with a WRE performed the 10MWT (preferred and maximal speeds) and the 6MWT under the three conditions. For the 10MWT, the speed progressively and significantly decreased from natural walking without a WRE (preferred: 1.40±0.18m/s; maximal: 2.16±0.19m/s), to active walking with a WRE (preferred: 0.48±0.10m/s; maximal: 0.61±0.14m/s), and to passive walking with a WRE (preferred: 0.38±0.09m/s; maximal: 0.42±0.10m/s). For the 6MWT, total distances decreased from walking without a WRE (609±53.9m), to active walking with a WRE (196.6±42.6m), and to passive walking with a WRE (144.3±33.3m). The 10MWT and 6MWT provide distinct information and can't be used interchangeably to document speed only during active walking with the WRE. Speed and distance drastically decrease during active and, even more so, passive walking with the WRE in comparison to walking without a WRE. Selection of walking tests should depend on the level of assistance provided by the WRE.

Older adults must hurry at pedestrian lights! A cross-sectional analysis of preferred and fast walking speed under single- and dual-task conditions

Slow walking speed is strongly associated with adverse health outcomes, including cognitive impairment, in the older population. Moreover, adequate walking speed is crucial to maintain older pedestrians’ mobility and safety in urban areas. This study aimed to identify the proportion of Swiss older adults that didn’t reach 1.2 m/s, which reflects the requirements to cross streets within the green–yellow phase of pedestrian lights, when walking fast under cognitive challenge. A convenience sample, including 120 older women (65%) and men, was recruited from the community (88%) and from senior residences and divided into groups of 70–79 years (n = 59, 74.8 ± 0.4 y; mean ± SD) and ≥80 years (n = 61, 85.5 ± 0.5 y). Steady state walking speed was assessed under single- and dual-task conditions at preferred and fast walking speed. Additionally, functional lower extremity strength (5-chair-rises test), subjective health rating, and retrospective estimates of fall frequency were recorded. Results showed that 35.6% of the younger and 73.8% of the older participants were not able to walk faster than 1.2 m/s under the fast dual-task walking condition. Fast dual-task walking speed was higher compared to the preferred speed single- and dual-task conditions (all p < .05, r = .31 to .48). Average preferred single-task walking speed was 1.19 ± 0.24 m/s (70–79 y) and 0.94 ± 0.27 m/s (≥80 y), respectively, and correlated with performance in the 5-chair-rises test (r_s = −.49, p < .001), subjective health (τ = .27, p < .001), and fall frequency (τ = −.23, p = .002). We conclude that the fitness status of many older people is inadequate to safely cross streets at pedestrian lights and maintain mobility in the community’s daily life in urban areas. Consequently, training measures to improve the older population’s cognitive and physical fitness should be promoted to enhance walking speed and safety of older pedestrians.

Correlation of Physical Performance and Patient-Reported Outcomes Following Total Ankle Arthroplasty

BACKGROUND

Functional recovery following total ankle arthroplasty (TAA) is assessed with patient-reported metrics, but physical performance tests may allow for a more accurate assessment of patient function. We quantified correlations between patient-reported measures and physical performance tests in patients after TAA to determine the usefulness of physical performance tests in post-TAA assessment.

METHODS

In total, 140 patients with end-stage ankle osteoarthritis were assessed prior to TAA and again at 12 and 24 months postoperatively. At each time point, the visual analog scale (VAS), Foot and Ankle Disability Index (FADI), American Orthopaedic Foot & Ankle Society (AOFAS), Short Musculoskeletal Function Assessment (SMFA), and Short-Form 36 (SF-36) scores were collected, as well as walking speed, Four-Square Step Test (FSST) times, and Short Physical Performance Battery (SPPB) balance scores.

RESULTS

All but 1 (SF-36 general health component) of the patient-reported outcomes improved significantly from preoperative assessment to both 1 and 2 years postoperatively ( P < .001 in all cases). Walking speed, FSST times, and balance scores improved significantly across time ( P < .001 in all cases). Walking speed was moderately correlated with total SF-36 scores at both 1 and 2 years postoperatively ( P < .001 in both cases), both components of the SMFA at 1 year postoperatively ( P < .001 in both cases), and total AOFAS scores at 2 years postoperatively ( P = .001).

CONCLUSION

The lack of strong correlations between the 2 sets of metrics indicates that they provide different information about a patient's recovery following TAA. Therefore, it is important to include both sets of metrics in post-TAA assessments to better understand operative success and functional recovery.

LEVEL OF EVIDENCE

Level IV, cohort study.