Quantifying gait deviations in individuals with rheumatoid arthritis using the Gait Deviation Index

OBJECTIVES

In this study we evaluated the usability of the Gait Deviation Index (GDI), an index that summarizes the amount of deviation in movement from a standard norm, in adults with rheumatoid arthritis (RA). The aims of the study were to evaluate the ability of the GDI to identify gait deviations, assess inter-trial repeatability, and examine the relationship between the GDI and walking speed, physical disability, and pain.

METHOD

Sixty-three adults with RA and 59 adults with typical gait patterns were included in this retrospective case-control study. Following a three-dimensional gait analysis (3DGA), representative gait cycles were selected and GDI scores calculated. To evaluate the effect of walking speed, GDI scores were calculated using both a free-speed and a speed-matched reference set. Physical disability was assessed using the Health Assessment Questionnaire (HAQ) and subjects rated their pain during walking.

RESULTS

Adults with RA had significantly increased gait deviations compared to healthy individuals, as shown by lower GDI scores [87.9 (SD = 8.7) vs. 99.4 (SD = 8.3), p < 0.001]. This difference was also seen when adjusting for walking speed [91.7 (SD = 9.0) vs. 99.9 (SD = 8.6), p < 0.001]. It was estimated that a change of ≥ 5 GDI units was required to account for natural variation in gait. There was no evident relationship between GDI and low/high RA-related physical disability and pain.

CONCLUSIONS

The GDI seems to useful for identifying and summarizing gait deviations in individuals with RA. Thus, we consider that the GDI provides an overall measure of gait deviation that may reflect lower extremity pathology and may help clinicians to understand the impact of RA on gait dynamics.

Superimposed electrical stimulation decreases maximal grip force

AIM

The purpose of this study was to assess maximal grip force in two conditions of voluntary muscular contraction (MVC) and electrical stimulation superimposed on voluntary muscular contraction (SES) to better understand mechanisms and effectiveness of electrical stimulation of the hand. There is conflicting evidence regarding the effectiveness of electrical stimulation superimposed on voluntary muscular contraction on improving maximal force. Increased knowledge of the physiologic and mechanical effects of electrical stimulation applied during voluntary muscular contraction can lead to refinement of its clinical application.

METHODS

Twenty subjects (36+/-13 years; 17 males and 3 females) participated in this study. All subjects were undergoing physical therapy within a hand rehabilitation center. They were instructed to randomly perform three grip determinations in both voluntary muscular contraction and superimposed electrical stimulation conditions to elicit maximal grip force of the unaffected hand. Force was assessed using a handheld dynamometer. Subjective force and contraction were assessed just after sessions as well as pain and discomfort using a visual analogue scale.

RESULTS

The mean force values were 22+/-7 kg and 30+/-1 kg for the superimposed electrical stimulation and voluntary muscular contraction conditions, respectively. Analyses of the force measures showed that force was weaker in the superimposed electrical stimulation condition (P<0.001). Patients rated their pain and discomfort at 0+/-0 mm and 4+/-2.9 mm, respectively.

CONCLUSION

Maximal grip force is reduced when electrical stimulation is superimposed to voluntary muscular contraction. This result could be explained by unbalanced muscular synergies at the hand due to SES, confirming these synergies as essential to produce maximal grip force.

Interventions to improve adherence and persistence with osteoporosis medications: a systematic literature review

SUMMARY

Adherence and persistence with osteoporosis medications are poor. We conducted a systematic literature review of interventions to improve adherence and persistence with osteoporosis medications. Seven studies met eligibility requirements and were included in the review. Few interventions were efficacious, and no clear trends regarding successful intervention techniques were identified. However, periodic follow-up interaction between patients and health professionals appeared to be beneficial.

INTRODUCTION

Adherence and persistence with pharmacologic therapy for osteoporosis are suboptimal. Our goal was to examine the design and efficacy of published interventions to improve adherence and persistence.

METHODS

We searched medical literature databases for English-language papers published between January 1990 and July 2008. We selected papers that described interventions and provided results for control and intervention subjects. We assessed the design and methods of each study, including randomization, blinding, and reporting of drop-outs. We summarized the results and calculated effect sizes for each trial.

RESULTS

Seven studies met eligibility requirements and were included in the review. Five of the seven studies provided adherence data. Of those five studies, three showed a statistically significant (p < or = 0.05) improvement in adherence by the intervention group, with effect sizes from 0.17 to 0.58. Five of the seven studies provided persistence data. Of those five, one reported statistically significant improvement in persistence by the intervention group, with an effect size of 0.36.

CONCLUSIONS

Few interventions were efficacious, and no clear trends regarding successful intervention techniques were identified in this small sample of studies. However, periodic follow-up interaction between patients and health professionals appeared to be beneficial.

Examination findings and self-reported walking capacity in patients with lumbar spinal stenosis

BACKGROUND AND PURPOSE

Spinal stenosis is a common, often disabling, condition resulting from compression of the cauda equina and nerve roots. This study was designed to: (1) characterize the impairments of patients with lumbar spinal stenosis (LSS) and (2) to identify predictors of self-reported walking capacity.

SUBJECTS

Forty-three patients with symptomatic LSS, from 3 specialty clinics, were evaluated. Twenty-eight subjects (65%) were female. The subjects' median age was 73.6 years (mean=72.4, SD=10.3, range=45.7-90.7), and the median duration of low back pain was 24 months (mean=36.6, SD=41.6, range=0-216).

METHODS

Demographic data, medical history, and information about low back pain and symptoms (eg, numbness, tingling, and lower-extremity weakness) were collected using a standardized questionnaire and physical examination.

RESULTS

Twenty-two subjects (51%) had lower-extremity weakness, primarily of the extensor hallucis longus muscle. Thirty-five subjects (81%) had absent or decreased neurosensory responses (eg, pinprick, vibration, reflexes), and 28 subjects (66%) reported that they were unable to walk farther than 2 blocks. Women were more likely than men to report difficulties walking, as were subjects with abnormal Romberg test scores and those with greater pain during walking.

DISCUSSION AND CONCLUSION

Pain and balance problems appeared to be the primary factors limiting ambulation in our subjects with LSS.

Rheumatologist-patient communication about exercise and physical therapy in the management of rheumatoid arthritis

OBJECTIVE

Little is known about the features and role of exercise discussions between rheumatologists and patients. The goals of this study were to: 1) describe rheumatologists' and patients' attitudes and beliefs regarding exercise and physical therapy for rheumatoid arthritis (RA); 2) describe frequency and length of exercise discussions; 3) determine the accuracy of recall for exercise discussions; and 4) assess the influence of attitudes regarding exercise on communication about exercise.

METHODS

Goals 1-3 were addressed with analysis of baseline questionnaires and audiotaped encounters. The influence of attitudes and beliefs regarding exercise on the frequency and length of exercise discussions was assessed prospectively. Patients and rheumatologists were enrolled from a large tertiary care institution. Clinical encounters were audiotaped, transcribed, coded, and analyzed to identify specific characteristics of the exercise discussions.

RESULTS

One hundred thirty-two patients and 25 rheumatologists participated in the study. Rheumatologists and patients discussed exercise in 53% of the encounters. Rheumatologists' beliefs regarding the usefulness of exercise for RA varied, with the least positive beliefs being reported for aerobic exercise. Exercise discussions were more likely to occur if the patient was currently exercising, odds ratio (OR) = 2.4; 95% confidence interval (CI) (1.2-4.9), and when the rheumatologist believed aerobic exercises were useful in managing RA, OR = 1.4; 95% CI (1.1-1.9). Current exercise behavior was associated with patients' positive attitude toward exercise (chi 2 1 = 8.4; P = 0.004) and perceived social support for exercise (chi 2 1 = 4.5; P = 0.04). When rheumatologists initiated exercise discussions, there was nearly twice as much discussion (beta = -8.4; P = 0.001).

CONCLUSIONS

Exercise talk was influenced by patients' and rheumatologists' beliefs and attitudes regarding the effectiveness of exercise and physical therapy in managing RA, patient experience with exercise, and by characteristics of the rheumatologist.

The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis

The influence of psychosocial variables in the outcome of surgery for lumbar stenosis (LSS) has not been evaluated. We studied 257 patients with LSS pre-operatively and at 6 months to: (a) relate patient expectations of surgery to baseline function and pain; and (b) determine how patient expectations and pre-operative function interact to predict post-operative outcomes.

RESULTS

On average, patients experienced substantial pain relief, improved function and satisfaction. Patients with many pre-operative expectations, particularly patients with low baseline function, reported more improvement in post-operative function than patients with few expectations. More ambitious expectations for physical function were also associated with improved function and satisfaction at 6 months. Conversely, having more numerous pain relief expectations was associated with more pain and less satisfaction with pain relief.

CONCLUSION

Patient expectations influence recovery from surgery at 6 months. To improve outcomes and satisfaction, clinicians should discuss expectations with patients pre-operatively.

A controlled trial of an educational program to prevent low back injuries

BACKGROUND

Low back injuries are common and costly, accounting for 15 to 25 percent of injuries covered by workers' compensation and 30 to 40 percent of the payments made under that program. The high costs of injury, the lack of effective treatment. and the evidence that there are behavioral risk factors have led to widespread use of employee education programs that teach safe lifting and handling. The effectiveness of those programs, however, has received little rigorous evaluation.

METHODS

We evaluated an educational program designed to prevent low back injury in a randomized, controlled trial involving about 4000 postal workers. The program, similar to that in wide use in so-called back schools, was taught by experienced physical therapists. Work units of workers and supervisors were trained in a two-session back school (three hours of training), followed by three to four reinforcement sessions over the succeeding few years. Injured subjects (from both the intervention and the control groups) were randomized a second time to receive either training or no training after their return to work.

RESULTS

Physical therapists trained 2534 postal workers and 134 supervisors. Over 5.5 years of follow-up, 360 workers reported low back injuries, for a rate of 21.2 injuries per 1000 worker-years of risk. The median time off from work per injury was 14 days (range, 0 to 1717); the median cost was $204 (range, zero to $190,380). After their return to work, 75 workers were injured again. Our comparison of the intervention and control groups found that the education program did not reduce the rate of low back injury, the median cost per injury, the time off from work per injury, the rate of related musculoskeletal injuries, or the rate of repeated injury after return to work; only the subjects' knowledge of safe behavior was increased by the training.

CONCLUSIONS

A large-scale, randomized, controlled trial of an educational program to prevent work-associated low back injury found no long-term benefits associated with training.

Effectiveness of minimally supervised home aerobic training in patients with systemic rheumatic disease

The effectiveness of an exercise prescription and unsupervised home exercise programme was tested on 37 subjects with rheumatoid arthritis and 34 with systemic lupus erythematosus. Subjects were randomly assigned to control or stationary bicycling at home, using loaned bicycles. Exercise subjects (with bicycles) did better than controls, but not significantly, on all outcomed measures (exercise tolerance test, fatigue, depression and helplessness) at 3 months. Bicycles were reclaimed at 3 months and all subjects in both groups given instructions for home exercise. Exercise in the second 3 months was predicted primarily by baseline exercise habits and fatigue. It is concluded that although safe, unsupervised home exercise programmes may benefit few patients. Future research should address methods of stimulating and maintaining unsupervised exercise programmes in patients with systemic rheumatic disease.

Teaching and social support: effects on knowledge, attitudes, and behaviors to prevent low back injuries in industry

An educational program designed to reduce low back injuries was modeled after several well-known back schools and taught to postal workers in a randomized trial of about 4,000 workers. Physical therapists taught 3 hours of class sessions, including knowledge, skills, and individual work station assessment, to small groups of workers and supervisors, with reinforcement every 6 months afterward. At 2 1/2 years, a random sample of 209 workers was surveyed for program impact on intermediate outcomes. We observed increased knowledge among experimental unit workers, but no significant improvements in behaviors associated with back health or in proportion of workers with tired backs. Experimental unit workers who had received training by the time of the survey were less likely to report helping/reinforcement for healthy behaviors than controls or untrained experimental unit workers. The program might have led trained workers to perceive a lack of support and reinforcement for back safety among coworkers and supervisors by sensitizing them to what is possible and raising expectations. There appeared to be group social effects in the dissemination of knowledge and perhaps of helpful behaviors; however, it is apparent that worker social support for change in health behaviors is a complex phenomenon that cannot always be relied upon to enhance program goals.

Does musculoskeletal function deteriorate in a predictable sequence in the elderly?

A variety of functions decline with aging, but whether losses occur in a predictable sequence is unknown. Improved understanding might facilitate the early detection and possible prevention of functional deterioration. We assessed self-reported difficulty with functional tasks in 288 community-dwelling elderly aged 65 to 97. We hypothesized that the ability to perform tasks involving strength, skill, and endurance (run errands, shop, yardwork or housework) would be lost first, followed by activities requiring less strength or mobility (rise from a chair with no hands, walk), followed by easier, but essential tasks (pick up clothes, rise from bed, lift a cup to the mouth). The patterns of decline were evaluated with Guttman scalograms. Picking up clothes and walking were reversed from the predicted order. Scale reliability was 0.92, indicating that functional decline is ordered; 75% of subjects fell into one of the modal sequence types. Analysis by self-reported presence of arthritis showed that 83% of nonarthritic subjects fit the predicted patterns (reliability = 0.95) versus 65% of arthritic subjects (reliability = 0.86), who tended to lose hand ability out of sequence. Sequential functional loss scales may tell more than the typical simple summation of functional loss, and may have predictive value to the clinician monitoring an elderly patient. If the sequence is accelerated or out of order, such as was seen in patients with arthritis, it may indicate the need for intervention. Examination of sequences of loss may help characterize adaptations to impairment and differences among subgroups.

Rehabilitation management of homebound elderly with locomotor disability

Functional disabilities, the final common pathway of all medical and surgical conditions, are frequently preventable and treatable. Etiologic diagnosis of functional problems is important so that one does not miss the opportunity to improve and increase independence. Rehabilitation of the elderly can be a special problem. Their habits are longstanding and difficult to change. It is important to establish realistic and attainable goals with the patient. Not every habit needs to be altered. What is more important is that the patient safely achieve maximum independence. An environmental assessment is "key" to a full understanding the limitations of function, and how well management strategies can be integrated.