Association Between Performance on an Interdisciplinary Stroke Assessment Battery and Falls in Patients With Acute Stroke in an Inpatient Rehabilitation Facility: A Retrospective Cohort Study.

OBJECTIVE: To explore the association between demographic factors and functional performance measures of patients with acute stroke in an inpatient rehabilitation facility (IRF) and falls during the IRF stay and to quantify the diagnostic accuracy of functional outcome measures in identifying fallers. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation facility. PARTICIPANTS: Individuals with acute stroke admitted to hospital-based IRF (N=139). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Odds ratios were used to examine the relationship between fall frequency and functional outcome measures (National Institute of Stroke Scale, neglect [Item #11], Berg Balance Scale, Stroke Rehabilitation Assessment of Movement mobility and Stroke Rehabilitation Assessment of Movement lower extremity subscales [STREAM-LE], Montreal Cognitive Assessment, Dynamic Gait Index, and Stroke Impact Scale). Receiver operator characteristic analysis with area under the curve, sensitivity, specificity, and diagnostic odds ratio were used to assess the diagnostic accuracy of each functional outcome measure to distinguish patients who fell vs those who did not fall in the IRF. RESULTS: A total of 23 patients (16.2%) fell during the IRF hospitalization. Patients who did and did not fall did not differ in terms of age, sex, stroke type, or stroke location. Only the STREAM-LE was associated with falls (odds ratio, 0.93; 95% CI, 0.86-0.99). Area under the curve was 0.67 (95% CI, 0.51-0.82). With a positivity cutoff point of 12, sensitivity and specificity were 73.3% (95% CI, 54.6%-92.2%) and 50.0% (95% CI, 39.9%-59.2%), respectively. The diagnostic odds ratio was 3.4. CONCLUSIONS: The STREAM-LE score at admission to IRF may identify patients with acute stroke who are more likely to fall during their stay. However, the search for measures with greater diagnostic accuracy should continue.

Oxygen Consumption Deficits in Patients With Residual Fatigue After Primary Coccidioidomycosis.

Patients with coccidioidomycosis often report prolonged and debilitating fatigue after other evidence of infection has resolved. In this study, we quantify fatigue, muscle weakness, and impaired aerobic capacity in 5 such individuals. A closer examination of the cardiorespiratory system may contribute to a better understanding of underlying mechanisms and potential interventions.

The association between social participation and lower extremity muscle strength, balance, and gait speed in US adults.

Social participation is associated with healthy aging, and although associations have been reported between social participation and demographics, no published studies have examined a relationship between social participation and measures amenable to intervention. The purpose was to explore the association between self-reported social participation and lower extremity strength, balance, and gait speed. A cross-sectional analysis of US adults (n = 2291; n = 1,031 males; mean ± standard deviation age 63.5 ± 0.3 years) from the 2001-2 National Health and Nutrition Examination Survey was conducted. Two questions about self-reported difficulty with social participation were categorized into limited (yes/no). The independent variables included knee extension strength (n = 1537; classified as tertiles of weak, normal, and strong), balance (n = 1813; 3 tests scored as pass/fail), and gait speed (n = 2025; dichotomized as slow [less than 1.0 m/s] and fast [greater than or equal to 1.0 m/s]). Logistic regression, accounting for the complex survey design and adjusting for age, sex, physical activity, and medical conditions, was used to estimate the odds of limitation in social participation with each independent variable. Alpha was decreased to 0.01 due to multiple tests. Slower gait speed was significantly associated with social participation limitation (odds ratio = 3.1; 99% confidence interval: 1.5-6.2). No significant association was found with social participation and lower extremity strength or balance. The odds of having limitation in social participation were 3 times greater in those with slow gait speed. Prospective studies should examine the effect of improved gait speed on levels of social participation.

Distal Vibration Perception Threshold in Children Who Toe Walk.

PURPOSE: To compare distal vibratory perception threshold and sensation in children who toe walked (TW) and controls. METHODS: Vibration perception threshold was measured at the metacarpal and metatarsal phalangeal (MCP and MTP) joints in 11 TW and 15 age-matched controls. Mean vibratory threshold (MVT) was calculated for each site; a Pearson correlation coefficient was determined for MVT at MCP and MTP joints. Groups were compared using a Mann-Whitney U test. Parent/caregiver responses on the Short Sensory Profile (SSP) were compared using a χ test. RESULTS: MVTs at the MCP and MTP joints were highly correlated in both groups. MVT was higher in TW compared with controls at each site. Children who TW were more likely to have a total SSP score in the "probable difference" or "definite difference" categories compared with the "no difference" category. CONCLUSION: Sensation should not be overlooked in the evaluation and clinical management of toe walking.

Health-related fitness in children and adolescents.

PURPOSE: The American Physical Therapy Association Section on Pediatrics developed a task force to summarize fitness guidelines for children and adolescents. The purposes of this article were to review components, measurement methods, and consequences of physical fitness, and to summarize evidence-based activity recommendations for youth. SUMMARY OF KEY POINTS: Health-related fitness is comprised of body composition, flexibility, cardiorespiratory endurance, and muscular strength and endurance. Each of these components is reviewed in terms of definition, assessment, normative values, and recommendations. CONCLUSIONS: The task force supports the guidelines of the US Department of Health and Human Services, which state that to promote overall health and wellness, youth should participate in 60 minutes or more of physical activity every day. RECOMMENDATIONS FOR CLINICAL PRACTICE: Physical therapists should apply research relevant to health-related fitness when treating youth. Promoting fitness, health, and wellness in our communities is a responsibility all therapists should assume.

Fuel oxidation at the walk-to-run-transition in humans.

Multiple factors (including anthropometric, kinetic, mechanical, kinematic, perceptual, and energetic factors) are likely to play a role in the walk-to-run transition in humans. The primary purpose of the present study was to consider an additional factor, the metabolic fuel source. Indirect calorimetry was used to measure fuel oxidation, and perception of effort was recorded as 10 overnight-fasted adults locomoted on a level treadmill at speeds progressing from 1.56 to 2.46 m s(-1) in increments of 0.11 m s(-1) and 10.0 minutes under 3 conditions: (1) unconstrained choice of gait, (2) walking at all speeds, and (3) running at all speeds. The preferred transition speed was 2.08 ± 0.03 m s(-1). Gait transition from walking to running increased oxygen consumption rate, decreased the perception of effort, and decreased the rate of carbohydrate oxidation. We propose that, in an evolutionary context, gait transition, guided by the perception of effort, can be viewed as a carbohydrate-sparing strategy.

Temporal characteristics of lower extremity moment generation in children with cerebral palsy.

Lower extremity weakness has been documented in children with cerebral palsy (CP). However, the temporal characteristics of moment generation have not been characterized, and they may be important to function. This study tested ankle, knee, and hip flexion and extension moment generation capabilities in children with CP and in able-bodied children. Maximum voluntary isometric contractions (MVIC), the maximum rates of moment development and relaxation, and the time to produce and reduce the moments were quantified. Relationships between the temporal measures, Gross Motor Function Measure-66 (GMFM-66), and MVICs were also examined. Children with CP had significantly reduced MVICs, maximum development, and relaxation rates, and increased times to produce and reduce moments. The maximum rates of moment development and relaxation at some joints were correlated with the GMFM-66 and MVICs. These results suggest that both the magnitude and temporal characteristics of moment generation need to be targeted during therapeutic interventions for children with CP.

A comprehensive joint replacement program for total knee arthroplasty: a descriptive study.

BACKGROUND: Total knee arthroplasty (TKA) is a commonly performed surgical procedure in the US. It is important to have a comprehensive inpatient TKA program which maximizes outcomes while minimizing adverse events. The purpose of this study was to describe a TKA program - the Joint Replacement Program (JRP) - and report post-surgical outcomes. METHODS: 74 candidates for a primary TKA were enrolled in the JRP. The JRP was designed to minimize complications and optimize patient-centered outcomes using a team approach including the patient, patient's family, and a multidisciplinary team of health professionals. The JRP consisted of a pre-operative class, standard pathways for medical care, comprehensive peri-operative pain management, aggressive physical therapy (PT), and proactive discharge planning. Measures included functional tests, knee range of motion (ROM), and medical record abstraction of patient demographics, length of stay, discharge disposition, and complications over a 6-month follow-up period. RESULTS: All patients achieved medical criteria for hospital discharge. The patients achieved the knee flexion ROM goal of 90 degrees (91.7 +/- 5.4 degrees ), but did not achieve the knee extension ROM goal of 0 degrees (2.4 +/- 2.6 degrees ). The length of hospital stay was two days for 53% of the patients, with 39% and 7% discharged in three and four days, respectively. All but three patients were discharged home with functional independence. 68% of these received outpatient physical therapy compared with 32% who received home physical therapy immediately after discharge. Two patients (< 3%) had medical complications during the inpatient hospital stay, and 9 patients (12%) had complications during the 6-month follow-up period. CONCLUSION: The comprehensive JRP for TKA was associated with satisfactory clinical outcomes, short lengths of stay, a high percentage of patients discharged home with outpatient PT, and minimal complications. This JRP may represent an efficient, effective and safe protocol for providing care after a TKA.

Muscle metabolism during overground walking in persons with poststroke hemiparesis.

PURPOSE: Muscle energy metabolism is associated with speed, endurance, and effort during walking, yet data regarding muscle metabolism during walking in persons with poststroke hemiparesis have not been published. The primary purpose of this study was to compare the energy metabolism during overground walking in persons with poststroke hemiparesis to controls. The secondary purpose was to determine whether the walking behavior of persons with poststroke hemiparesis conforms to the fuel selection patterns previously observed in controls. METHOD: O2 consumption and CO2 production were measured as 7 individuals with poststroke hemiparesis and 7 age-matched controls walked at self-selected preferred and fast speeds. Indirect calorimetry was used to measure fuel oxidation. RESULTS: Walking speeds and economy were lower in the clinical cohort, although VO2 and fuel oxidation were consistent between groups. Fat was the dominant fuel source at preferred speeds; whereas, carbohydrate rates increased substantially at fast speeds. CONCLUSIONS: Within each condition, similar contributions of fat and carbohydrate were observed despite a wide disparity in speeds. It is hypothesized that fuel selection contributed to preferred walking speeds in the individuals with poststroke hemiparesis and that high rates of carbohydrate oxidation may have prevented higher, more functional, preferred walking speeds.

Intersegmental dynamics during the swing phase of gait: a comparison of knee kinetics between 7 year-old children and adults.

Existing literature suggests that kinetic patterns associated with children's gait may not be adult-like until after 7 years of age. The development of adult-like kinetic patterns, especially those involving non-muscular interaction moments, occurs with time and experience. We tested the hypothesis that compared to adults, 7 year-old children would demonstrate a relatively larger contribution of muscle moment and a smaller contribution of interaction moment to the net knee joint moment during the swing phase of gait was tested. Net knee joint moments and the contributions of muscle and interaction moments to the net moments were compared between 7 year-old children and adults. Knee kinematics and net joint moments were similar between the two groups. Also, the contributions of the muscle and interaction moments to the net joint moment were similar (P > 0.05), suggesting that the ability to employ interaction moments during the swing phase of gait did not differ between the two groups.

Fuel oxidation during human walking.

Human adults walk at a characteristic speed, but the mechanisms responsible for this ubiquitous and reproducible behavior remain unknown. In this study, preferred walking speed (PWS) was 4.7 +/- 0.1 km h -1 in 12 overnight-fasted adults, mean age 30.0 +/- 2.6 years. Indirect calorimetry was used to measure fuel oxidation during level treadmill walking from 3.2 to 7.2 km h -1 progressively increased at increments of 0.8 km h -1 and 10.0-min intervals. Corroborating many previous reports, the O2 cost of transport (mL O2 kg -1 km -1 ) was numerically lowest at 4.8 km h -1 , near PWS, but was not significantly different than 5.6 km h -1 . The impact of walking speed on the fuel selection of skeletal muscle was much more dramatic. At speeds less than or equal to PWS, muscle carbohydrate (CHO) oxidation rates were quite low, in the range that could be matched by gluconeogenesis. Above 4.8 km h -1 , CHO oxidation rate increased abruptly and tracked the perception of effort (RPE). Stepwise linear regression revealed that CHO oxidation explained 70% of the variance in RPE, and speed provided an additional 4%. In contrast, the other variables included in the analysis, fat oxidation rate, heart rate, and O2 cost of transport, contributed no additional explained variance in RPE. We conclude that PWS is just below a threshold speed, above which CHO oxidation abruptly increases. The central nervous system may be guided by the perception of effort in selecting a PWS that minimizes dependence on CHO oxidation. We further conclude that skeletal muscle metabolic control is an important factor to be taken into account by the central nervous system motor control of human locomotion.

Gait kinematics and kinetics of 7-year-old children: a comparison to adults using age-specific anthropometric data.

The purpose of this study was to determine if sagittal plane gait kinematics and kinetics of 7-year-old children differed from those of adults when age-specific anthropometrics were used in the calculations. Joint angles, moments, and power obtained during level walking in 7-year-old children (n=15) were compared to data from adults (n=15). Calculations were performed using age-specific anthropometric data obtained from dual energy X-ray absorptiometry. For most of the variables examined, 7-year-olds were similar to adults, however children demonstrated a diminished peak plantar flexor moment and less peak power absorption and generation at the ankle during late stance. These results provide support for the hypothesis that children lack the neuromuscular maturity, especially at the ankle, to produce an adult-like gait pattern.

Anthropometric parameters in children: a comparison of values obtained from dual energy x-ray absorptiometry and cadaver-based estimates.

Anthropometric data used in gait analysis for children are often estimated from older adult cadavers. The extent to which these estimates accurately represent children or affect the calculation of net joint moments during gait analysis is unknown. The purpose of this study was: (1) to compare dual energy X-ray absorptiometry (DXA)-derived anthropometric parameters to cadaver-based estimates in children, and (2) to determine if DXA-derived anthropometric data alter the results of gait analyses in children. Using DXA, the mass, center of mass location, and moment of inertia of the foot, shank, and thigh were obtained from 7 to 13 year-old children (n=50) and compared to cadaver-based estimates. Additionally, lower extremity net joint moments were calculated (inverse dynamics equations) for three children during gait using (a) DXA-derived, and (b) cadaver-based estimates of anthropometric parameters. Statistically significant differences were identified for most DXA-derived and cadaver-based anthropometric values. However, based on gait analysis of three children, it is likely that the differences between DXA-derived and cadaver-based anthropometric estimates would have a negligible effect on the calculation of net joint moments during gait in 7-13 year-old children.

Determination of lower extremity anthropometric parameters using dual energy X-ray absorptiometry: the influence on net joint moments during gait.

OBJECTIVE: The purpose of this study was threefold: (1) to report on a method of determining lower extremity anthropometric data using dual energy X-ray absorptiometry, (2) to compare values obtained with this method to predictions from cadaver-based estimates, and (3) to quantify the extent to which these data affect the calculation of net joint moments during walking. BACKGROUND: Anthropometric data used in inverse dynamics equations are often estimated from older cadaveric specimens. A practical method for determining population-specific data is needed. METHODS: Using DXA scans obtained from 20 healthy adults, the mass, center of mass, and moment of inertia of each lower extremity segment were determined and compared to cadaver-based estimates. In addition, gait analysis was performed on 10 of these subjects, and net joint moments (sagittal plane) were calculated at the ankle, knee, and hip using anthropometric data obtained from (a) DXA, and (b) cadaver-based estimates. RESULTS: Statistically significant differences were identified for DXA-derived and cadaver-based anthropometric values. Overall, moment curves computed using the two data sets differed more during the swing phase than during the stance of gait. CONCLUSIONS: DXA appears to be an appropriate method for obtaining population-specific anthropometric data. Moment calculations for activities involving high accelerations and no ground reaction forces (i.e. swing phase of gait, kicking, etc.) would be most influenced by the differences between the anthropometric data sets.