Everyday walking with Parkinson's disease: understanding personal challenges and strategies.

PURPOSE: This qualitative study was designed to explore the personal experience of everyday walking with Parkinson's disease (PD), the challenges and the strategies employed to compensate for difficulties, to help contextualise the scientific knowledge base. METHODS: Semi-structured interviews were undertaken with a sample of 20 people with idiopathic PD (12 male, 8 female; mean age 65 years (range 50 - 80); mean disease duration 10 years (range 2.5 - 26). Verbatim interview transcripts were analyzed thematically using NUD*IST N6 qualitative data analysis software. RESULTS: Walking was invariably performed as an integral part of a purposeful activity within a specific context, termed walking 'plus', with challenges encountered by people with PD in three main areas: Undertaking tasks; negotiating environments; and making transitions to walking. The two key strategies to compensate for difficulties experienced were monitoring through the use of concentration, and correcting through generating rhythm and size of steps. Carers supported monitoring and correcting. CONCLUSION: People with PD need to constantly assess and drive their walking performance. Attentional resources, which can themselves be compromised in PD, were used to accomplish what is normally a largely automatic activity. Personal accounts support scientific hypotheses. Rehabilitation interventions and measurements in PD need to reflect both the physical and psychosocial context of everyday walking.

From A to Z: Wearable technology explained.

Wearable technology (WT) has become a viable means to provide low-cost clinically sensitive data for more informed patient assessment. The benefit of WT seems obvious: small, worn discreetly in any environment, personalised data and possible integration into communication networks, facilitating remote monitoring. Yet, WT remains poorly understood and technology innovation often exceeds pragmatic clinical demand and use. Here, we provide an overview of the common challenges facing WT if it is to transition from novel gadget to an efficient, valid and reliable clinical tool for modern medicine. For simplicity, an A-Z guide is presented, focusing on key terms, aiming to provide a grounded and broad understanding of current WT developments in healthcare.

Cueing training in the home improves gait-related mobility in Parkinson's disease: the RESCUE trial.

OBJECTIVES: Gait and mobility problems are difficult to treat in people with Parkinson's disease. The Rehabilitation in Parkinson's Disease: Strategies for Cueing (RESCUE) trial investigated the effects of a home physiotherapy programme based on rhythmical cueing on gait and gait-related activity. METHODS: A single-blind randomised crossover trial was set up, including 153 patients with Parkinson's disease aged between 41 and 80 years and in Hoehn and Yahr stage II-IV. Subjects allocated to early intervention (n = 76) received a 3-week home cueing programme using a prototype cueing device, followed by 3 weeks without training. Patients allocated to late intervention (n = 77) underwent the same intervention and control period in reverse order. After the initial 6 weeks, both groups had a 6-week follow-up without training. Posture and gait scores (PG scores) measured at 3, 6 and 12 weeks by blinded testers were the primary outcome measure. Secondary outcomes included specific measures on gait, freezing and balance, functional activities, quality of life and carer strain. RESULTS: Small but significant improvements were found after intervention of 4.2% on the PG scores (p = 0.005). Severity of freezing was reduced by 5.5% in freezers only (p = 0.007). Gait speed (p = 0.005), step length (p<0.001) and timed balance tests (p = 0.003) improved in the full cohort. Other than a greater confidence to carry out functional activities (Falls Efficacy Scale, p = 0.04), no carry-over effects were observed in functional and quality of life domains. Effects of intervention had reduced considerably at 6-week follow-up. CONCLUSIONS: Cueing training in the home has specific effects on gait, freezing and balance. The decline in effectiveness of intervention effects underscores the need for permanent cueing devices and follow-up treatment. Cueing training may be a useful therapeutic adjunct to the overall management of gait disturbance in Parkinson's disease.

The effect of rhythmic somatosensory cueing on gait in patients with Parkinson's disease.

BACKGROUND AND AIMS: Gait and gait related activities in patients with Parkinson's disease (PD) can be improved with rhythmic auditory cueing (e.g. a metronome). In the context of a large European study, a portable prototype cueing device was developed to provide an alternative for rhythmic auditory cueing: rhythmic somatosensory cueing (RSC, a miniature vibrating cylinder attached to the wrist). We investigated whether PD patients could adapt their walking pattern using RSC under conditions of changing walking speed and the presence of potentially distracting visual flow while walking on a treadmill. METHODS: A total of 17 patients with PD participated (mean age 63.4+/-10.3 years; Hoehn-Yahr score 2.5+/-0.9, mean Unified Parkinson's Disease Rating Scale score 49.8+/-13.7, mean disease duration 7.7+/-5.1 years). They performed systematic walking speed manipulations under 4 conditions in a random order: (1) no cue, no visual flow, (2) no cue, visual flow, (3) cue, no visual flow and (4) cue, visual flow. Visual flow in the form of a virtual corridor that moved at the current walking speed was projected on a 2 x 2 m rear-projection screen. The cueing rhythm was set at -10% of preferred stride frequency at each speed. Stride frequency was assessed using peaks in the trajectories of thigh sagittal plane segmental angles. RESULTS: Walking with RSC resulted in lower stride frequencies, and thus larger step lengths (p-values <0.05), regardless of walking speed. The presence of visual flow did not impair the use of RSC, as evidenced by the lack of differences between conditions 3 and 4 (p>0.05). CONCLUSION: Rhythmic somatosensory cueing may be a viable alternative for auditory cueing and is robust to changes in walking speed and visual distractors.

The effects of visual rhythms and optic flow on stride patterns of patients with Parkinson's disease.

This study was aimed at determining the effects of rhythmic visual cueing under changing visual conditions on stride frequency in patients with Parkinson's disease (PD; n = 21) and healthy age matched controls (n = 7) while walking at different speeds on a treadmill. Stride frequency and stride length in patients with PD as well as controls were not rigidly coupled to walking speed and could be manipulated with walking speed as well as by using spatial and temporal rhythmic visual cues.

Measuring gait and gait-related activities in Parkinson's patients own home environment: a reliability, responsiveness and feasibility study.

The aim of this study was to assess reliability, responsiveness and feasibility of gait and gait related tests in the home of patients with Parkinson's disease (PD). The Unified Parkinson's Disease Rating Scale, a timed walking test, the Timed Get Up and Go test the Berg Balance Scale and the Functional Reach test were applied by three independent observers on 26 PD patients. Moderate to high Intraclass Correlation Coefficients were found, ranging from 0.74 to 0.88 and 0.64 to 0.87 for the intra- and inter-observer reliability, respectively. All test showed Reliable Change Indexes under 11% and the whole test battery was applicable within 30 min.

Challenges and opportunities facing the Ohio College of Podiatric Medicine.

This article presents the problems and challenges facing the Ohio College of Podiatric Medicine in the view of its President and its Chief Academic Officer. It explores the progress made and the challenges facing the Ohio College overall and in the areas of education. It presents an exciting new vision of the style of podiatric medical education, and the methods that are and will be used to assess the quality of the educational program.

Evaluation of surgical experience and the use of an osteotomy guide on the apical angle of an Austin osteotomy.

BACKGROUND: Distal osteotomies of the first metatarsal are commonly used to correct hallux valgus deformities. Of the distal osteotomies, the Austin osteotomy is popular among foot surgeons on an international level. The precision of the osteotomy is important to achieve a congruous osteotomy. OBJECTIVES: The purpose of this study was to examine the effects of experience and technique on creating a precise Austin osteotomy. METHOD: Three individuals with varying levels of experience (student, resident and podiatric physician) created Austin osteotomies in metatarsal sawbones, using three different techniques (freehand, guide wire and osteotomy guide). The medial and lateral apical angles were measured, and the mean, standard deviation, and range of the angles were calculated. The differences between medial and lateral angles were also calculated. RESULTS: The results indicated that the mean and range of the angles varied considerably with the freehand and guide wire techniques at all experience levels. The angles were accurate and consistent for all experience levels; however, when an osteotomy guide was used. The use of an osteotomy guide also noticeably reduced the number of divergent and convergent osteotomies. CONCLUSIONS: The use of an osteotomy guide consistently resulted in a more precise Austin osteotomy for all experience levels.

The attentional cost of external rhythmical cues and their impact on gait in Parkinson's disease: effect of cue modality and task complexity.

Changes in gait performance in 153 subjects with PD using three rhythmical cues (auditory, visual and somatosensory) were measured during a simple walking task and a dual walking task in the home. Subjects were 'on' medication and were cued at preferred step frequency. Accelerometers recorded gait and walking speed, step amplitude and step frequency were determined from raw data. Data were analysed with SAS using linear regression models. Gait performance during a single task reduced with cues in contrast to a dual task where PD subjects appeared to benefit from rhythmical cues (increased speed and step length). Effects were dependent on cue modality with significant improvements for auditory cues compared to others. A significant short-term carry-over effect of cues reduced 3 weeks later. Cues may reduce attentional demands by facilitating attentional allocation, accounting for differences of cue seen during single and dual task. Furthermore cue modality may influence attentional demand which is an important consideration for rehabilitation.

Experience with deep venous thrombosis and IPG - 200 as a diagnostic aid.

Deep venous thrombosis is a potentially dangerous alteration in the venous hemodynamics of the lower extremities. Clinical diagnosis, at best, is difficult because of the percentage of silent thrombi and the nonspecificity of the signs and symptoms. Noninvasion evaluation is accurate when performed properly. Venography, however, is the most accurate method of diagnosis. Current methods of prophylaxis are many and varied--some controversial. The effects of tourniquets on the venous system is reviewed. The author's experience with the 1PG-200 is presented. Further studies utilizing the 1PG-200 in preoperative versus postoperative evaluation in podiatric surgery are necessary.

Austin bunionectomy: transpositional "V" osteotomy of the first metatarsal for hallux valgus.

The authors present results of their experiences with the Austin procedure in a group of patients approximately 24 months postoperatively. The overall patients' satisfaction rate was 96%. The overall clinical rating was 77%. Reasons for poor results were analyzed.

Evaluation of lower extremity ulcerations.

The authors provide a simplified system for the initial approach and diagnostic evaluation of the more commonly occurring ulcerations encountered by the Podiatric physician. This system provides a logical basis for evaluation, identification, and therapeutic intervention of lower extremity ulcers.

Retrospective assessment of antibiotic and tourniquet use in an ambulatory surgery center.

In this study, 459 lower extremity surgeries were evaluated to assess and improve the quality of patient care at the Carnegie Surgery Center, Cleveland, Ohio. Two aspects of surgery were studied: the antibiotic usage and tourniquet application. The authors analyzed the rate of infection and the number of tourniquet complications that resulted from the surgeries. The infection rate was 0.65%, and there were no tourniquet complications. Using the information learned from the study and reviewing pertinent literature, recommendations were made to further enhance patient care.

Cardiovascular disorders. Diagnostic and therapeutic implications for the podiatric medical practice.

The cardiovascular system has multiple implications in the podiatric patient. The examination should begin with a complete and careful history. The physical examination should be thorough. Noninvasive evaluation should be performed as indicated with both a static and functional component. Cardiac disease should be investigated in all patients with a history or physical findings consistent with this disorder, such as blue toe syndrome, palpitations, or chest pain.

Experiences with the chevron (V-)osteotomy on adolescent hallux valgus.

The results of a distal chevron (V-)osteotomy in 31 adolescent patients are reported. The distal V-osteotomy of the first metatarsal appeared to provide excellent correction of hallux valgus deformities. The surgical technique and the advantages over other forms of distal osteotomy are described. The authors recommend that distal V-osteotomy be considered as an alternative to other forms of distal osteotomy when treating hallux valgus in adolescents and growing children.

The Austin bunionectomy: a follow-up study.

The Austin procedure, a distal metaphyseal "V" osteotomy for the management of hallux valgus was evaluated in several distinct patient groups. The results of the procedure were found to be both reproducible and predictable. Medial capsular reefing in an attempt to maintain the intermetatarsal angle reduction or hallux alignment does not appear to enhance the postoperative results.

Silicone implant arthroplasty: a retrospective analysis.

Fifteen patients totalling 19 first metatarsophalangeal implants were evaluated both subjectively and objectively. The average time of follow-up was 5.9 years. Sixteen implants were evaluated radiographically and the incidence of complications including implant deformation, bony erosions, and bony encroachment is reported. Postoperative clinical evaluation revealed several of the patients complained of pain and stiffness. Postoperative motion was restricted in most patients and toe purchase was present in only 6 of 16 patients. Despite the clinical objective findings, patient satisfaction was very favorable. Although the apparent complication rate appeared high, the authors recommend an effort be made to develop a multicentered retrospective analysis to find the true incidence of first metatarsophalangeal implant complications.

A review of pyrolytic carbon: application in bone and joint surgery.

The authors review pyrolytic carbon as a biomaterial. Its potential applications in bone and joint surgery are discussed. This manuscript includes work performed in the early 1980s through present day research.

Necessary dorsiflexion of the first metatarsophalangeal joint during gait.

Previous studies of first metatarsophalangeal joint range of motion have resulted in varying values for dorsiflexion of this joint. These values reflect assisted dorsiflexion of the first metatarsophalangeal joint, which has been believed to be the same value that would be obtained during the toe-off phase of gait. These values range from 60 degrees to 90 degrees. This study attempts to obtain measurements during toe-off and to compare obtained values with those of assisted dorsiflexion from the previously mentioned studies.