Applying the Knowledge-to-Action Framework to Implement Gait and Balance Assessments in Inpatient Stroke Rehabilitation.

OBJECTIVES: The overall objectives of this project were to implement and sustain use of a gait assessment battery (GAB) that included the Berg Balance Scale, 10-meter walk test, and 6-minute walk test during inpatient stroke rehabilitation. The study objective was to assess the effect of the study intervention on clinician adherence to the recommendations and its effect on clinician perceptions and the organization. DESIGN: Pre- and post-training intervention study. SETTING: Subacute inpatient rehabilitation facility. PARTICIPANTS: Physical therapists (N=6) and physical therapist assistants (N=2). INTERVENTION: The intervention comprised a bundle of activities, including codeveloping and executing the plan with clinicians and leaders. The multicomponent implementation plan was based on the Knowledge-to-Action Framework and included implementation facilitation, implementation leadership, and a bundle of knowledge translation interventions that targeted barriers. Implementation was an iterative process in which results from one implementation phase informed planning of the next phase. MAIN OUTCOME MEASURES: Clinician administration adherence, surveys of perceptions, and organizational outcomes. RESULTS: Initial adherence to the GAB was 46% and increased to more than 85% after 6 months. These adherence levels remained consistent 48 months after implementation. Clinician perceptions of measure use were initially high (>63%), with significant improvements in knowledge and use of one measure after implementation. CONCLUSIONS: We successfully implemented the assessment battery with high levels of adherence to recommendations, likely because of using the bundle of knowledge translation activities, facilitation, and use of a framework to codevelop the plan. These changes in practice were sustainable, as determined by a 4-year follow-up.

Use of Robot-Assisted Gait Training in Pediatric Patients with Cerebral Palsy in an Inpatient Setting-A Randomized Controlled Trial.

Robot-assisted gait training (RAGT) provides a task-based support of walking using exoskeletons. Evidence shows moderate, but positive effects in the therapy of patients with cerebral palsy (CP). This study investigates the impact of RAGT on walking speed and gait parameters in pediatric CP patients. Thirty subjects (male = 23; female = 7), with a mean age of 13.0 ± 2.5 (9-17) years, and with spastic CP, were recruited. The intervention group (n = 15) underwent six 20-minute RAGT sessions with the Hybrid Assistive Limb (HAL) during an 11-day hospital stay. Additionally, a therapy concept including physiotherapy, physician-performed manual medicine, massage and exercise therapy was provided. The control group (n = 15) was treated with the therapy concept only. The outcome was based on a 10-Metre Walking Test (10MWT), 6-Minute Walking Test (6MWT), Gross Motor Function Measure (GMFM-88) and lower extremities passive range of motion. The intervention group achieved a mean increase in walking speed in the 10MWT (self-selected walking speed SSW) of 5.5 s (p = 0.378). There were no significant differences between the groups in the 10MWT (max) (p = 0.123) and the 6MWT (p = 0.8). Changes in the GMFM (total) and in the dimension standing and walking, running and jumping (D + E) showed clinically relevant significant results (p = 0.002 and p = 0.046). RAGT as a supplement to an inpatient therapy stay appears to have a positive, yet not significant impact on the gait parameters of pediatric CP patients as well as motivating them to practice walking. Further studies with adapted study designs are needed to evaluate different influencing factors.

Effect of Dual-Mode and Dual-Site Noninvasive Brain Stimulation on Freezing of Gait in Patients With Parkinson Disease.

OBJECTIVE: To investigate the effect of dual-mode noninvasive brain stimulation (NIBS) with high-frequency repetitive transcranial magnetic stimulation (rTMS) over the primary motor cortex of the lower leg and anodal transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex compared with rTMS alone in patients with Parkinson disease (PD) with freezing of gait (FOG). DESIGN: Randomized, double-blind, controlled study. SETTING: Outpatient rehabilitation clinics. PARTICIPANTS: Patients diagnosed as having PD with FOG (N=32). INTERVENTIONS: Patients in the dual-mode group underwent 5 consecutive daily sessions of dual-mode NIBS with high-frequency rTMS and tDCS simultaneously, whereas patients in the rTMS group underwent high-frequency rTMS and sham tDCS. MAIN OUTCOME MEASURES: Assessments of FOG and motor, ambulatory, and cognitive function were performed 3 times: at baseline before NIBS, immediately after NIBS, and 1 week after cessation of NIBS. RESULTS: Serious adverse effects were not observed in either group. Significant changes over time were observed in FOG, motor function, and ambulatory function in each group; however, there was no significant difference between the 2 groups. Executive function showed significant improvement after NIBS only in the dual-mode group. CONCLUSIONS: These results suggest the potential for dual-mode NIBS to modulate 2 different cortices simultaneously. Dual-mode NIBS might be considered a novel therapeutic approach for patients with PD.

Functional Electrical Stimulation for Foot Drop in Multiple Sclerosis: A Systematic Review and Meta-Analysis of the Effect on Gait Speed.

OBJECTIVE: To review the efficacy of functional electrical stimulation (FES) used for foot drop in people with multiple sclerosis (pwMS) on gait speed in short and long walking performance tests. DATA SOURCES: Five databases (Cochrane Library, CINAHL, Embase, MEDLINE, and PubMed) and reference lists were searched. STUDY SELECTION: Studies of both observational and experimental design where gait speed data in pwMS could be extracted were included. DATA EXTRACTION: Data were independently extracted and recorded. Methodologic quality was assessed using the Effective Public Health Practice Project tool. DATA SYNTHESIS: Nineteen studies (described in 20 articles) recruiting 490 pwMS were identified and rated as moderate or weak, with none gaining a strong rating. All studies rated weak for blinding. Initial and ongoing orthotic and therapeutic effects were assessed regarding the effect of FES on gait speed in short and long walking tests. Meta-analyses of the short walk tests revealed a significant initial orthotic effect (t=2.14, P=.016), with a mean increase in gait speed of .05m/s, and ongoing orthotic effect (t=2.81, P=.003), with a mean increase of .08m/s. There were no initial or ongoing effects on gait speed in long walk tests and no therapeutic effect on gait speed in either short or long walk tests. CONCLUSIONS: FES used for foot drop has a positive initial and ongoing effect on gait speed in short walking tests. Further fully powered randomized controlled trials comparing FES with alternative treatments are required.

Parkinsonian gait ameliorated with a moving handrail, not with a banister.

OBJECTIVE: To determine whether haptic (touch and proprioception) cues from touching a moving handrail while walking can ameliorate the gait symptoms of Parkinson disease (PD), such as slowness and small stride length. DESIGN: Nonrandomized, controlled before-after trial. SETTING: Physical therapy clinic. PARTICIPANTS: People with PD (n=16) and healthy age-matched control subjects (n=16) with no neurologic disorders volunteered. No participants withdrew. INTERVENTIONS: We compared gait using a moving handrail as a novel assistive aid (speed self-selected) versus a banister and unassisted walking. Participants with PD were tested on and off dopaminergic medication. MAIN OUTCOME MEASURES: Mean gait speed, stride length, stride duration, double-support duration, and medial-lateral excursion. RESULTS: With the moving handrail, participants with PD increased gait speed relative to unassisted gait by 16% (.166m/s, P=.009, d=.76; 95% confidence interval [CI], .054-.278m/s) and increased stride length by 10% (.053m, P=.022, d=.37; 95% CI, .009-.097m) without significantly changing stride or double-support duration. The banister reduced speed versus unassisted gait by 11% (-.097m/s, P=.040, d=.40; 95% CI, .002-.193m/s) and reduced stride length by 8% (.32m, P=.004, d=.26; 95% CI, .010-.054m), whereas it increased stride duration by 3% (.023s, P=.022, d=.21; 95% CI, .004-.041s) and double-support duration by 35% (.044s, P=.031, d=.58; 95% CI, .005-.083s). All medication × condition interactions were P>.05. CONCLUSIONS: Using haptic speed cues from the moving handrail, people with PD walked faster by spontaneously (ie, without specific instruction) increasing stride length without altering cadence; banisters slowed gait. Haptic cues from the moving handrail can be used by people with PD to engage biomechanical and neural mechanisms for interpreting tactile and proprioception changes related to gait speed to control gait better than static cues afforded by banisters.

Feasibility study of a take-home array-based functional electrical stimulation system with automated setup for current functional electrical stimulation users with foot-drop.

OBJECTIVE: To investigate the feasibility of unsupervised community use of an array-based automated setup functional electrical stimulator for current foot-drop functional electrical stimulation (FES) users. DESIGN: Feasibility study. SETTING: Gait laboratory and community use. PARTICIPANTS: Participants (N=7) with diagnosis of unilateral foot-drop of central neurologic origin (>6mo) who were regular users of a foot-drop FES system (>3mo). INTERVENTION: Array-based automated setup FES system for foot-drop (ShefStim). MAIN OUTCOME MEASURES: Logged usage, logged automated setup times for the array-based automated setup FES system and diary recording of problems experienced, all collected in the community environment. Walking speed, ankle angles at initial contact, foot clearance during swing, and the Quebec User Evaluation of Satisfaction with Assistive Technology version 2.0 (QUEST version 2.0) questionnaire, all collected in the gait laboratory. RESULTS: All participants were able to use the array-based automated setup FES system. Total setup time took longer than participants' own FES systems, and automated setup time was longer than in a previous study of a similar system. Some problems were experienced, but overall, participants were as satisfied with this system as their own FES system. The increase in walking speed (N=7) relative to no stimulation was comparable between both systems, and appropriate ankle angles at initial contact (N=7) and foot clearance during swing (n=5) were greater with the array-based automated setup FES system. CONCLUSIONS: This study demonstrates that an array-based automated setup FES system for foot-drop can be successfully used unsupervised. Despite setup's taking longer and some problems, users are satisfied with the system and it would appear as effective, if not better, at addressing the foot-drop impairment. Further product development of this unique system, followed by a larger-scale and longer-term study, is required before firm conclusions about its efficacy can be reached.

Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial.

OBJECTIVE: To examine the effects of activity-based therapy (ABT) on neurologic function, walking ability, functional independence, metabolic health, and community participation. DESIGN: Randomized controlled trial with delayed treatment design. SETTING: Outpatient program in a private, nonprofit rehabilitation hospital. PARTICIPANTS: Volunteer sample of adults (N=48; 37 men and 11 women; age, 18-66y) with chronic (≥12mo postinjury), motor-incomplete (ASIA Impairment Scale grade C or D) spinal cord injury (SCI). INTERVENTIONS: A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. MAIN OUTCOME MEASURES: Neurologic function (International Standards for Neurological Classification of Spinal Cord Injury); walking speed and endurance (10-meter walk test, 6-minute walk test, and Timed Up and Go test); community participation (Spinal Cord Independence Measure, version III, and Reintegration to Normal Living Index); and metabolic function (weight, body mass index, and Quantitative Insulin Sensitivity Check). RESULTS: Significant improvements in neurologic function were noted for experimental versus control groups (International Standards for Neurological Classification of Spinal Cord Injury total motor score [5.1±6.3 vs 0.9±5.0; P=.024] and lower extremity motor score [4.2±5.2 vs -0.6±4.2; P=.004]). Significant differences between experimental and control groups were observed for 10-meter walk test speed (0.096±0.14m/s vs 0.027±0.10m/s; P=.036) and 6-minute walk test total distance (35.97±48.2m vs 3.0±25.5m; P=.002). CONCLUSIONS: ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, further analysis is needed to determine for whom ABT is going to lead to meaningful clinical benefits.

Activity-based therapy for recovery of walking in chronic spinal cord injury: results from a secondary analysis to determine responsiveness to therapy.

OBJECTIVE: To gain insight into who is likely to benefit from activity-based therapy (ABT), as assessed by secondary analysis of data obtained from a clinical trial. DESIGN: Secondary analysis of results from a randomized controlled trial with delayed treatment design. SETTING: Outpatient program in a private, nonprofit rehabilitation hospital. PARTICIPANTS: Volunteer sample of adults (N=38; 27 men; 11 women; age, 22-63y) with chronic (≥12mo postinjury), motor-incomplete (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade C or D) spinal cord injury (SCI). INTERVENTIONS: A total of 9h/wk of ABT for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. MAIN OUTCOME MEASURES: Walking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test). RESULTS: This secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability. Training effects were the most clinically significant in AIS grade D participants with injuries <3 years in duration. This information, along with information about preliminary responsiveness to therapy (gains after 12wk), can help predict the degree of recovery likely from participation in an ABT program. CONCLUSIONS: ABT has the potential to promote neurologic recovery and enhance walking ability in individuals with chronic, motor-incomplete SCI. However, not everyone with goals of walking recovery will benefit. Individuals with SCI should be advised of the time, effort, and resources required to undertake ABT. Practitioners are encouraged to use the findings from this trial to assist prospective participants in establishing realistic expectations for recovery.

Accuracy of Video-Based Gait Analysis Using Pose Estimation During Treadmill Walking Versus Overground Walking in Persons After Stroke.

OBJECTIVE: Video-based pose estimation is an emerging technology that shows significant promise for improving clinical gait analysis by enabling quantitative movement analysis with little costs of money, time, or effort. The objective of this study is to determine the accuracy of pose estimation-based gait analysis when video recordings are constrained to 3 common clinical or in-home settings (ie, frontal and sagittal views of overground walking and sagittal views of treadmill walking). METHODS: Simultaneous video and motion capture recordings were collected from 30 persons after stroke during overground and treadmill walking. Spatiotemporal and kinematic gait parameters were calculated from videos using an open-source human pose estimation algorithm and from motion capture data using traditional gait analysis. Repeated-measures analyses of variance were then used to assess the accuracy of the pose estimation-based gait analysis across the different settings, and the authors examined Pearson and intraclass correlations with ground-truth motion capture data. RESULTS: Sagittal videos of overground and treadmill walking led to more accurate measurements of spatiotemporal gait parameters versus frontal videos of overground walking. Sagittal videos of overground walking resulted in the strongest correlations between video-based and motion capture measurements of lower extremity joint kinematics. Video-based measurements of hip and knee kinematics showed stronger correlations with motion capture versus ankle kinematics for both overground and treadmill walking. CONCLUSION: Video-based gait analysis using pose estimation provides accurate measurements of step length, step time, and hip and knee kinematics during overground and treadmill walking in persons after stroke. Generally, sagittal videos of overground gait provide the most accurate results. IMPACT: Many clinicians lack access to expensive gait analysis tools that can help identify patient-specific gait deviations and guide therapy decisions. These findings show that video-based methods that require only common household devices provide accurate measurements of a variety of gait parameters in persons after stroke and could make quantitative gait analysis significantly more accessible.

Freezing of gait in idiopathic normal pressure hydrocephalus.

BACKGROUND: Reports of freezing of gait (FoG) in idiopathic normal pressure hydrocephalus (iNPH) are few and results are variable. This study's objective was to evaluate the frequency of FoG in a large cohort of iNPH patients, identify FoG-associated factors, and assess FoG's responsiveness to shunt surgery. METHODS: Videotaped standardized gait protocols with iNPH patients pre- and post-shunt surgery (n = 139; median age 75 (71-79) years; 48 women) were evaluated for FoG episodes by two observers (Cohens kappa = 0.9, p < 0.001). FoG episodes were categorized. Mini-mental state examination (MMSE) and MRI white matter hyperintensities (WMH) assessment using the Fazekas scale were performed. CSF was analyzed for Beta-amyloid, Tau, and Phospho-tau. Patients with and without FoG were compared. RESULTS: Twenty-two patients (16%) displayed FoG at baseline, decreasing to seven (8%) after CSF shunt surgery (p = 0.039). The symptom was most frequently exhibited during turning (n = 16, 73%). Patients displaying FoG were older (77.5 vs. 74.6 years; p = 0.029), had a slower walking speed (0.59 vs. 0.89 m/s; p < 0.001), a lower Tinetti POMA score (6.8 vs. 10.8; p < 0.001), lower MMSE score (21.3 vs. 24.0; p = 0.031), and longer disease duration (4.2 vs. 2.3 years; p < 0.001) compared to patients not displaying FoG. WMH or CSF biomarkers did not differ between the groups. CONCLUSIONS: FoG is occurring frequently in iNPH patients and may be considered a typical feature of iNPH. FoG in iNPH was associated with higher age, longer disease duration, worse cognitive function, and a more unstable gait. Shunt surgery seems to improve the symptom.

Relative Aerobic Load of Daily Activities After Stroke.

OBJECTIVE: Individuals after stroke are less active, experience more fatigue, and perform activities at a slower pace than peers with no impairments. These problems might be caused by an increased aerobic energy expenditure during daily tasks and a decreased aerobic capacity after stroke. The aim of this study was to quantify relative aerobic load (ie, the ratio between aerobic energy expenditure and aerobic capacity) during daily-life activities after stroke. METHODS: Seventy-nine individuals after stroke (14 in Functional Ambulation Category [FAC] 3, 25 in FAC 4, and 40 in FAC 5) and 22 peers matched for age, sex, and body mass index performed a maximal exercise test and 5 daily-life activities at a preferred pace for 5 minutes. Aerobic energy expenditure (mL O2/kg/min) and economy (mL O2/kg/unit of distance) were derived from oxygen uptake ($\dot{\mathrm{V}}{\mathrm{O}}_2$). Relative aerobic load was defined as aerobic energy expenditure divided by peak aerobic capacity (%$\dot{\mathrm{V}}{\mathrm{O}}_2$peak) and by $\dot{\mathrm{V}}{\mathrm{o}}_2$ at the ventilatory threshold (%$\dot{\mathrm{V}}{\mathrm{o}}_2$-VT) and compared in individuals after stroke and individuals with no impairments. RESULTS: Individuals after stroke performed activities at a significantly higher relative aerobic load (39%-82% $\dot{\mathrm{V}}{\mathrm{o}}_2$peak) than peers with no impairments (38%-66% $\dot{\mathrm{V}}{\mathrm{o}}_2$peak), despite moving at a significantly slower pace. Aerobic capacity in individuals after stroke was significantly lower than that in peers with no impairments. Movement was less economical in individuals after stroke than in peers with no impairments. CONCLUSION: Individuals after stroke experience a high relative aerobic load during cyclic daily-life activities, despite adopting a slower movement pace than peers with no impairments. Perhaps individuals after stroke limit their movement pace to operate at sustainable relative aerobic load levels at the expense of pace and economy. IMPACT: Improving aerobic capacity through structured aerobic training in a rehabilitation program should be further investigated as a potential intervention to improve mobility and functioning after stroke.

Good vibrations: tactile cueing for freezing of gait in Parkinson's disease.

BACKGROUND: Cueing strategies can alleviate freezing of gait (FOG) in people with Parkinson's disease (PD). We evaluated tactile cueing delivered via vibrating socks, which has the benefit of not being noticeable to bystanders. OBJECTIVE: To evaluate the effect of tactile cueing compared to auditory cueing on FOG. METHODS: Thirty-one persons with PD with FOG performed gait tasks during both ON and OFF state. The effect of open loop and closed loop tactile cueing, as delivered by vibrating socks, was compared to an active control group (auditory cueing) and to a baseline condition (uncued gait). These four conditions were balanced between subjects. Gait tasks were videotaped and annotated for FOG by two experienced raters. Motion data were collected to analyze spatiotemporal gait parameters. Responders were defined as manifesting a relative reduction of > 10% in the percent time frozen compared to uncued gait. RESULTS: The average percent time frozen during uncued gait was 11.2% in ON and 21.5% in OFF state. None of the three tested cueing modalities affected the percentage of time frozen in either the ON (p = 0.20) or OFF state (p = 0.12). The number of FOG episodes and spatiotemporal gait parameters were also not affected. We found that 22 out of 31 subjects responded to cueing, the response to the three types of cueing was highly individual. CONCLUSIONS: Cueing did not improve FOG at the group level; however, tactile as well as auditory cueing improved FOG in many individuals. This highlights the need for a personalized approach when using cueing to treat FOG.

Safety and Feasibility of Robot-assisted Gait Training in Adults with Cerebral Palsy in an Inpatient Setting - an Observational Study.

BACKGROUND: To investigate the safety and feasibility of six sessions of Hybrid Assistive Limb (HAL) robot-assisted gait training (RAGT) integrated into an inpatient therapy concept and their influence on walking speed and gait parameters in adult CP patients. METHODS: Eleven subjects (male = 8, female = 3, mean age: 23 years and 2 months, ± 4.5 years) with spastic CP underwent six 20-minute RAGT sessions with the HAL during an 11-day hospital stay. Additionally, physiotherapy, physician-performed manual medicine, massage and exercise therapy were provided. Pre- (T1) and post- (T2) intervention assessments were: 10-metre walking test (10MWT), 6-minute walking test (6MWT), Gross Motor Function Measure (GMFM-88) and lower extremities passive range of motion (pROM). RESULTS: All subjects completed the study. No adverse events were noted. Walking speed in the 10MWT test increased from 32.5 s (± 24.5 s) at T1 to 27.5 s (± 21.4 s) at T2, without significance. Slight, but non-significant improvements were detected in the 6MWT, GMFM and pROM. Confounding factors did not significantly affect the results. Conclusion: Intensive therapy including HAL training leads to non-significant improvements. Further studies with more patients and longer intervention time could provide further insights into the RAGT therapy of adult patients with CP. Registration DRKS-ID: DRKS00020275.

Feasibility, acceptability and effects of dance therapy in stroke patients: A systematic review.

INTRODUCTION: Stroke is the leading cause of non-traumatic disability in adults, with balance and gait disturbances representing the main limitations of body functions. Dance therapy (DT) has shown positive effects in older adults and in patients with neurological pathologies. This systematic review aims to examine the feasibility, acceptability and effects of DT in stroke rehabilitation, specifically on functional gains of gait and balance. METHODS: A systematic search was carried out for articles published in the MEDLINE, PEDro, Web of Science, Scopus and CINHAL in February 2021 and updated in April 2021. RESULTS: Eight studies were included (2 clinical cases, 5 case series and 1 randomized controlled trial), 7 of them in patients with chronic stroke and only 1 in subacute stroke phase. The most widely used dance modality was tango and ballet, with sessions ranging from 30 to 110 min. DT seems to show positive effects on post-stroke body functions and activities such as gait and balance. Reported dropout rates are inconsistent, no adverse effects were reported, and participant satisfaction was high. CONCLUSION: Given the heterogeneity and uneven quality of the included studies, strong conclusions cannot be put forward on the effectiveness of DT in post-stroke body function and activities. Nevertheless, DT seems to be safe and acceptable therapy for patients, and no adverse effects have been reported. More studies with a high level of evidence and feasibility are needed to determine the patient profile, the characteristics of the intervention, the participation rate and the role of the rehabilitation professional most likely to generate optimal benefit.

Measurement Properties of Assessments of Freezing of Gait Severity in People With Parkinson Disease: A COSMIN Review.

OBJECTIVE: Parkinson disease (PD) is the second-most common neurodegenerative condition worldwide. Approximately 50% of people with PD experience freezing of gait, a motor symptom associated with falls, disability, and poorer quality of life. Accurate assessment of freezing of gait severity is important for guiding management. The aim of this systematic review was to determine the measurement properties of subjective and objective clinical assessments of freezing of gait severity using the COSMIN methodology to facilitate better outcome measure selection. METHODS: Three databases (MEDLINE, EMBASE, and CINAHL) were searched. The COSMIN Risk of Bias checklist was used for evaluating quality of included studies. Data on measurement properties were extracted. Where possible, meta-analysis was performed. RESULTS: Nineteen studies investigating measurement properties of 7 outcome measures (patient-reported outcome measures, n = 3; objective assessment tools, n = 4) were included. Ten studies evaluated the Freezing of Gait Questionnaire. Based on COSMIN criteria, the best performing outcome measures were the Freezing of Gait Questionnaire and the Dynamic Parkinson Gait Scale. Both outcome measures demonstrated sufficient structural validity, internal consistency, reliability, construct validity, and responsiveness. The Freezing of Gait Questionnaire was supported with mostly moderate to high quality of evidence, but the evidence for the Dynamic Parkinson Gait Scale was of low quality due to inadequate sample size. CONCLUSIONS: Content validity and measurement invariance remain unknown for all outcome measures. The Freezing of Gait Questionnaire is the best measure currently available. Further external validation and reliability studies would strengthen the evidence to support the use of the Dynamic Parkinson Gait Scale. IMPACT: Awareness of limitations of outcome measures facilitates better selection. Without evidence for content validity and measurement invariance, clinicians should consider if their chosen test accurately measures freezing of gait severity and whether it can be applied in populations different to the original study's population. LAY SUMMARY: Accurately assessing freezing of gait severity is important for guiding management of this disabling symptom. The best clinical assessment currently available is one that relies on the self-report of patients.

Falls and Fear of Falling in Shunted Idiopathic Normal Pressure Hydrocephalus-The Idiopathic Normal Pressure Hydrocephalus Comorbidity and Risk Factors Associated With Hydrocephalus Study.

BACKGROUND: Gait and balance impairment are typical symptoms of idiopathic normal pressure hydrocephalus (INPH), implicating that falls may afflict these patients. OBJECTIVE: To investigate falls, related injuries, and associated psychological features, before and after shunt surgery for INPH and compared to the general population. METHODS: The study included 176 patients shunted for INPH and 368 age- and sex-matched controls. Falls, fear of falling (FOF), fall-related injuries (mild-severe), confidence in avoiding falls (Swedish Falls Efficacy Scale (FES(S)), quality of life (QoL; EuroQoL 5-dimension 5 level instrument), and symptoms of depression (Geriatric Depression Scale 15) were investigated. Pre- and postoperative observational times were 12 mo before surgery and 21 mo after (mean). Recurrent fallers fell ≥2 times. RESULTS: More INPH patients than controls were recurrent fallers (67% vs 11%; P < .001). They feared falling more often (FOF, mean ± standard deviation: 3.3 ± 1.1 vs 1.6 ± 0.9; P < .001) and had lower confidence in avoiding falls (FES(S) 78 ± 40 vs 126 ± 14; P < .001). After surgery, INPH patients improved in all parameters but they did not reach the levels of the controls. Among fallers there was no difference between patients and controls in the severity of injuries suffered. Low QoL and symptoms of depression were more common among recurrent fallers than one-time or nonfallers in both shunted patients and controls (P ≤ .001). CONCLUSION: Falls, FOF, and low confidence in avoiding falls are considerable problems in INPH that may be reduced by shunt surgery. We suggest that remaining risk of falling and preventative measures are routinely considered in postoperative follow-ups and rehabilitation planning.

Frontal ataxia: historical aspects and clinical definition / Ataxia frontal: aspectos históricos e definição clínica

Abstract Frontal ataxia, originally described by Bruns, is characterized by the presence of signs of frontal lobe dysfunction, such as perseveration, paratonia, frontal release signs, cognitive changes, and urinary difficulty, associated with imbalance, slow gait, broad-based, the presence of postural instability and falls, retropulsion, and bradykinesia in the lower limbs. The goal of the present study is to recall the historical aspects of this condition, to draw attention to the importance of this clinical finding for the differential diagnosis of ataxias and to review the main semiological differences between primary ataxias (frontal, cerebellar, and sensory ataxia).

Resumo A ataxia frontal, originalmente descrita por Bruns, caracteriza-se pela presença de sinais de disfunção do lobo frontal, como perseveração, paratonia, sinais de liberação frontal, alterações cognitivas e dificuldade urinária, associados a desequilíbrio, marcha lenta, base ampla, presença de instabilidade postural e quedas, retropulsão e bradicinesia em membros inferiores. O objetivo do presente trabalho é recordar os aspectos históricos desta condição, ressaltar a importância deste achado clínico para o diagnóstico diferencial das ataxias e revisar as principais diferenças semiológicas entre as ataxias primárias (ataxia frontal, cerebelar e sensitiva).

[Foot drop treatment by implantation of a neuroprosthesis (ActiGait®)]. / Behandlung des Fallfußes durch Implantation einer Neuroprothese (ActiGait®).

OBJECTIVE: Gait improvement by restoring dorsiflexion using a neuroprosthesis implant. INDICATIONS: Foot drop with damage to the 1st motor neuron; passive mobility in ankle is possible; adult patients. CONTRAINDICATIONS: Foot drop with peripheral damage and injury to the peroneal nerve; already implanted stimulators (e.g., defibrillator, pacemaker, or pain stimulator); severe anesthesia risks in multimorbid patients. SURGICAL TECHNIQUE: Surgery in lateral position. Searching for the peroneal nerve after dorsal incision in the popliteal fossa, using the medial edge of the biceps femoris as anatomic landmark. After identification of the motor branch of the peroneal nerve by positive dorsiflexion after using electrostimulation apply the electrode cuff on the nerve. Epifascial implantation of stimulation body lateral at the middle third of the thigh over the tractus iliotibialis. POSTOPERATIVE MANAGEMENT: Pain-adapted full weight bearing, no knee flexion more than 90° for 4-6 weeks, activation of neuroprosthesis 3 weeks after surgery, physiotherapy with gait training is required. RESULTS: Between 2013 and 2015, implantation of the neuroprosthesis was performed in 21 patients (13 men/8 women) with chronic foot drop due to a central lesion. Significant improvement in walking speed measured with the 10 meter walk test (11.8 ± 5.4 s to 7.9 s ± 3.4; p = 0.007), in gait endurance with 6 min walk test (212.2 ± 75.5 m to 306.4 ± 96.4 m; p ≤ 0.001), and in gait performance using the Emory Functional Ambulation Profile (105.9 ± 49.7 s to 63.2 ± 31. 3 s; p ≤ 0.001). No patient required surgical revision. Postoperative bleeding was recorded in one case (4%). Patient satisfaction and improvement in mobility and quality of life could be achieved (95% and 90%, respectively).

Behavior Changes and Gait Unsteadiness: The Value of Imaging and Prompt Neurosurgical Intervention.

Cavernous angiomas are central nervous system malformations. Most common manifestations are seizures and acute focal neurological deficits. We present a case report of a seventy-one year-old man with a two-month history of behavior changes, attention deficit and indifference followed by gait unsteadiness. Neuropsychological evaluation showed severe cognitive impairment and executive dysfunction. Head computed tomography depicted a supraventricular hydrocephaly. Magnetic resonance imaging revealed a small hemorrhage, contiguous to a mesencephalic cavernous angioma, obstructing the Sylvius aqueduct, causing secondary hydrocephalus. Four months after endoscopic ventriculocisternostomy, neuropsychological evaluation showed improvement and the patient regained autonomy. Parenchyma cavernous angiomas causing direct hemorrhage and subsequent obstruction of the Sylvian aqueduct are uncommon. Sub-acute behavior and mental state abnormalities are rare first manifestations of cavernous angioma and requires high clinical suspicion for its correct diagnosis. Magnetic resonance imaging evaluation is crucial in the detection of such patients as prompt neurosurgical intervention may substantially improve cognitive function.

Os angiomas cavernosos são malformações do sistema nervoso central cujas manifestações mais comuns são crises epiléticas e défices neurológicos agudos. Apresentamos o caso clínico de um doente de 71 anos com uma história com dois meses de evolução de alteração do comportamento, défice de atenção e apatia, sucedidas por marcada instabilidade da marcha. A avaliação neuropsicológica revelava alterações cognitivas e disfunção executiva marcadas. Na Tomografia Computorizada Cerebral observava-se hidrocefalia supraventricular enquanto na Ressonância Magnética cerebral era possível observar uma pequena hemorragia que obstruía o aqueduto de Sylvius localizada contiguamente a um angioma cavernoso mesencefálico. Quatro meses após o tratamento com ventriculocisternostomia endoscópica, o doente apresentava melhoria significativa na avaliação neuropsicológica tendo voltado a adquirir a autonomia prévia. A apresentação de um angioma cavernoso parenquimatoso como uma obstrução do aqueduto de Sylvius secundária a hemorragia é invulgar. Rara é também a sua apresentação como alterações do comportamento e do estado mental subagudas. Uma avaliação neuroimagiológica e uma intervenção neurocirúrgica precoces foram essenciais para a melhoria cognitiva observada.