A systematic review of the determinants of implementation of a locomotor training program using a powered exoskeleton for individuals with a spinal cord injury.

BACKGROUND: Wearable powered exoskeletons represent a promising rehabilitation tool for locomotor training in various populations, including in individuals with a spinal cord injury. The lack of clear evidence on how to implement a locomotor powered exoskeleton training program raises many challenges for patients, clinicians and organizations. OBJECTIVE: To report determinants of implementation in clinical practice of an overground powered exoskeleton locomotor training program for persons with a spinal cord injury. DATA SOURCES: Medline, CINAHL, Web of Science. STUDY SELECTION: Studies were included if they documented determinants of implementation of an overground powered exoskeleton locomotor training program for individuals with spinal cord injury. DATA EXTRACTION: Eligible studies were identified by two independent reviewers. Data were extracted by one reviewer, based on constructs of the Consolidated Framework for Implementation Research, and validated by a second reviewer. RESULTS: Sixty-three articles were included. 49.4% of all determinants identified were related to the intervention characteristics, 29.6% to the individuals' characteristic and 13.5% to the inner setting. Recurrent barriers identified were the high prevalence of adverse events (e.g., skin issues, falls) and device malfunctions. Adequate training for clinicians, time and resource available, as well as discussion about patients' expectations were identified as facilitators. CONCLUSIONS: Powered exoskeleton training is a complex intervention. The limited information on the context and the implementation process domains may represent a barrier to a successful transition from knowledge to action.

Substituting anticipatory locomotor adjustments online is time constrained.

Two crucial, multi-articular strategies for anticipatory locomotor adjustments (ALA) are knee flexor generation to step over obstacles and hip flexor generation to step up. While lower limb control can be adapted online to modify an already planned obstacle avoidance, or to avoid the sudden appearance of an obstacle, it is not known whether a planned ALA can be substituted by different one online. The present objective was to study such ALA substitutions at two specific timepoints: the final planning stage and the initiation of ALA execution. Ten healthy, young adults (22.0 ± 1.7 years; 5 males) walked in a Virtual Environment (VE) representing the laboratory within a head mounted display. Two blocks of trials, one involving an initial VE with an obstacle (OB) and the other an initial VE with a platform (PL) (heights of 15% of lower limb length for both), were presented, where the initial VE could remain unchanged or be randomly switched between them at one of the two timepoints. The final VE always corresponded to the real environment. Lead limb kinematics, joint kinetics and energetics, as well as electromyography were measured. Repeated measures ANOVAs were used to compare across conditions. Foot clearance, knee flexor generation, and hip flexor generation all changed in the expected directions for the final VEs when requiring early substitution, but not when switched late. These findings show that volitional, locomotor strategies may be substituted at the end of the ALA planning phase, but not once execution is initiated.

Visuo-locomotor control in persons with spinal cord injury in a manual or power wheelchair for direction change and obstacle circumvention.

Many individuals, such as persons with spinal cord injury (SCI), rely on wheeled locomotion involving manual (MWC) or power (PWC) wheelchairs to navigate their environments. Yet, visuo-locomotor control underlying WC navigation in experienced users is not well understood. The objective of this study was to compare the visuo-locomotor control between MWC and PWC in individuals with SCI while changing direction and circumventing an obstacle. Participants with SCI using a MWC (n = 12, 38.5 ± 10.7 years) or a PWC (n = 10, 47.8 ± 8.6 years) were asked to maneuver their chair straight ahead, while changing direction 45° to the right, and while circumventing an obstacle to the right, all at self-selected speeds. Speed, minimal clearance, point of deviation, temporal body and WC coordination, relative timing of segment rotations and visual behavior were analyzed. There was no main effect of group for speed, clearance and point of deviation. During direction change, the head always led body and wheelchair reorientation while an "en bloc" strategy was used for circumventing obstacle for both groups. In straight-ahead locomotion, participants predominantly fixed their gaze on the end target. During direction change and obstacle circumvention, participants fixated more on the future path and the obstacle for both WC modes. Overall, specific gaze behavior depended on environmental demands. While MWC and PWC users adopt similar navigational strategies and visuo-locomotor coordination while changing direction and circumventing obstacle, there were some differences in the amount of head rotation that could be related to a counter-movement used more by PWC users.

Walking aid training as a clinical competence in Canadian entry-to-practice professional academic programs.

PURPOSE: Multiple healthcare professionals fit walking aids (WA) and train individuals on their use. The purpose of this investigation was to describe curricula on WA fitting and training in Canadian entry-to-practice professional programs. MATERIALS AND METHODS: An online survey was administered to leads from all accredited programs (n = 199). Seventeen questions asked about the importance of WA education, instructional methods and time dedicated to WA fitting and skills training, and how the pandemic had affected WA curriculum delivery. RESULTS: Responses were received from 97 programs. While most occupational therapy (OT, 8/15), physiatry (PM&R, 5/9), and physical therapy (PT, 12/19) trainees received more than 3 h of instruction on WA fitting, most nursing (29/40) and pharmacy (7/8) programs spent less than 3 h on this topic. Most OT (9/15) and PT (15/19) programs spent more than 3 h on WA skills training whereas most nursing (25/40), pharmacy (4/8), and PM&R (5/9) programs spent less than 3 h on this subject. Across all programs, 52% educated students on adapting activities of daily living for WA while 18% provided education on WA maintenance and repair. Only 19/89 programs consulted a formal WA skills training resource for curriculum development. Seventeen of 55 programs modified their WA curricula due to the pandemic. CONCLUSIONS: There is a wide range in curricular approaches to WA education in Canadian professional programs. This highlights the need for a standardised WA education program to guide curricular development to ultimately improve safe WA use for clients with short- and long-term mobility impairments.IMPLICATIONS FOR REHABILITATIONCurricula on walking aids is extremely variable within and between programs.Navigating terrains, adapting activities of daily living, and maintenance are poorly taught.There is a need for a national standardized curriculum on walking aids.This curriculum should be modular and designed for practitioners, students, and patients.

Community-dwelling older adults with mild cognitive impairments show subtle visual attention costs when descending stairs.

BACKGROUND: Older adults are at greater risk of falls while descending stairs. Cognitive deficits can further influence one's ability and mild cognitive impairments (MCI) specifically affect visual attention and dual tasking behavior. The present study aimed at comparing the attentional costs at different points during the approach to and descent of a staircase between older adults with and without MCI. METHODS: Eleven older adults with MCI and twenty-three healthy older individuals without cognitive impairments were recruited. Neuropsychological tests were carried out. In addition, participants approached and descended a 5-step staircase while a simultaneous visual Stroop dual-task was randomly introduced during the approach, transition or steady state descent phases across trials. Three-dimensional kinematics and accuracy on the Stroop task were analyzed and dual task costs were calculated. RESULTS: The MCI group showed deficits for visuo-spatial attention, memory and multi-tasking abilities, as well as balance and decreased confidence for falls efficacy, but not for daily activity scores. Despite such changes, this group of community-dwelling individuals with MCI presented a functional capacity to descend stairs even during divided visual attention. However, there were subtle, but significant, group differences for movement fluidity and performance on the simultaneous cognitive task, particularly during the approach and transition to descent phases. The MCI group also tended to descend slower while using the handrails more than healthy older adults. CONCLUSION: The present cohort of community-dwelling older adults with MCI were functional, but appeared to prioritize locomotor demands over the simultaneous cognitive task in a possible "posture first" strategy to descend stairs. The present findings should be considered for developing more ecologically based clinical assessments of mobility deficits following cognitive impairments, with the approach and transition phases during stair descent as key points of focus.

Walking Aid Use in Canada: Prevalence and Demographic Characteristics Among Community-Dwelling Users.

Background: Mobility limitations represent the third most prevalent cause of disability, affecting more than 1.9 million community-dwelling Canadians. Walking aids are often prescribed to reduce the impacts of mobility impairments. There are limited data on walking aids since 2004. Objective: The objectives of this study were to investigate the prevalence of walking aid use in Canada and to explore demographic characteristics among users of walking aids. Design: The design used was a secondary analysis of a cross-sectional national survey. Methods: Data were obtained from the 2012 Canadian Survey on Disability from community-dwelling individuals who were 15 years old or older, had a self-identified activity limitation, and indicated that they used at least 1 walking aid (cane/walking stick/crutches or walker). Prevalence estimates were calculated as weighted frequencies. Analytic variables included walking aid type, sex, age, province/territory of residence, and main cause of activity limitation. Results: Approximately 1,125,000 community-dwelling individuals who were 15 years old or older used walking aids, representing 4.1% of the Canadian population. Of these individuals, 962,290 used canes/walking sticks/crutches, and 465,340 used a walker. Users of walking aids were predominantly female, with a mean age of 68 years. Limitations: Self-reported results reflect only the perceptions of individuals living in Canadian communities. Analyses excluded individuals in residential or long-term care settings and individuals living on First Nations reserves. Conclusions: Since 2004, there has been a 2% increase in the prevalence of walking aid use by the Canadian population, which is likely related to the aging of the population. The high prevalence of walking aid use highlights the need for better use of existing resources to ensure that individuals are receiving the correct devices. Results of this study suggest a need to evaluate the impact of device use to better understand how resources should be allocated for prescription and maintenance of walking aids and training of users.

Visuo-locomotor coordination for direction changes in a manual wheelchair as compared to biped locomotion in healthy subjects.

The visual system during walking provides travel path and environmental information. Although the manual wheelchair (MWC) is also a frequent mode of locomotion, its underlying visuo-locomotor control is not well understood. This study begins to understand the visuo-locomotor coordination for MWC navigation in relation to biped gait during direction changes in healthy subjects. Eight healthy male subjects (26.9±6.4 years) were asked to walk as well as to propel a MWC straight ahead and while changing direction by 45° to the right guided by a vertical pole. Body and MWC movement (speed, minimal clearance, point of deviation, temporal body coordination, relative timing of body rotations) and gaze behavior were analysed. There was a main speed effect for direction and a direction by mode interaction with slower speeds for MWC direction change. Point of deviation was later for MWC direction change and always involved a counter movement (seen for vehicular control) with greater minimal distance from the vertical pole as compared to biped gait. In straight ahead locomotion, subjects predominantly fixed their gaze on the end target for both locomotor modes while there was a clear trend for subjects to fixate on the vertical pole more for MWC direction change. When changing direction, head movement always preceded gaze changes, which was followed by trunk movement for both modes. Yet while subjects turned the trunk at the same time during approach regardless of locomotor mode, head movement was earlier for MWC locomotion. These results suggest that MWC navigation combines both biped locomotor and vehicular-based movement control. Head movement to anticipate path deviations and lead steering for locomotion appears to be stereotypic across locomotor modes, while specific gaze behavior predominantly depends on the environmental demands.