Can adults with cerebral palsy perform and benefit from ballistic strength training to improve walking outcomes? A mixed methods feasibility study.

BACKGROUND: Power bursts of hips and ankle plantar flexors are prerequisites to walking propulsion. However, these power bursts are reduced during gait for persons with cerebral palsy (CP) and mainly in the ankle plantar flexors. Hence, task specific training, such as ballistic strength training, is suggested to increase muscle power in walking but not investigated in adults with CP. Therefore, the aim was to investigate if adults with CP could perform and benefit from ballistic strength training to improve walking, evaluated through physical measures and self-reported measures and interviews. METHODS: In this mixed methods feasibility study, eight ambulatory adults (aged 24-56) with spastic CP conducted ballistic strength training on a glideboard targeting the ankle plantarflexors two times a week for eight weeks. The feasibility of the training was assessed through objectives described by Orsmond and Cohn. Before and after the intervention, physical measures (6-Minute Walk Test and the eight-item High-level Mobility Assessment Tool) and self-reported measures (Patient Global Impression of Change, Numeric Pain Rating Scale, Fatigue Impact and Severity Self-Assessment, and Walk-12) were collected. After the intervention, semi-structured interviews explored experiences of this training. RESULTS: The participants experienced training the ankle plantar flexor as relevant but reported it took about four weeks to coordinate the exercises successfully. Although we observed no changes in the physical performance measures, most participants reported improvements; some felt steadier when standing, walking, and hopping. CONCLUSION: This study demonstrated that ballistic strength training was feasible and suitable in adults with CP. However, guidance and a long (4 weeks) familiarization time were reported necessary to master the exercises. Most participants reported self-experienced improvements, although no physical performance measures improved. Thus, prolonged intervention may be required for perceived physical improvements to emerge. Also, other outcome measures sensitive to power output remains to be investigated.

Two-year changes in gait variability in community-living older adults.

BACKGROUND: Increases in stride-to-stride fluctuations (gait variability) are common among older adults, but little is known about the natural progression of gait variability with increasing age. RESEARCH QUESTION: Does gait variability change with increasing age in a group of community-living older adults? METHODS: The participants were community-living volunteers between 70-81 years, who were tested with a two-year interval between tests. They walked 6.5 m under four different conditions: At preferred speed, at fast speed, during a dual task condition and on an uneven surface. Trunk accelerations in the anteroposterior (AP), mediolateral (ML) and vertical (V) direction were captured using a body-worn sensor worn at the lower back. Gait variability was estimated using an autocorrelation procedure, where coefficients tending towards 1.0 indicated low variability and 0.0 as high variability. To estimate change, we used an ANOVA-procedure with baseline gait speed as a covariate. RESULTS: At baseline, 85 older adults were tested, and data for 56 of these were available for analysis over a two-year period of time. The average age at inclusion was 75.8 years (SD 3.43) and 60% were women. During preferred speed walking, variability increased in the AP direction (mean difference 0.05, p = .038), during fast speed walking it increased in the V direction (mean difference 0.04, p = .037) and during dual task-walking, it increased in the ML and V directions (mean differences 0.03, p = .032 and 0.09, p = .020 respectively). SIGNIFICANCE: The findings from this study could be helpful for discriminating between normal and pathological progression of gait variability in older adults.

Reduced Walking Speed in Subjective and Mild Cognitive Impairment: A Cross-Sectional Study.

BACKGROUND AND PURPOSE: Walking speed is reduced in people with dementia, but less is known about predementia conditions. We, therefore, studied the relationship between walking speed, cognition, and cerebrospinal fluid biomarkers in persons with subjective (SCI) and mild cognitive impairment (MCI). METHODS: We conducted a cross-sectional study of 22 healthy controls, 30 SCI and 17 MCI (N = 69). Walking speed was measured by a 10-m gait test at usual and fast pace. We analyzed the association between walking speed and the ordered categories of controls, SCI, and MCI in a generalized proportional odds model. Neuropsychological tests, Consortium to Establish a Registry for Alzheimer's Disease (delayed recall), and Trail Making (TMT) A and B, were analyzed by negative binomial, linear, and robust regression for association with walking speed. RESULTS: Walking speed at usual pace was slower moving from controls to SCI (odds ratio: 0.46, P = 0.031) and MCI (odds ratio: 0.44, P = .019) on an ordinal scale. In MCI, walking speed was reduced at fast speed (odds ratio: 0.46, P = 0.04). There were significant associations between walking speeds and neuropsychological test performance. Usual walking speed was associated with slower test performance on TMT-A (ß: -.02, P = .04) and fast pace with slower performance on TMT-B (ß: -.01, P = .03). There were no associations between cerebrospinal fluid biomarkers and walking speeds. CONCLUSION: Usual walking speed is reduced in a graded fashion with the early symptoms of cognitive impairment. Our results suggest that reduced walking speed at both usual and fast speed is associated with impaired cognitive function, and that walking speed could be affected at very early stages of neurodegeneration.

The walk ratio: Investigation of invariance across walking conditions and gender in community-dwelling older people.

BACKGROUND: The step length-cadence ratio, also called the walk ratio (WR; cm/steps/min) is a measure of cautious gait, poor balance control or impaired gait, but has not been investigated for both genders in a general population of older adults across different speeds and conditions. METHOD: The participants were community-dwelling volunteers between 70 and 81 years. They walked 6.5 m under four different conditions: At preferred speed, fast speed, during a dual task condition and on an uneven surface. Step length (cm) and cadence (steps/minute) was captured using a body-worn sensor. Both cadence and step lengths were adjusted for body height. RESULTS: 70 older adults participated (mean age 75.5 (SD 3.4), 60 percent women). The WR was 0.60 cm/steps/min (SD 0.07) during preferred speed walking, 0.58 cm/steps/min (SD 0.07) during fast walking, 0.68 cm/steps/min (SD 0.18) during dual task-walking and 0.59 cm/steps/min (0.07) during uneven surface-walking. In planned pairwise comparisons, the WR during dual task was significantly different from preferred speed walking (mean difference -0.087 cm/steps/min, 95% CI -0.140, -0.033), from fast speed walking (mean difference -0.098 cm/steps/min, 95% CI -0.154, -0.041) and uneven surface walking (mean difference 0.092 cm/steps/min, 95% CI 0.040, 0.145). There were no gender differences except during the fast walking condition, where women had a significantly lower WR than the men (0.56 cm/steps/min vs 0.61 cm/steps/min, p = 0.002). DISCUSSION: We found that the WR is invariant during different speeds, and during an uneven surface condition, but is affected during a dual task-condition, when attention must be divided between a cognitive and a motor task.

A longitudinal study investigating how stroke severity, disability, and physical function the first week post-stroke are associated with walking speed six months post-stroke.

OBJECTIVES: To investigate to which degree stroke severity, disability, and physical function the first week post-stroke are associated with preferred walking speed (PWS) at 6 months. DESIGN: Longitudinal observational study. METHOD: Participants were recruited from a stroke unit and tested within the first week (baseline) and at 6 months post-stroke. Outcome measures were the National Institutes of Health Stroke Scale (NIHSS), the Barthel Index (BI), modified Rankin Scale (mRS), PWS, Postural Assessment Scale for Stroke (PASS), and the Trunk Impairment Scale modified-Norwegian version. Multiple regression models were used to explore which variables best predict PWS at 6 months, and the Receiver Operating Characteristics (ROC) curves to determine the cutoffs. RESULTS: A total of 132 participants post-stroke were included and subdivided into two groups based on the ability to produce PWS at baseline. For the participants that could produce PWS at baseline (WSB group), PASS, PWS, and age at baseline predicted PWS at 6 months with an explained variance of 0.77. For the participants that could not produce a PWS at baseline (NoWSB group), only PASS predicted PWS at 6 months with an explained variance of 0.49. For the Walking speed at baseline (WSB) group, cutoffs at baseline for walking faster than 0.8 m/s at 6 months were 30.5 points on the PASS, PWS 0.75 m/s, and age 73.5 years. For the NoWSB group, the cutoff for PASS was 20.5 points. CONCLUSION: PASS, PWS, and age the first week predicted PWS at 6 months post-stroke for participants with the best walking ability, and PASS alone predicted PWS at 6 months post-stroke for participants with the poorest walking ability.

Predictors of outcomes following reablement in community-dwelling older adults.

BACKGROUND: Reablement is a rehabilitation intervention for community-dwelling older adults, which has recently been implemented in several countries. Its purpose is to improve functional ability in daily occupations (everyday activities) perceived as important by the older person. Performance and satisfaction with performance in everyday life are the major outcomes of reablement. However, the evidence base concerning which factors predict better outcomes and who receives the greatest benefit in reablement is lacking. OBJECTIVE: The objective of this study was to determine the potential factors that predict occupational performance and satisfaction with that performance at 10 weeks follow-up. METHODS: The sample in this study was derived from a nationwide clinical controlled trial evaluating the effects of reablement in Norway and consisted of 712 participants living in 34 municipalities. Multiple linear regression was used to investigate possible predictors of occupational performance (COPM-P) and satisfaction with that performance (COPM-S) at 10 weeks follow-up based on the Canadian Occupational Performance Measure (COPM). RESULTS: The results indicate that the factors that significantly predicted better COPM-P and COPM-S outcomes at 10 weeks follow-up were higher baseline scores of COPM-P and COPM-S respectively, female sex, having a fracture as the major health condition and high motivation for rehabilitation. Conversely, the factors that significantly predicted poorer COPM-P and COPM-S outcomes were having a neurological disease other than stroke, having dizziness/balance problems as the major health condition and having pain/discomfort. In addition, having anxiety/depression was a predictor of poorer COPM-P outcomes. The two regression models explained 38.3% and 38.8% of the total variance of the dependent variables of occupational performance and satisfaction with that performance, respectively. CONCLUSION: The results indicate that diagnosis, functional level, sex and motivation are significant predictors of outcomes following reablement.

Psychometric properties of the Canadian Occupational Performance Measure in home-dwelling older adults.

BACKGROUND: The Canadian Occupational Performance Measure (COPM) is an occupational therapy instrument designed to help participants identify, prioritize, and evaluate performance of important occupations. OBJECTIVE: To investigate the validity, responsiveness, interpretability, and feasibility of the COPM when used by various health professions in home-dwelling older adults receiving reablement. Reablement is a new form of multidisciplinary home-based rehabilitation for older adults experiencing functional decline. PARTICIPANTS AND METHODS: The sample of 225 participants, mean age 80.8 years, who were in need of rehabilitation for various health conditions were included in the study. Data collection was conducted at baseline and at 10 weeks follow-up. The COSMIN guidelines and recommendations for evaluating methodological quality were followed. RESULTS: Content validity, construct validity, and feasibility were found to be adequate. Responsiveness, however, was moderate. Functional mobility was the most frequently prioritized occupational category of all. Regarding interpretability, the minimal important change was 3.0 points and 3.2 points for performance and satisfaction, respectively. The older adults reported that COPM was a useful and manageable instrument. The majority of the occupational therapists, physiotherapists, and nurses reported that they had the required expertise to conduct the COPM assessments. CONCLUSION: The results support the multidisciplinary use of the COPM in clinical practice and research in a home-dwelling, heterogeneous population of older adults. Based on the findings, 3 points are recommended as a cutoff point to distinguish between older adults who have a minimal important change in COPM performance and COPM satisfaction and those who have not.

Reablement in community-dwelling older adults: a randomised controlled trial.

BACKGROUND: There has been an increasing interest in reablement in Norway recently and many municipalities have implemented this form of rehabilitation despite a lack of robust evidence of its effectiveness. The aim of this study was to investigate the effectiveness of reablement in home-dwelling older adults compared with usual care in relation to daily activities, physical functioning, and health-related quality of life. METHODS: This is a parallel-group randomised controlled trial conducted in a rural municipality in Norway. Sixty-one home-dwelling older adults with functional decline were randomised to an intervention group (n = 31) or a control group (n = 30). The intervention group received ten weeks of multicomponent home-based rehabilitation. The Canadian Occupational Performance Measure (COPM) was used to measure self-perceived activity performance and satisfaction with performance. In addition, physical capacity and health-related quality of life were measured. The participants were assessed at baseline and at 3- and 9-month follow-ups. RESULTS: There were significant improvements in mean scores favouring reablement in COPM performance at 3 months with a score of 1.5 points (p = 0.02), at 9 months 1.4 points (p = 0.03) and overall treatment 1.5 points (p = 0.01), and for COPM satisfaction at 9 months 1.4 points (p = 0.03) and overall treatment 1.2 points (p = 0.04). No significant group differences were found concerning COPM satisfaction at 3 months, physical capacity or health-related quality of life. CONCLUSION: A 10-week reablement program resulted in better activity performance and satisfaction with performance on a long-term basis, but not the other outcomes measured. TRIAL REGISTRATION: The trial was registered in ClinicalTrials.gov November 20, 2012, identifier NCT02043262 .

Walking during body-weight-supported treadmill training and acute responses to varying walking speed and body-weight support in ambulatory patients post-stroke.

Rehabilitating walking in ambulatory patients post-stroke, with training that is safe, task-specific, intensive, and of sufficient duration, can be challenging. Some challenges can be met by using body-weight-supported treadmill training (BWSTT). However, it is not known to what degree walking characteristics are similar during BWSTT and overground walking. In addition, important questions regarding the training protocol of BWSTT remain unanswered, such as how proportion of body-weight support (BWS) and walking speed affect walking characteristics during training. The objective was therefore to investigate if and how kinematic walking characteristics are different between overground walking and treadmill walking with BWS in ambulatory patients post-stroke, and the acute response of altering walking speed and percent BWS during treadmill walking with BWS. A cross-sectional repeated-measures design was used. Ambulating patients post-stroke walked in slow, preferred, and fast walking speed overground and at comparable speeds on the treadmill with 20% and 40% BWS. Kinematic walking characteristics were obtained using a kinematic sensor attached over the lower back. Forty-four patients completed the protocol. Kinematic walking characteristics were similar during treadmill walking with BWS, compared to walking overground. During treadmill walking, choice of walking speed had greater impact on kinematic walking characteristics than proportion of BWS. Faster walking speeds tended to affect the kinematic walking characteristics positively. This implies that in order to train safely and with sufficient intensity and duration, therapists may choose to include BWSTT in walking rehabilitation also for ambulatory patients post-stroke without aggravating gait pattern during training.

Familiarisation to body weight supported treadmill training for patients post-stroke.

INTRODUCTION: Walking on a treadmill with body weight support (BWS) may require familiarisation. Patients post-stroke fatigue easily and the time needed to reach stable walking is important. However, even if body weight supported treadmill training (BWSTT) is commonly used in gait rehabilitation for patients post-stroke, it is not known how much time that is needed before stable walking is reached in this population. The objective of this study therefore, was to investigate if patients post-stroke manage to stabilise walking patterns during a 5-min familiarisation-trial on the treadmill with BWS. METHOD: 35 patients post-stroke walked on a treadmill at preferred speed and with 20 percent BWS during a 5-min familiarisation-period. A body-worn sensor assessed trunk acceleration. Intraclass correlation coefficient (ICC) was used for pairwise comparisons of successive 30s intervals during familiarisation, and one-way repeated-measures analysis of variance was used to investigate if there were linear trends between intervals. RESULTS: Mean ICCs across all variables stabilised above 0.90 after 3 min. Across intervals, walk ratio, cadence and step length obtained mean ICCs that were high, while interstride trunk regularity and trunk asymmetry obtained lower ICCs. However, except for mediolateral trunk acceleration, there was no linear trend after the first 3 min indicating that differences between intervals during the last 2 min were random. DISCUSSION AND CONCLUSION: This was the first study investigating familiarisation to BWSTT for patients post-stroke. Findings revealed that most of the familiarisation occurred within the first 3 min of walking, and therefore relatively stable walking could be achieved within a 5-min walking trial on the treadmill with BWS.

Gait variability measures may represent different constructs.

Many measures of gait variability have been reported, but the degree to which such measures are associated and thus represent a common construct is inconclusive. The purpose of this paper is to establish construct validity of commonly used spatio-temporal footfall variability and trunk variability measures taking into account the effect of measurement error. Twenty-three older individuals, aged 80+/-5 years performed four repeated walks at preferred speed, 0.97+/-0.16m/s. Gait data were obtained by an electronic walkway and by trunk accelerometry. Of initially 13 variability measures, five satisfied a reliability criterion of ICC> or =0.80 and were included in a subsequent construct validity analysis. Of these, step length variability and step time variability did not correlate significantly, while step length variability correlated closely with anteroposterior interstep trunk variability, and step time variability with vertical interstep trunk variability. Mediolateral interstep trunk variability did not correlate significantly with any of the other measures. This finding supports the notion that this measure may represent still a different aspect of variability. Different gait variability measures representing different constructs should be included in gait analysis to enhance our understanding of variability in gait.

Treadmill walking with body weight support effect of treadmill, harness and body weight support systems.

This study aims to provide new knowledge on the principles of treadmill walking with body weight support (BWS) by qualifying and quantifying the effects on gait in 28 healthy individuals. Gait assessment included measuring trunk movements during different conditions. Walking overground and on a treadmill with and without harness, and on a treadmill with 30% dynamic and static body weight support, was assessed. Gait variables for all conditions were compared at 1.2m/s. On the treadmill, cadence increased, the trunk tilted more forwards, vertical acceleration increased and anteroposterior acceleration became more variable. Wearing a harness resulted in more restricted vertical acceleration. Walking with body weight support restricted acceleration in all directions. It also produced variable interstride trunk acceleration in the anteroposterior and vertical directions, but more consistent interstride trunk acceleration in the mediolateral direction. Static BWS gave larger differences than dynamic BWS.