Assessment of Foot Strike Angle and Forward Propulsion with Wearable Sensors in People with Stroke.

Effective retraining of foot elevation and forward propulsion is a critical aspect of gait rehabilitation therapy after stroke, but valuable feedback to enhance these functions is often absent during home-based training. To enable feedback at home, this study assesses the validity of an inertial measurement unit (IMU) to measure the foot strike angle (FSA), and explores eight different kinematic parameters as potential indicators for forward propulsion. Twelve people with stroke performed walking trials while equipped with five IMUs and markers for optical motion analysis (the gold standard). The validity of the IMU-based FSA was assessed via Bland-Altman analysis, ICC, and the repeatability coefficient. Eight different kinematic parameters were compared to the forward propulsion via Pearson correlation. Analyses were performed on a stride-by-stride level and within-subject level. On a stride-by-stride level, the mean difference between the IMU-based FSA and OMCS-based FSA was 1.4 (95% confidence: -3.0; 5.9) degrees, with ICC = 0.97, and a repeatability coefficient of 5.3 degrees. The mean difference for the within-subject analysis was 1.5 (95% confidence: -1.0; 3.9) degrees, with a mean repeatability coefficient of 3.1 (SD: 2.0) degrees. Pearson's r value for all the studied parameters with forward propulsion were below 0.75 for the within-subject analysis, while on a stride-by-stride level the foot angle upon terminal contact and maximum foot angular velocity could be indicative for the peak forward propulsion. In conclusion, the FSA can accurately be assessed with an IMU on the foot in people with stroke during regular walking. However, no suitable kinematic indicator for forward propulsion was identified based on foot and shank movement that could be used for feedback in people with stroke.

The effects of small variations in shoe heel height on gait in people with a transtibial amputation.

BACKGROUND: Shoe heel height is considered to influence prosthetic alignment, walking comfort, and gait symmetry in people with a transtibial amputation (TTA). However, research on the effect of heel height is scarce, and no evidence is available on the effects of variations smaller than 20 mm. These small heel height variations between store-bought shoes are often overlooked by people with an amputation and may cause secondary musculoskeletal problems in the long term. OBJECTIVE: To examine the effects of small increases in heel height on gait symmetry in people with a TTA and healthy individuals. STUDY DESIGN: Experimental repeated measures study. METHODS: Fourteen participants with a TTA and 15 healthy controls were included. Pressure data, spatiotemporal data, and experienced walking comfort were measured during walking with four heel height conditions: original height and increased heights of 3, 5, and 8 mm. Symmetry in center of pressure velocity (VCOP), gait parameters, and experienced walking comfort were compared between the heel heights and between healthy controls and prosthetic walkers. RESULTS: Increased heel height resulted in a significant decrease in VCOP symmetry (P = 0.001) and experienced walking comfort (P < 0.001). The VCOP trajectory of the prosthetic leg mainly differed within the first 14.5% of the stance phase. Healthy individuals showed better VCOP symmetry in all conditions (P < 0.001). CONCLUSIONS: Healthcare professionals should advice their clients to be alert of small heel height differences between store-bought shoes, especially those larger than 5 mm. A prosthetic alignment adjustment should be considered when purchasing new shoes.

Incidence of urinary tract infection following initiation of intermittent catheterization among patients with recent spinal cord injury in Germany and the Netherlands.

Objective: To assess incidence of urinary tract infection (UTI) among patients with recent spinal cord injury (SCI) who initiated intermittent catheterization (IC).Design: Retrospective chart review.Setting: Two European SCI rehabilitation centers.Participants: Seventy-three consecutive patients with recent SCI who initiated IC.Outcome measures: Incidence of UTI, using six different definitions, each based on microbiology ± symptomatology ± mention of UTI . Rates were expressed in terms of numbers of UTIs per 100 patient-months (PMs). Attention was focused on first-noted UTI during the three-month follow-up, as assessed with each of the six definitions.Results: Fifty-eight percent of patients (n = 33) met ≥1 definitions for UTI during follow-up (rate: 31.5 UTIs per 100 PMs), ranging from 14% (5.3 per 100 PMs; definition requiring bacteriuria, pyuria, and presence of symptoms) to 45% (22.7 per 100 PMs; definition requiring "mention of UTI"). Ten cases were identified using the definition that required bacteriuria, pyuria, and symptoms, whereas definitions that required bacteriuria and either pyuria or symptoms resulted in the identification of 20-25 cases. Median time to UTI ranged from 42 days ("mention of UTI") to 81 days (definition requiring bacteriuria and ≥100 leukocytes/mm3).Conclusion: Depending on definition, 14% to 45% of patients with recent SCI experience UTI within three months of initiating IC. Definitions requiring bacteriuria and either pyuria or symptoms consistently identified about twice as many cases as those that required all three conditions. Standardizing definitions may help improve detection, treatment, and prevention of UTI within this vulnerable population.

Pre- and peroperative diagnosis of Cutibacterium acnes infections in shoulder surgery: A systematic review.

BACKGROUND: Cutibacterium acnes is the most commonly detected pathogen during shoulder surgery. Lack of typical infection signs make Cutibacterium acnes infections difficult to diagnose. This systematic review aims to determine which pre- and peroperative diagnostic tools are most reliable to identify Cutibacterium acnes infections after shoulder surgery. METHODS: PubMed/Embase were searched for diagnostic studies. Methodological quality of included studies was assessed using QUADAS-2. Forest plots summarized results (sensitivity and specificity) for each pre- and peroperative diagnostic tool. RESULTS: Twenty-two studies were included, of which 8 described preoperative, 10 peroperative, and 4 both pre- and peroperative diagnostic tools. Quality of the studies varied widely. For preoperative tools, synovial calprotectin, interleukin-6, and combined interleukin-6/interleukin-2/tumor necrosis factor-α had the best efficacy measures. Pre-revision biopsies and arthroscopic tissue cultures were the best peroperative tools. CONCLUSION: Despite a lack of evidence and the use of different Cutibacterium acnes infection criteria and reference standards, the use of combined interleukin-6/interleukin-2/tumor necrosis factor-α as preoperative and arthroscopic tissue cultures as peroperative diagnostic tool is for now recommended based on results and validity. More research should be performed to provide valid evidence on these tools. In order to do so, an internationally accepted definition of Cutibacterium acnes infections is essential. LEVEL OF EVIDENCE: Systematic review.

Management of gait impairments in people with Charcot-Marie-Tooth disease: A treatment algorithm.

Gait impairments in people with Charcot Marie Tooths disease are the combined result of ankle-foot deformities, muscle weakness, and somatosensory impairments. People with Charcot-Marie-Tooth disease often experience pain and difficulties when walking, especially barefoot. They also trip and fall frequently and have a lower than normal gait speed and distance. Because these gait impairments and related complaints are disabling, clinical management aimed at improving gait is important. Management involves both conservative and surgical treatment options, each with limited scientific evidence. However, a treatment algorithm that describes both conservative and surgical treatment options is currently lacking. This study sets out a step-wise treatment algorithm, based on evidence, if available, and otherwise reflecting practice-based experience. The treatment algorithm will be of value in daily clinical practice, and will serve as a template for future research.

Maximal Walking Distance in Persons with a Lower Limb Amputation.

The distance one can walk at a time could be considered an important functional outcome in people with a lower limb amputation. In clinical practice, walking distance in daily life is based on self-report (SIGAM mobility grade (Special Interest Group in Amputee Medicine)), which is known to overestimate physical activity. The aim of this study was to assess the number of consecutive steps and walking bouts in persons with a lower limb amputation, using an accelerometer sensor. The number of consecutive steps was related to their SIGAM mobility grade and to the consecutive steps of age-matched controls in daily life. Twenty subjects with a lower limb amputation and ten age-matched controls participated in the experiment for two consecutive days, in their own environment. Maximal number of consecutive steps and walking bouts were obtained by two accelerometers in the left and right trouser pocket, and one accelerometer on the sternum. In addition, the SIGAM mobility grade was determined and the 10 m walking test (10 MWT) was performed. The maximal number of consecutive steps and walking bouts were significantly smaller in persons with a lower limb amputation, compared to the control group (p < 0.001). Only 4 of the 20 persons with a lower limb amputation had a maximal number of consecutive steps in the range of the control group. Although the maximal covered distance was moderately correlated with the SIGAM mobility grade in participants with an amputation (r = 0.61), for 6 of them, the SIGAM mobility grade did not match with the maximal covered distance. The current study indicated that mobility was highly affected in most persons with an amputation and that the SIGAM mobility grade did not reflect what persons with a lower limb amputation actually do in daily life. Therefore, objective assessment of the maximal number of consecutive steps of maximal covered distance is recommended for clinical treatment.

Are current foot- and ankle outcome measures appropriate for the evaluation of treatment for osteoarthritis of the ankle?: Evaluation of ceiling effects in foot- and ankle outcome measures.

BACKGROUND: Many PROMs used for evaluation of ankle osteoarthritis are not validated for this purpose. We hypothesize that frequently used PROMs have an early ceiling or floor effect. METHODS: We prospectively collected data from patients with ankle osteoarthritis between 2011 and 2013. At baseline visit patients completed the Foot and Ankle Outcome Score, the Ankle Osteoarthritis Score, the American Orthopaedic Foot and Ankle Society scale, a visual analogue scale for pain and quality of life. Outcomes were analyzed for floor or ceiling effects. RESULTS: 197 patients were included in the study. A floor effect was present for the AOFAS and VAS for pain in all groups. Floor and ceiling effect are absent for the FAOS outcome measure for all groups. CONCLUSIONS: Physicians should be aware of floor or ceiling effects when evaluating treatment using patient reported outcome measures. The FAOS outcome measure lacks early ceiling or floor effects.

Hyaluronic acid and other conservative treatment options for osteoarthritis of the ankle.

BACKGROUND: The cause of ankle osteoarthritis (OA) is usually trauma. Patients are relatively young, since ankle trauma occurs at a relatively young age. Several conservative treatment options are available, evidence of the benefits and harms of these options are lacking. OBJECTIVES: To assess the benefits and harms of any conservative treatment for ankle OA in adults in order to provide a synthesis of the evidence as a base for future treatment guidelines. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, issue 9), MEDLINE (Ovid) (1946 up to 11 September 2014), EMBASE (1947 to September 2014), PsycINFO (1806 to September 2014), CINAHL (1985 to September 2014), PEDro (all years till September 2014), AMED until September 2014, ClinicalTrials.gov, Current Controlled Trials, The Dutch Register. To identify potentially relevant studies we screened reference lists in retrieved review articles and trials. SELECTION CRITERIA: We considered randomised or controlled clinical trials investigating any non-surgical intervention for ankle OA for inclusion. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: No other RCT concerning any other conservative treatment besides the use of hyaluronic acid (HA) for ankle OA was identified. Six randomised controlled trials (RCTs) were included.A total of 240 participants diagnosed with ankle OA were included in this review. The primary analysis included three RCTs (109 participants) which compared HA to placebo. One study compared HA to exercise therapy, one compared HA combined with exercise therapy to an intra-articular injection of botulinum toxin and one compared four different dosages of HA.Primary analysis: a pooled analysis of two trials (45 participants) found that the Ankle Osteoarthritis Scale (AOS) total score (measuring pain and physical function) was reduced by 12% (95% CI -24% to -1%) at six months (mean difference (MD) -12.53 (95% CI -23.84 to -1.22) on a scale of 0 to 100; number needed to treat for an additional beneficial outcome (NNTB) = 4 (95% CI 2 to 205); this evidence was graded as low quality, due to limitations in study design (unclear risk of selection bias for two studies and unclear risk for attrition bias for one study) and imprecision of results: a small population size (45 participants). It is not known if a mean difference of 12.53 points on a 100 point scale is clinically relevant. No minimal important clinical difference is known for this score. Pain and function outcomes were not reported separately. Radiographic joint structure changes were not investigated. For the mean quality of life at six months (two trials; 45 participants) no meta-analysis could be performed due to missing data. No serious adverse events (SAEs) were noted and no participants withdrew because of an adverse event. There were a few adverse events (AEs) 5/63 (8%) in the HA group and 2/46 (4%) in the placebo group. The Peto odds ratio (Peto OR) to have an adverse event was 2.34 higher compared to the control group (95% CI 0.45 to 12.11). This evidence is inconclusive because of a wide CI and a small number of events.For comparing HA to exercise therapy (30 participants) the results for pain on a Visual Analogue Scale (VAS 0 to 10) at 12 months are inconclusive (MD 0.70, 95% CI -2.54 to 1.14). The American Orthopedic Foot and Ankle Society score (AOFAS score) was 13.10 points (MD) higher in favour of HA (95% CI 2.97 to 23.23) on a scale of 0 to 100. The evidence was graded as low. No adverse events were found. Radiographic structure changes were not measured; no participants withdrew due to AEs; no SAEs were found.For the comparison of HA injection combined with exercise therapy to an intra-articular injection of botulinum toxin A (BoNT-A) (75 participants), the outcome of the AOS pain score of the affected joint at six months is inconclusive (MD 0.10, 95% CI -0.42 to 0.62). The physical function (the AOS disability score) at six months is inconclusive (MD 0.20, 95% CI -0.34 to 0.74). The same number of AEs were found in both groups; HA 2/37 (5.9%), BoNT-A 2/38 (5.8%) (risk ratio (RR) 1.03, 95% CI 0.15 to 6.91). Radiographic changes were not examined, no SAEs were found and no participants withdrew because of an AE. The evidence was graded as low.The RCT comparing four different dosing schedules for HA (26 participants) showed the best median decrease in pain on walking VAS (on a scale of 0 to 100) for 3 x 1 ml at 27 weeks with a median decrease of 30. Physical function, radiographic changes and quality of life were not measured.Twenty-seven percent of all participants had AEs, most of them in the 2ml group (57% in this group). No participants withdrew due to an AE and no SAEs were noted.Overall the quality of the evidence showed some serious limitations. The evidence was graded low for the primary analysis comparing HA to placebo. This was based on a limitation in design and implementation: sample sizes were small (45 to 92 participants) and and imprecision in results: there was an unclear risk of bias for several items concerning the three studies used in the meta analysis. AUTHORS' CONCLUSIONS: Currently, there is insufficient data to create a synthesis of the evidence as a base for future guidelines for ankle OA. Since the aetiology of ankle OA is different, guidelines that are currently used for hip and knee OA may not be applicable for ankle OA. Simple analgesics as recommended for hip and knee OA seem however a reasonable first step to treat ankle OA. It is unclear if there is a benefit or harm for HA as treatment for ankle OA compared to placebo at six months based on a low quality of evidence. Inconclusive results were found comparing HA to other treatments. HA can be conditionally recommended if patients have an inadequate response to simple analgesics. It remains unclear which patients (age, grade of ankle OA) benefit the most from HA injections and which dosage schedule should be used.

The impact of ankle osteoarthritis. The difference of opinion between patient and orthopedic surgeon.

BACKGROUND: Outcome measures for ankle osteoarthritis (OA) are created by physicians with little input of the target patient group. The aim of this study was to determine the difference in opinion between patients and orthopedic surgeons concerning the importance of specific symptoms of ankle OA and its impact on daily life and function. METHODS: A modified Delphi method was applied, consisting of structured interviews with patient focus groups and experts, followed by a poll using 32 statements. The difference in opinion between patients and orthopedic surgeons was evaluated. RESULTS: Forty patients and forty orthopedic surgeons responded to the 32 statements. Statistically significant differences in opinion on symptoms, function and the impact of ankle OA on daily life were found. CONCLUSIONS: This study demonstrates a significant difference in opinion between patients and orthopedic surgeons concerning specific symptoms of ankle OA. These results advocate incorporating the needs and demands of the individual patient for new outcome measures.

Evidence for bilaterally delayed and decreased obstacle avoidance responses while walking with a lower limb prosthesis.

OBJECTIVE: To examine whether the increased failure rates in obstacle avoidance of patients with lower limb amputation can be understood on the basis of increased delay and/or decreased amplitudes of obstacle avoidance responses. METHODS: Subjects performed obstacle avoidance on a treadmill while EMG recordings were made of several major muscles of the leg. RESULTS: It was found that subjects with a lower limb amputation have delayed responses (e.g. delays of 20 ms for the Biceps Femoris) and have decreased response amplitudes (36-41% smaller). Furthermore, such changes were observed not only on the prosthetic side, but also on the sound side. The decreased amplitudes were associated with increased failure rates in the obstacle avoidance task. CONCLUSIONS: It is concluded that the bilaterally delayed and reduced responses in persons with a lower limb prosthesis reflect a basic reorganization within the central nervous system aimed at providing synchronized activity in both lower limbs, even though the peripheral deficit involves only one limb. SIGNIFICANCE: The present results on obstacle avoidance responses can be used to evaluate future prosthetic training involving obstacle crossings for amputee rehabilitation.

From satisfaction to expectation: the patient's perspective in lower limb prosthetic care.

PURPOSE: To obtain information about the wishes and experiences of patients with a lower limb amputation with regard to prosthetic prescription and their exchange of information with the healthcare providers. DESIGN: Cross-sectional questionnaire. SETTING: Outpatient clinic of a Rehabilitation Centre. STUDY PARTICIPANTS: A random sample of patients with a lower limb amputation (n = 81). MAIN OUTCOME MEASURES: In analogy with the QUOTE questionnaire a focus group technique was used. Prosthetic users formulated 24 specific items, which were of importance according to them. The items were divided into 4 categories: (i) service demand, (ii) prosthetic prescription, (iii) information, (iv) insurance aspects. The questionnaire consisted of two sets (A and B) of 24 items rating importance of items and experience in everyday practice. To identify different dimensions within the 24 items, a factor analysis in SPSS was performed for lists A and B followed by a varimax rotation. Impact factors were calculated by multiplying the mean score of importance on an item with the percentage of patients that experienced this item as negative. RESULTS: A total of 113 questionnaires were sent by e-mail with a response of 73%. The outcomes of the questionnaires resulted in 2 sets of information: One concerning the importance of several items in the process of prosthetic prescription, the other the experience of the prosthetic user about those items. By multiplying the scores on importance by the percentage of negative experience per item (impact score) points of improvement for clinical practice were formulated. CONCLUSIONS: A discrepancy between the needs of patients and what they experience in their contacts with clinical professionals as the most important dimension was noticed. A questionnaire with specific items for a homogeneous target group is a good method to formulate points of improvement for clinical practice in healthcare.

High failure rates when avoiding obstacles during treadmill walking in patients with a transtibial amputation.

OBJECTIVE: To investigate if and to what extent patients with a transtibial amputation are less successful in avoiding unexpected obstacles while walking than healthy adults. DESIGN: Experimental 2-group design. SETTING: Dutch rehabilitation center. PARTICIPANTS: Eleven patients with a transtibial amputation and 14 healthy controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subjects walked on a treadmill at .56m/s. In 2 series of 12 trials each, an obstacle was dropped in front of the prosthetic or the nonprosthetic leg of the amputation group and the left leg of the control group at different phases during the step cycle. It was noted which avoidance strategy was used (a long step strategy [LSS] or a short step strategy [SSS]) and whether the obstacle was avoided successfully or not. These data were expressed as a percentage of the total number of trials completed by each subject. RESULTS: With either leg, the amputation group made significantly more errors than the control subjects (prosthetic leg, 24%+/-17%; nonprosthetic leg, 21%+/-17% vs 2%+/-2% for the control group). Highest failure rates were in the amputation group when time pressure was high, requiring an SSS, especially on the prosthetic side. An LSS under time pressure, however, nearly always resulted in failure for both the prosthetic and nonprosthetic legs. Subjects with the longest time since amputation were most successful in avoiding unexpected obstacles. CONCLUSIONS: Under time pressure, patients with a lower-leg prosthesis perform best when they use their nonprosthetic leg as the lead limb in an SSS. The fact that some subjects with the longest time since amputation made no errors suggests that over many years it is possible to relearn the appropriate avoidance reactions sufficiently fast.

Use of the Delphi Technique for developing national clinical guidelines for prescription of lower-limb prostheses.

The aim of this project was the development of evidence- and consensus-based clinical practice guidelines for lower-limb prosthesis prescription for achieving transparency and consensus among clinicians, manufacturers, and insurance companies. This article describes a modified Delphi Technique, which is based on different methods of collecting evidence, and its role in the development of national clinical guidelines for prosthesis prescription. We used a multimethod approach to develop guidelines for the clinical practice of prosthesis prescription for lower-limb amputees. The Delphi Technique was central in the process, and the panel was made up of experts from three key disciplines on a national level. Our approach involved various methods: a systematic review, a survey of national clinical practice on prosthesis prescription, and interviews with experts. These activities resulted in 45 postulates about prosthesis prescription. The views of the national expert panel were then presented at a consensus development conference. The participants in the Delphi Technique sessions reached a consensus on 37 of the postulates on prosthesis prescription for lower-limb amputees. The postulates were categorized according to amputation level and partitioned into different domains. The total process resulted in the development of draft clinical guidelines comprising guidance for prescribing prostheses for the lower limb. The scope and applicability of these guidelines will have to be measured and evaluated in future work.

A systematic literature review of the effect of different prosthetic components on human functioning with a lower-limb prosthesis.

A correct prosthetic prescription can be derived from adapting the functional benefits of a prosthesis to the functional needs of the prosthetic user. For adequate matching, the functional abilities of the amputees are of value, as well as the technical and functional aspects of the various prosthetic components. No clear clinical consensus seems to be given on the precise prescription criteria. To obtain information about different prosthetic components and daily functioning of amputees with a prosthesis, we performed a systematic literature search. The quality of the studies was assessed with the use of predetermined methodological criteria. Out of 356 potentially relevant studies, 40 studies eventually qualified for final methodological analysis and review. Four satisfied all the criteria and were classified as A-level studies, 26 as B-level, and 10 studies as C-level studies. Despite a huge amount of literature, our formal clinical knowledge had considerable gaps concerning the effects of different prosthetic components and their mechanical characteristics on human functioning with a lower-limb prosthesis. Therefore, with regard to prosthetic guideline development, we must still largely rely on clinical consensus among experts. The integration of knowledge from research with the expert opinion of clinical professionals and the opinions and wishes of consumers can form a solid base for a procedure on guideline development for prosthetic prescription.