Functional performance in self-care and mobility after selective dorsal rhizotomy: a 10-year practice-based follow-up study.

AIM: To explore changes in performance in daily activities (self-care and mobility) 10 years after selective dorsal rhizotomy (SDR). METHOD: Twenty-four children with bilateral spastic cerebral palsy were followed; the median age at SDR was 4 years 1 month (range 2y 5mo-6y 4mo) and at 10-year follow-up was 14 years 6 months (range 12y 3mo-16y 9mo). The preoperative Gross Motor Function Classification System (GMFCS) levels were: I (n=1), II (n=7), III (n=4), IV (n=11), and V (n=1). The Pediatric Evaluation of Disability Inventory (PEDI) was used to assess performance in functional skills, caregiver assistance, and frequency of modifications and adaptive equipment (MAE) in self-care and mobility domains. Changes were analysed in relation to preoperative GMFCS levels, PEDI scores, and age at operation. RESULTS: All scores improved significantly (p<0.01) during the first 5 years in patients assigned to GMFCS levels I-III and IV-V. Between 5 years and 10 years, changes were seen in patients grouped in GMFCS levels I-III in the functional skills, mobility (p=0.04), caregiver assistance self-care (p=0.03), and caregiver assistance mobility (p=0.03) domains. Those grouped in GMFCS levels IV-V showed small changes between 5 years and 10 years after surgery. Changes were dependent on the preoperative GMFCS levels in all domains; caregiver assistance, self-care and mobility changes were dependent on preoperative values. The use of MAE increased in participants in GMFCS levels IV-V. INTERPRETATION: Children who underwent SDR and physiotherapy improved in functional performance in self-care and mobility and were more independent 10 years postoperatively.

Older women with dementia can perform fast alternating forearm movements and performance is correlated with tests of lower extremity function.

BACKGROUND: The purpose of this work was to study the performance and reliability of a test of fast alternating forearm movements and its relationship with measures of lower extremity function in older women with dementia. METHODS: Fast alternating movements was studied in 26 female patients (mean age 81.7 ± 5.9 years) with dementia and 34 controls (mean age 87.5 ± 4.7 years). Subgroup analyses for those aged 80-89 years were performed due to significant differences in the mean ages of the study groups. Test-retest reliability for alternating forearm movements was studied in 11 patients (mean age 80.3 ± 6.7 years) and 10 controls (mean age 87.4 ± 1.6 years). Pulses generated were transformed to an analog signal shown on a modified electrocardiogram. Numbers of cycles at 10 and 15 seconds were calculated for the right and left hand. Walking 2 × 15 m and the Get-Up-and Go (GUG) test were performed at self-selected and maximal speed. Associations between tests of upper and lower extremity function were sought in eight patients (mean age 85 ± 2.7 years) and 16 controls (mean age 85.1 ± 2.8 years) and also according to types of dementia in nine patients with probable Alzheimer's disease and 10 patients with other types of dementia. RESULTS: Patients with dementia could perform the test and had significantly fewer cycles (P = 0.02-0.006) at both 10 and 15 seconds compared with controls after age adjustment. A higher number of cycles was associated with higher self-selected walking speeds in patients (r = -0.79). Test-retest reliability for alternating forearm movements was high for both patients (intraclass correlation 0.88-0.94) and controls (intraclass correlation 0.74-0.94). CONCLUSION: Alternating forearm movements at fast speed can be used as a reliable test in both patients with dementia and healthy older subjects. The test can be used as a measure of bradykinesia and might be useful as a proxy for lower extremity function in older persons with dementia when testing of the lower extremities is not applicable due to walking disability.

Separate physical tests of lower extremities and postural control are associated with cognitive impairment. Results from the general population study Good Aging in Skåne (GÅS-SNAC).

PURPOSE: To investigate whether separate physical tests of the lower extremities, that assess movement speed and postural control, were associated with cognitive impairment in older community-dwelling subjects. SUBJECTS AND METHODS: In this population-based, cross-sectional, cohort study, the following items were assessed: walking speed, walking 2 × 15 m, Timed Up and Go (TUG) at self-selected and fast speeds, one-leg standing, and performance in step- and five chair-stand tests. The study comprised 2115 subjects, aged 60-93 years, with values adjusted for demographics, health-related factors, and comorbidity. Global cognitive function was assessed using the Mini-Mental State Examination (MMSE), and cognitive impairment was defined by the three-word delayed recall task of the MMSE. Subjects who scored 0/3 on the three-word delayed recall task were defined as cases (n = 328), those who scored 1/3 were defined as intermediates (n = 457), and the others as controls (n = 1330). RESULTS: Physical tests performed rapidly were significantly associated with cognitive impairment; this was the case in increased time of five chair stands (P = 0.009, odds ratio [OR] = 1.03), TUG (P < 0.001, OR = 1.11) and walking 2 × 15 m (P < 0.001, OR = 1.05). Inability to stand on one leg for 10 seconds was associated with increased risk of being a case (P < 0.001, OR = 1.78), compared to those able to stand for 30 seconds or longer. More steps during the step test (P < 0.001, OR = 0.95) and higher fast walking speed (P < 0.001, OR = 0.51) were associated with lower risk of being a case. CONCLUSION: Slower movements and reduced postural control were related to an increased risk of being cognitively impaired. All tests that were performed rapidly were able to separate cases from controls. These findings suggest that physical tests that are related to lower extremity and postural control, emphasizing velocity, might be useful in investigating relationships between physical and cognitive function; furthermore, they can be used to complement cognitive impairment diagnoses.

Motor function after selective dorsal rhizotomy: a 10-year practice-based follow-up study.

AIM: The aim of this study was to explore changes in motor function up to 10 years after selective dorsal rhizotomy (SDR). METHOD: The participants comprised 29 children (20 males, nine females) with bilateral spastic diplegia who were consecutively operated on at a median age of 4 years and 3 months and followed until a median age of 15 years. SDR was combined with physiotherapy and regular follow-up visits. The distribution of preoperative Gross Motor Function Classification System (GMFCS) levels was as follows: I, n=1; II, n=7; III, n=8; IV, n=12; and V, n=1. Muscle tone in hip flexors, hip adductors, knee flexors, and plantar flexors was assessed with the modified Ashworth scale, passive range of motion in hip abduction, popliteal angle, maximum knee extension, dorsiflexion of the foot was measured with a goniometer, and gross motor function was assessed using the Gross Motor Function Measure (GMFM-66). The results were compared with preoperative values, taking into account age at the time of SDR. RESULTS: After 10 years, muscle tone in hip flexors, hip adductors, knee flexors and plantar flexors was normalized in 19, 24, 13 and 23 participants respectively; mean change in passive range of motion ranged from -2.0° to 8.6°, and the mean increase in GMFM-66 was 10.6. Changes in GMFM-66 were associated with preoperative GMFCS level and GMFM-66 scores. INTERPRETATION: Children who underwent SDR and physiotherapy and were regularly followed up by an experienced team showed improved gross motor function for up to 10 years postoperatively.

The effects of high frequency subthalamic stimulation on balance performance and fear of falling in patients with Parkinson's disease.

BACKGROUND: Balance impairment is one of the most distressing symptoms in Parkinson's disease (PD) even with pharmacological treatment (levodopa). A complementary treatment is high frequency stimulation in the subthalamic nucleus (STN). Whether STN stimulation improves postural control is under debate. The aim of this study was to explore the effects of STN stimulation alone on balance performance as assessed with clinical performance tests, subjective ratings of fear of falling and posturography. METHODS: Ten patients (median age 66, range 59-69 years) with bilateral STN stimulation for a minimum of one year, had their anti-PD medications withdrawn overnight. Assessments were done both with the STN stimulation turned OFF and ON (start randomized). In both test conditions, the following were assessed: motor symptoms (descriptive purposes), clinical performance tests, fear of falling ratings, and posturography with and without vibratory proprioceptive disturbance. RESULTS: STN stimulation alone significantly (p = 0.002) increased the scores of the Berg balance scale, and the median increase was 6 points. The results of all timed performance tests, except for sharpened Romberg, were significantly (p or= 0.109) in torque variance values when comparing the two test situations. This applied both during quiet stance and during the periods with vibratory stimulation, and it was irrespective of visual input and sway direction. CONCLUSION: In this sample, STN stimulation alone significantly improved the results of the clinical performance tests that mimic activities in daily living. This improvement was further supported by the patients' ratings of fear of falling, which were less severe with the STN stimulation turned ON. Posturography could not be performed by three out of the ten patients when the stimulation was turned OFF. The posturography results of the seven patients with complete data showed no significant differences due to STN stimulation.

Longitudinal construct validity of the GMFM-88 total score and goal total score and the GMFM-66 score in a 5-year follow-up study.

BACKGROUND: The Gross Motor Function Measure (GMFM) is the instrument most commonly used to measure gross motor function in children with cerebral palsy (CP). Different scoring options have been developed, and their measurement properties have been assessed. Limited information is available regarding longitudinal construct validity. OBJECTIVE: The objective of this research was to study the longitudinal construct validity of 3 scoring options: the 88-item GMFM (GMFM-88) total, the GMFM-88 goal total, and the 66-item GMFM (GMFM-66). DESIGN: A clinical measurement design was used in this study. METHODS: Forty-one children with CP diplegia who were undergoing selective dorsal rhizotomy (SDR) were monitored with the GMFM for 5 years. The mean age at SDR was 4.4 years (range=2.5-6.6). Two subgroups for gross motor function before surgery were created according to the Gross Motor Function Classification System (GMFCS): GMFCS levels I to III and GMFCS levels IV and V. This study included results obtained before SDR and at 6, 12, and 18 months and 3 and 5 years after SDR. The effect size (ES) and the standardized response mean (SRM) were calculated. RESULTS: At 6 months postoperatively, ES and SRM values were small (

Health, balance, and walking as correlates of climbing steps.

The aim of this study was to investigate walking and health among woman age 75 yr or older, in the associations between the highest step up performed without support by an individual and balance, walking, and health among women age 75+. Records of the highest step, balance, walking, and health were made for 307 women age 75-93 yr living in the community. Eighty percent managed to climb steps higher than 20 cm. There was a statistically significant negative relationship between age and stair-climbing capacity. The highest steps registered were significantly and independently associated with a short time on the timed up-and-go test, long functional reach, low body weight, lack of perceived difficulty walking outdoors, low number of "missteps" when walking in a figure of 8, longer time in one-leg stance, ability to carry out tandem stance, no walking aids outdoors, and not being afraid of falling. These variables together explained 67% of the variance in the step-height score.

Transfemoral amputees' experiences of the first meeting and subsequent interactions with hospital staff.

PURPOSE: To describe, by use of a phenomenological approach, how transfemoral amputees experience their first meeting and subsequent interaction with hospital staff in the acute phase, in the long term and suggestions for future care-giving. METHOD: Eleven transfemoral amputees, median age 33.5 years, were interviewed. The amputations, performed in median 7.5 years before the interview, were caused by tumour, motorcycle accidents or work-related traumas. The participants were community dwelling and managed well indoors. All, except one, worked or studied full time. The interviews were tape-recorded and transcribed verbatim. RESULTS: Three themes emerged: (i) Communication/information - limitations in preparing the patient for the new situation, (ii) empathy and emotional support, and (iii) ability to meet the need of individually tailored rehabilitation. For future care-giving three categories emerged: (i) Individually tailored communication/information, (ii) rehabilitation to be prepared to adapt to one's new situation, and (iii) support in regaining control. CONCLUSION: The participants expressed a need for both professional and emotional support in the acute phase. Over time they preferred a patient-centred approach which improved coping skills and facilitated their own ability to gain control. Increased awareness of how meeting and interacting with hospital staff influences rehabilitation processes may further improve patient satisfaction and outcomes.

Validity and responsiveness of the Clubfoot Assessment Protocol (CAP). A methodological study.

BACKGROUND: The Clubfoot Assessment Protocol (CAP) is a multi dimensional instrument designed for longitudinal follow up of the clubfoot deformity during growth. Item reliability has shown to be sufficient. In this article the CAP's validity and responsiveness is studied using the Dimeglio classification scoring as a gold standard. METHODS: Thirty-two children with 45 congenital clubfeet were assessed prospectively and consecutively at ages of new-born, one, two, four months and two years of age. For convergent/divergent construct validity the Spearman's correlation coefficients were calculated. Discriminate validity was evaluated by studying the scores in bilateral clubfeet. The floor-ceiling effects at baseline (untreated clubfeet) and at two years of age (treated clubfeet) were evaluated. Responsiveness was evaluated by using effect sizes (ES) and by calculating if significant changes (Wilcoxons signed test) had occurred between the different measurement occasions. RESULTS: High to moderate significant correlation were found between CAP mobility I and morphology and the Dimeglio scores (rs = 0.77 and 0.44 respectively). Low correlation was found between CAP muscle function, mobility II and motion quality and the Dimeglio scoring system (rs = 0.20, 0.09 and 0.06 respectively). Of 13 children with bilateral clubfeet, 11 showed different CAP mobility I scores between right and left foot at baseline (untreated) compared with 5 with the Dimeglio score. At the other assessment occasions the CAP mobility I continued to show higher discrimination ability than the Dimeglio. No floor effects and low ceiling effects were found in the untreated clubfeet for both instruments. High ceiling effects were found in the CAP for the treated children and low for the Dimeglio. Responsiveness was good. ES from untreated to treated ranged from 0.80 to 4.35 for the CAP subgroups and was 4.68 for the Dimeglio. The first four treatment months, the CAP mobility I had generally higher ES compared with the Dimeglio. CONCLUSION: The Clubfoot Assessment Protocol shows in this study good validity and responsiveness. The CAP is more responsive when severity ranges between mild-moderate to severe, while the Dimeglio focuses more on the extremes. The ability to discriminate between different mobility status of the right and left foot in bilaterally affected children in this population was higher compared with the Dimeglio score implicating a better sensitivity for the CAP.

The clubfoot assessment protocol (CAP); description and reliability of a structured multi-level instrument for follow-up.

BACKGROUND: In most clubfoot studies, the outcome instruments used are designed to evaluate classification or long-term cross-sectional results. Variables deal mainly with factors on body function/structure level. Wide scorings intervals and total sum scores increase the risk that important changes and information are not detected. Studies of the reliability, validity and responsiveness of these instruments are sparse. The lack of an instrument for longitudinal follow-up led the investigators to develop the Clubfoot Assessment Protocol (CAP). The aim of this article is to introduce and describe the CAP and evaluate the items inter- and intra reliability in relation to patient age. METHODS: The CAP was created from 22 items divided between body function/structure (three subgroups) and activity (one subgroup) levels according to the International Classification of Function, Disability and Health (ICF). The focus is on item and subgroup development. Two experienced examiners assessed 69 clubfeet in 48 children who had a median age of 2.1 years (range, 0 to 6.7 years). Both treated and untreated feet with different grades of severity were included. Three age groups were constructed for studying the influence of age on reliability. The intra- rater study included 32 feet in 20 children who had a median age of 2.5 years (range, 4 months to 6.8 years). The Unweighted Kappa statistics, percentage observer agreement, and amount of categories defined how reliability was to be interpreted. RESULTS: The inter-rater reliability was assessed as moderate to good for all but one item. Eighteen items had kappa values > 0.40. Three items varied from 0.35 to 0.38. The mean percentage observed agreement was 82% (range, 62 to 95%). Different age groups showed sufficient agreement. Intra- rater; all items had kappa values > 0.40 [range, 0.54 to 1.00] and a mean percentage agreement of 89.5%. Categories varied from 3 to 5. CONCLUSION: The CAP contains more detailed information than previous protocols. It is a multi-dimensional observer administered standardized measurement instrument with the focus on item and subgroup level. It can be used with sufficient reliability, independent of age, during the first seven years of childhood by examiners with good clinical experience.A few items showed low reliability, partly dependent on the child's age and /or varying professional backgrounds between the examiners. These items should be interpreted with caution, until further studies have confirmed the validity and sensitivity of the instrument.

Older patients with distal forearm fracture. A challenge to future fall and fracture prevention.

BACKGROUND AND AIMS: Falls and fractures in older people are a common health problem. Patients with distal forearm fracture are at risk of sustaining new fractures. The aim of this work was to describe the characteristics of this patient group. METHODS: Sixty women and six men, mean age 68 years (50-86), with a recent fall-related distal forearm fracture, filled in a questionnaire about medical history, previous falls and fractures. Handgrip strength on the non-fractured side, one-leg standing, walking tests, and test of vibration sensation were measured and a video-nystagmoscopy was performed. RESULTS: One-third of the subjects had fallen during the last year, and one-third had had previous fall-related fractures during the last 10 years. Half of the patients took medication and were examined for chronic ailments regularly. Handgrip strength, balance and walking capacity declined with age and were similar to reference values. In three patients, the vibration sensation value was above the threshold value. Fifty patients (76%) had nystagmus, but no relationship between fall direction, physical performance and nystagmus was found. CONCLUSIONS: Although apparently healthy, many patients exhibited risk factors for new falls and fractures. Our recommendation is that these patients should be screened for fall and fracture risk and be targeted for preventive measures, besides fracture treatment. Physical therapists must play a major role in increasing and maintaining general physical functions in this patient group.

Activities of daily living decrease similarly in hospital-treated patients with a hip fracture or a vertebral fracture: a one-year prospective study in 151 patients.

AIMS: A hip fracture is commonly regarded as the most devastating fragility fracture, as regards both morbidity and mortality, while a vertebral fracture is usually regarded as having lower general morbidity. The purpose of this study was to investigate whether hospitalized patients with a hip or a vertebral fracture experience similar functional deterioration following the fracture as regards activity of daily living (ADL) and experienced quality of life (QOL). METHODS: Eighty-seven women and 22 men, mean age 81 (range 66-96), with a hip fracture and 34 women and 8 men, mean age 81 (range 68-92), with a vertebral fracture were followed up for 12 months. ADL before fracture and at 4 and 12 months after the fracture were evaluated as well as QOL at 4 and 12 months after the fracture, by questionnaires. RESULTS: A hip and a vertebral fracture in community dwellers within the same age range confers a similar decrease in ADL during the four months following the fracture. No restoration was seen in ADL or total QOL during the year following the fracture. Patients with a vertebral fracture had a lower QOL than patients with a hip fracture 4 and 12 months after the fracture. CONCLUSION: The need for external community assistance for patients with a vertebral fracture that forces them to have hospital treatment may be similar to the need following a hip fracture.

Predictors of falls in the elderly by location.

BACKGROUND AND AIMS: In the elderly, balance and walking impairments are assumed to play an important role in causing falls. We have assessed prospectively the predictive ability of health, function and balance variables regarding falls and their location. METHODS: Falls which occurred during one year in a random sample of 307 women aged 75 years and over (mean 80.8 years, response rate 74.5%) living in the community were recorded and related to baseline registrations of health, medication and tests of walking and balance. RESULTS: In all, 155 women (50.5%) reported 308 falls. Outdoor falls were significantly more frequent than indoor falls (57.5 vs 42.5%). The variables having had a fall before the start of the study, osteoporosis, hypertension, feeling depressed, unable to climb 40 cm high steps and walking slowly, all independently predicted a higher number of falls overall. Regarding fall location, having experienced a fall before study start was associated with more falls indoors as well as outdoors. Vision impairment, symptoms of depression, a faster comfortable walking speed, and being able to cope with higher steps were all independent predictors of more outdoor falls also after adjustment for outdoor exposure. A slower comfortable walking speed, a higher amplitude of the center of pressure movements in the frontal plane, a poorer score on the Timed Up & Go test, multimorbidity, poor cognition and hypertension were independent risk factors for indoor falls. Neither number of drugs used nor any specific medication appeared as independent risk factors for falls in this study. CONCLUSIONS: The findings of this study suggest that risk factors for indoor and outdoor falls are different. Location of fall may be an important confounder in studies of predictors of falls in the elderly which should encompass this type of information.