Corrigendum to factors associated with COVID-19 length of hospitalization and mortality during four epidemic waves, March 2020–November 2021, Suriname

[ENGLISH]. Corrigendum to Gokoel AR; Jairam M; Mendeszoon A; Liauw Kie Fa L; Poese F; Jarbandhan A, et al. Factors associated with COVID-19 length of hospitalization and mortality during four epidemic waves, March 2020–November 2021, Suriname. Rev Panam Salud Publica. 2023;47:e100. https://doi.org/10.26633/RPSP.2023.100

[ESPAÑOL]. Corrigendum a Gokoel AR; Jairam M; Mendeszoon A; Liauw Kie Fa L; Poese F; Jarbandhan A, et al. Factores asociados a la duración de la hospitalización y la mortalidad por COVID-19 en cuatro oleadas epidémicas, de marzo del 2020 a noviembre del 2021 en Suriname. Rev Panam Salud Publica. 2023;47:e100. https://doi.org/10.26633/RPSP.2023.100

[PORTUGUÊS]. Corrigendum à Fatores associados à duração da internação e à mortalidade por COVID-19 durante quatro ondas epidêmicas, de março de 2020 a novembro de 2021, no Suriname. Rev Panam Salud Publica. 2023;47:e100. https://doi.org/10.26633/RPSP.2023.100

Factors associated with COVID-19 length of hospitalization and mortality during four epidemic waves, March 2020–November 2021, Suriname

[ABSTRACT]. Objective. To determine the sociodemographic risk factors associated with coronavirus disease 2019 (COVID- 19) mortality in Suriname. Methods. This was a retrospective cohort study. All registered deaths from COVID-19 in Suriname (n=1112) between March 13, 2020 and November 11, 2021 were included. Data were collected from medical records and included demographic variables and hospitalization duration of patients who died. Descriptive statistics, chi-squared tests, ANOVA models, and logistic regression analyses were used to determine associations between sociodemographic variables, length of hospitalization, and mortality during four epidemic waves. Results. The case fatality rate over the study period was 22 per 1 000 population. The first epidemic wave was from July to August 2020, the second from December 2020 to January 2021, the third from May to June 2021, and the fourth from August to September 2021. Significant differences were found in the number of deaths and hospitalization duration by wave (p<0.001). Patients were more likely to have a longer hospitalization during the first (OR 1.66; 95% CI: 0.98, 2.82) and third waves (OR 2.37; 95% CI: 1.71, 3.28) compared with the fourth wave. Significant differences in mortality were also seen between ethnicities by wave (p=0.010). Compared with the mixed and other group, people of Creole ethnicity (OR 2.7; 95% CI: 1.33, 5.29) and Tribal people (OR 2.8; 95% CI: 1.12, 7.02) were more likely to die during the fourth wave than the third wave. Conclusions. Tailored interventions are needed for males, people of Creole descent, Tribal and Indigenous peoples, and people older than 65 years.

[RESUMEN]. Objetivo. Determinar los factores de riesgo sociodemográficos asociados a la mortalidad por la enfermedad por el coronavirus del 2019 (COVID-19) en Suriname. Métodos. Este fue un estudio de cohortes retrospectivo. Se analizaron todas las muertes por COVID-19 reg- istradas en Suriname (n=1112) entre el 13 de marzo del 2020 y el 11 de noviembre del 2021. Los datos se recopilaron a partir de los expedientes médicos, e incluyeron las variables demográficas y la duración de la hospitalización de los pacientes fallecidos. Se utilizaron métodos estadísticos descriptivos, la prueba de la ji al cuadrado, modelos de análisis de la varianza y análisis de regresión logística para determinar las asocia- ciones entre las variables sociodemográficas, la duración de la hospitalización y la mortalidad durante cuatro oleadas epidémicas. Resultados. La tasa de letalidad en el período del estudio fue de 22 por cada 1 000 habitantes. La primera oleada epidémica fue de julio a agosto del 2020; la segunda, de diciembre del 2020 a enero del 2021; la tercera, de mayo a junio del 2021; y la cuarta, de agosto a septiembre del 2021. Se observaron diferencias significativas en el número de muertes y la duración de la hospitalización entre las oleadas (p<0,001). Fue más probable que los pacientes tuvieran una hospitalización más prolongada durante la primera oleada (razón de posibilidades [odds ratio, OR] 1,66; IC del 95%: 0,98, 2,82) y la tercera (OR 2,37; IC del 95%: 1,71, 3,28) en comparación con la cuarta. También se observaron diferencias significativas en la mortalidad entre etnias según la oleada (p=0,010). En comparación con el grupo poblacional de origen mixto y de otro origen, las personas de la etnia criolla (OR 2,7; IC del 95%: 1,33, 5,29) y de origen tribal (OR 2,8; IC del 95%: 1,12, 7,02) tuvieron una mayor probabilidad de fallecer durante la cuarta oleada que durante la tercera. Conclusiones. Es preciso llevar a cabo intervenciones diseñadas específicamente para los hombres, las personas de ascendencia criolla, los pueblos tribales e indígenas y las personas mayores de 65 años.

[RESUMO]. Objetivo. Determinar os fatores de risco sociodemográficos associados à mortalidade por doença pelo coro- navírus 2019 (COVID-19) no Suriname. Métodos. Este foi um estudo de coorte retrospectivo. Foram incluídos todos os óbitos por COVID-19 registra- dos no Suriname (n=1112) entre 13 de março de 2020 e 11 de novembro de 2021. Os dados foram coletados de registros médicos e incluíram variáveis demográficas e a duração da internação dos pacientes que mor- reram. Estatísticas descritivas, testes de qui-quadrado, modelos de ANOVA e análises de regressão logística foram usados para determinar associações entre variáveis sociodemográficas, a duração da internação e a mortalidade durante quatro ondas epidêmicas. Resultados. A taxa de letalidade durante o período do estudo foi de 22 por 1 000 habitantes. A primeira onda epidêmica ocorreu de julho a agosto de 2020, a segunda, de dezembro de 2020 a janeiro de 2021, a terceira, de maio a junho de 2021 e a quarta, de agosto a setembro de 2021. Foram encontradas diferenças signifi- cativas no número de mortes e na duração da internação entre as ondas (p<0,001). Os pacientes tinham maior probabilidade de ter uma internação mais longa na primeira (razão de chances [RC]: 1,66; intervalo de confiança (IC 95%): 0,98–2,82) e na terceira onda (RC: 2,37; IC 95%: 1,71–3,28) em comparação com a quarta. Também foram observadas diferenças significativas entre etnias na mortalidade por onda (p=0,010). Em comparação com o grupo misto e outros, as pessoas de etnia crioula (RC: 2,7; IC 95%: 1,33–5,29) e tribal (RC: 2,8; IC 95%: 1,12–7,02) tinham maior probabilidade de morrer na quarta onda do que na terceira onda. Conclusões. São necessárias intervenções adaptadas para homens, pessoas de descendência crioula, povos tribais e indígenas e pessoas com mais de 65 anos.

Feasibility of a home-based physiotherapy intervention to promote post-stroke mobility: A randomized controlled pilot study.

OBJECTIVES: Home-based physiotherapy interventions to improve post-stroke mobility are successful in high-income countries. These programs require less resources compared to center-based programs. However, feasibility of such an intervention in a low and middle-income setting remains unknown. Therefore, the SunRISe (Stroke Rehabilitation In Suriname) study aimed to assess feasibility and preliminary effectiveness of a home-based semi-supervised physiotherapy intervention to promote post-stroke mobility in a low resource setting. DESIGN: Prospective randomized controlled trial. METHODS: Chronic stroke patients were recruited and randomized into either an intervention group (IG (N = 20)) or a control group (CG (N = 10)). The IG received a 3-days-a-week home-based physiotherapy program that was supervised in the first 4 weeks and tele-supervised during the second 4 weeks. The physiotherapy program consisted of walking as well as functional and mobilization exercises. The CG received usual care. Feasibility outcome measures included adherence, patient satisfaction and safety. Efficacy measures included functional exercise tolerance (six-minute walking test (6MWT), functional balance (Berg Balance Score (BBS), upper extremity (UE) function (Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire), and UE strength ((non-)paretic handgrip (HG) strength). Two-way analysis of variance was used for data analysis. RESULTS: Thirty participants (61.8 ± 9.2 years old, 13 men) were enrolled in the study. The intervention was completed by 14 participants (70%). Adherence was affected by rainy season associated infrastructural problems (n = 2), the medical status of participants (n = 3) and insufficient motivation to continue the program without direct supervision (n = 1). No adverse events were noted and participants were satisfied with the program. Functional exercise tolerance (57.2 ± 67.3m, p = 0.02) and UE function (-9.8 ± 15.2, p = 0.04) improved in the IG compared to no change in the CG. HG strength was unaltered and a ceiling effect occurred for BBS. CONCLUSION: Our home-based semi-supervised physiotherapy intervention seems safe, associated with moderate to high levels of engagement and patient satisfaction and results in functional improvements.

Assessing the feasibility of the Healthy Life in Suriname Study: using advanced hemodynamics to evaluate cardiovascular risk.

OBJECTIVES: To determine the feasibility of assessing population cardiovascular risk with advanced hemodynamics in the Healthy Life in Suriname (HELISUR) study. METHODS: This was a preliminary study conducted in May - June 2012 using the Technical-Economic-Legal-Operational-Scheduling (TELOS) method to assess the feasibility of the HELISUR-a large-scale, cross-sectional population study of cardiovascular risk factors and disease in Suriname. Suriname, a middle-income country in South America with a population of mostly African and Asian ethnicity, has a high risk of cardiovascular disease. A total of 135 volunteers 18 - 70 years of age participated. A health questionnaire was tested in a primary health care center, and non-invasive cardiovascular evaluations were performed in an academic health center. The cardiovascular evaluation included sitting, supine, and standing blood pressure, and intermediate endpoints, such as cardiac output, peripheral vascular resistance, pulse wave velocity, and augmentation index. RESULTS: The TELOS testing found that communicating by cellular phone was most effective for appointment adherence, and that completion of the questionnaire often required assistance from a trained interviewer; modifications to improve the clarity of the questions are recommended. Regarding the extended cardiovascular assessments of peripheral and central hemodynamics, the findings showed these to be technically and operationally feasible and well tolerated by participants, in terms of burden and duration. CONCLUSIONS: Findings of this feasibility assessment indicate that large-scale, detailed evaluations of cardiovascular risk, including a questionnaire and advanced central and peripheral hemodynamics, are feasible in a high-risk population in a middle-income setting.

Assessing the feasibility of the Healthy Life in Suriname Study: using advanced hemodynamics to evaluate cardiovascular risk / Evaluación de la factibilidad del estudio Vida Sana en Suriname: uso de hemodinámica avanzada para evaluar el riesgo de enfermedades cardiovasculares / Avaliação da viabilidade do Estudo de Vida Saudável no Suriname: uso de hemodinâmica avançada para avaliar o risco cardiovascular

Objectives. To determine the feasibility of assessing population cardiovascular risk with advanced hemodynamics in the Healthy Life in Suriname (HELISUR) study. Methods. This was a preliminary study conducted in May – June 2012 using the Technical-Economic-Legal-Operational-Scheduling (TELOS) method to assess the feasibility of the HELISUR—a large-scale, cross-sectional population study of cardiovascular risk factors and disease in Suriname. Suriname, a middle-income country in South America with a population of mostly African and Asian ethnicity, has a high risk of cardiovascular disease. A total of 135 volunteers 18 – 70 years of age participated. A health questionnaire was tested in a primary health care center, and non-invasive cardiovascular evaluations were performed in an academic health center. The cardiovascular evaluation included sitting, supine, and standing blood pressure, and intermediate endpoints, such as cardiac output, peripheral vascular resistance, pulse wave velocity, and augmentation index. Results. The TELOS testing found that communicating by cellular phone was most effective for appointment adherence, and that completion of the questionnaire often required assistance from a trained interviewer; modifications to improve the clarity of the questions are recommended. Regarding the extended cardiovascular assessments of peripheral and central hemodynamics, the findings showed these to be technically and operationally feasible and well tolerated by participants, in terms of burden and duration. Conclusions. Findings of this feasibility assessment indicate that large-scale, detailed evaluations of cardiovascular risk, including a questionnaire and advanced central and peripheral hemodynamics, are feasible in a high-risk population in a middle-income setting.

Objetivos. Determinar la factibilidad de evaluar el riesgo de enfermedades cardiovasculares en la población utilizando hemodinámica avanzada en el estudio Vida Sana en Suriname (HELISUR por su sigla en inglés). Métodos. Este fue un estudio preliminar realizado de mayo a junio del 2012 empleando el método de factibilidad técnica, económica, legal, operativa y de programación (TELOS) para evaluar la factibilidad del HELISUR, un estudio poblacional transversal a gran escala de factores de riesgo y enfermedades cardiovasculares en Suriname. Suriname, un país de ingresos medianos de América del Sur, con una población de etnicidad principalmente africana y asiática, presenta un riesgo alto de enfermedades cardiovasculares. En el estudio participó un total de 135 voluntarios de 18 a 70 años de edad. Se puso a prueba un cuestionario de salud en un centro de atención primaria de salud, y se realizaron evaluaciones cardiovasculares no invasoras en un centro de salud académico. La evaluación cardiovascular incluyó mediciones de presión arterial en posición sentada, supina y de pie, y los criterios de valoración intermedios, como el gasto cardíaco, la resistencia vascular periférica, la velocidad de la onda de pulso y el índice de aumento. Resultados. En las pruebas del método TELOS se encontró que la comunicación por teléfono celular era la más eficaz para asegurar la asistencia a las citas y que a menudo se requería la presencia de un entrevistador capacitado para ayudar a los voluntarios a llenar el cuestionario; se recomienda modificar las preguntas para que sean más claras. Con respecto a las evaluaciones cardiovasculares prolongadas de hemodinámica periférica y central, los resultados demostraron que eran técnica y operativamente factibles, y bien toleradas por los participantes en cuanto a la carga y duración. Conclusiones. Los resultados de esta evaluación de factibilidad indican que las evaluaciones detalladas y a gran escala del riesgo de enfermedades cardiovasculares, que incluyen un cuestionario y hemodinámica central y periférica avanzada, son factibles para una población de alto riesgo en un país de ingresos medianos.

Objetivos. Determinar a viabilidade de avaliar o risco cardiovascular da população por meio de avaliação hemodinâmica avançada no Estudo de Vida Saudável no Suriname (HELISUR). Métodos. Estudo preliminar realizado em maio-junho de 2012 com o uso da metodologia TELOS (análise técnica, financeira, jurídica, operacional e do cronograma) para avaliar a viabilidade do HELISUR – estudo transversal de base populacional em grande escala dos fatores de risco e doenças cardiovasculares no Suriname. O Suriname é um país sul-americano de renda média de população majoritariamente de origem afro-asiática com alto risco da doença cardiovascular. Participaram do estudo 135 voluntários com 18 a 70 anos de idade. O questionário sobre saúde foi testado em uma unidade básica de saúde e avaliações cardiovasculares não invasivas foram realizadas em um centro de saúde acadêmico. A avaliação cardiovascular consistiu da medida da pressão arterial em posição sentada, supino e em pé, e da medida de parâmetros (endpoints) intermediários como débito cardíaco, resistência vascular periférica, velocidade da onda de pulso e índice de amplificação. Resultados. A análise TELOS indicou maior eficiência na adesão às consultas com a comunicação por celular e a necessidade frequente de auxílio de um entrevistador treinado para o preenchimento do questionário. Modificações para melhorar a compreensão das perguntas são recomendadas. Também se demonstrou que o amplo estudo da hemodinâmica central e periférica é viável do ponto de vista técnico e operacional e que os participantes toleram bem o incômodo e o tempo de avaliação. Conclusões. Os resultados da avaliação de viabilidade indicam que a avaliação aprofundada do risco cardiovascular em grande escala, incluindo a administração de questionário e estudos de hemodinâmica avançada central e periférica, é viável em uma população de renda média com alto risco.

Assessing the feasibility of the Healthy Life in Suriname Study: using advanced hemodynamics to evaluate cardiovascular risk / Evaluación de la factibilidad del estudio Vida Sana en Suriname: uso de hemodinámica avanzada para evaluar el riesgo de enfermedades cardiovasculares / Avaliação da viabilidade do Estudo de Vida Saudável no Suriname: uso de hemodinâmica avançada para avaliar o risco cardiovascular

ABSTRACT Objectives To determine the feasibility of assessing population cardiovascular risk with advanced hemodynamics in the Healthy Life in Suriname (HELISUR) study. Methods This was a preliminary study conducted in May – June 2012 using the Technical-Economic-Legal-Operational-Scheduling (TELOS) method to assess the feasibility of the HELISUR—a large-scale, cross-sectional population study of cardiovascular risk factors and disease in Suriname. Suriname, a middle-income country in South America with a population of mostly African and Asian ethnicity, has a high risk of cardiovascular disease. A total of 135 volunteers 18 – 70 years of age participated. A health questionnaire was tested in a primary health care center, and non-invasive cardiovascular evaluations were performed in an academic health center. The cardiovascular evaluation included sitting, supine, and standing blood pressure, and intermediate endpoints, such as cardiac output, peripheral vascular resistance, pulse wave velocity, and augmentation index. Results The TELOS testing found that communicating by cellular phone was most effective for appointment adherence, and that completion of the questionnaire often required assistance from a trained interviewer; modifications to improve the clarity of the questions are recommended. Regarding the extended cardiovascular assessments of peripheral and central hemodynamics, the findings showed these to be technically and operationally feasible and well tolerated by participants, in terms of burden and duration. Conclusions Findings of this feasibility assessment indicate that large-scale, detailed evaluations of cardiovascular risk, including a questionnaire and advanced central and peripheral hemodynamics, are feasible in a high-risk population in a middle-income setting.

RESUMEN Objetivos Determinar la factibilidad de evaluar el riesgo de enfermedades cardiovasculares en la población utilizando hemodinámica avanzada en el estudio Vida Sana en Suriname (HELISUR por su sigla en inglés). Métodos Este fue un estudio preliminar realizado de mayo a junio del 2012 empleando el método de factibilidad técnica, económica, legal, operativa y de programación (TELOS) para evaluar la factibilidad del HELISUR, un estudio poblacional transversal a gran escala de factores de riesgo y enfermedades cardiovasculares en Suriname. Suriname, un país de ingresos medianos de América del Sur, con una población de etnicidad principalmente africana y asiática, presenta un riesgo alto de enfermedades cardiovasculares. En el estudio participó un total de 135 voluntarios de 18 a 70 años de edad. Se puso a prueba un cuestionario de salud en un centro de atención primaria de salud, y se realizaron evaluaciones cardiovasculares no invasoras en un centro de salud académico. La evaluación cardiovascular incluyó mediciones de presión arterial en posición sentada, supina y de pie, y los criterios de valoración intermedios, como el gasto cardíaco, la resistencia vascular periférica, la velocidad de la onda de pulso y el índice de aumento. Resultados En las pruebas del método TELOS se encontró que la comunicación por teléfono celular era la más eficaz para asegurar la asistencia a las citas y que a menudo se requería la presencia de un entrevistador capacitado para ayudar a los voluntarios a llenar el cuestionario; se recomienda modificar las preguntas para que sean más claras. Con respecto a las evaluaciones cardiovasculares prolongadas de hemodinámica periférica y central, los resultados demostraron que eran técnica y operativamente factibles, y bien toleradas por los participantes en cuanto a la carga y duración. Conclusiones Los resultados de esta evaluación de factibilidad indican que las evaluaciones detalladas y a gran escala del riesgo de enfermedades cardiovasculares, que incluyen un cuestionario y hemodinámica central y periférica avanzada, son factibles para una población de alto riesgo en un país de ingresos medianos.

RESUMO Objetivos Determinar a viabilidade de avaliar o risco cardiovascular da população por meio de avaliação hemodinâmica avançada no Estudo de Vida Saudável no Suriname (HELISUR). Métodos Estudo preliminar realizado em maio-junho de 2012 com o uso da metodologia TELOS (análise técnica, financeira, jurídica, operacional e do cronograma) para avaliar a viabilidade do HELISUR – estudo transversal de base populacional em grande escala dos fatores de risco e doenças cardiovasculares no Suriname. O Suriname é um país sul-americano de renda média de população majoritariamente de origem afro-asiática com alto risco da doença cardiovascular. Participaram do estudo 135 voluntários com 18 a 70 anos de idade. O questionário sobre saúde foi testado em uma unidade básica de saúde e avaliações cardiovasculares não invasivas foram realizadas em um centro de saúde acadêmico. A avaliação cardiovascular consistiu da medida da pressão arterial em posição sentada, supino e em pé, e da medida de parâmetros (endpoints) intermediários como débito cardíaco, resistência vascular periférica, velocidade da onda de pulso e índice de amplificação. Resultados A análise TELOS indicou maior eficiência na adesão às consultas com a comunicação por celular e a necessidade frequente de auxílio de um entrevistador treinado para o preenchimento do questionário. Modificações para melhorar a compreensão das perguntas são recomendadas. Também se demonstrou que o amplo estudo da hemodinâmica central e periférica é viável do ponto de vista técnico e operacional e que os participantes toleram bem o incômodo e o tempo de avaliação. Conclusões Os resultados da avaliação de viabilidade indicam que a avaliação aprofundada do risco cardiovascular em grande escala, incluindo a administração de questionário e estudos de hemodinâmica avançada central e periférica, é viável em uma população de renda média com alto risco.

Exploring cardiovascular health: the Healthy Life in Suriname (HELISUR) study. A protocol of a cross-sectional study.

INTRODUCTION: Obesity, hypertension and diabetes are on a dramatic rise in low-income and middle-income countries, and this foretells an overwhelming increase in chronic disease burden from cardiovascular disease. Therefore, rapid action should be taken through preventive population-based programmes. However, in these regions, data on the population distribution of cardiovascular risk factors, and of intermediate and final end points for cardiovascular disease are scarce. The Healthy Life in Suriname (HELISUR) study is a cardiovascular population study in Suriname, which is part of the Caribbean Community. The HELISUR study is dedicated to provide data on risk factors and prevalent cardiovascular disease in the multiethnic population, which is mainly of African and Asian descent. METHODS AND ANALYSIS: In a cross-sectional, observational population-based setting, a random representative sample of 1800 citizens aged between 18 and 70 years will be selected using a cluster household sampling method. Self-reported demographic, socioeconomic and (cardiovascular) health-related data will be collected. Physical examination will include the assessment of cardiovascular risk factors and prevalent cardiovascular disease. In addition, we will study cardiovascular haemodynamics non-invasively, as a novel intermediate outcome. Finally, fasting blood and overnight urine samples will be collected to monitor cardiometabolic risk factors. The main outcome will be descriptive in reporting the prevalence of risk factors and measures of (sub) clinical end organ damage, stratified for ethnicity and sex-age groups. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the State Secretary of Health. Data analysis and manuscript submission are scheduled for 2016. Findings will be disseminated in peer-reviewed journals, and at national, regional and international scientific meetings. Importantly, data will be presented to Surinamese policymakers and healthcare workers, to develop preventive strategies to combat the rapid rise of cardiovascular disease.

Effect of balance support on the energy cost of walking after stroke.

OBJECTIVE: To examine the influence of balance support on the energy cost of treadmill and overground walking in ambulatory patients with stroke. DESIGN: Cross-sectional. SETTING: Research laboratory at a rehabilitation center. PARTICIPANTS: Patients with stroke depending on a walking aid in daily life (n=12; walking aid dependent ambulators) and walking aid independent ambulators (n=12), all able to walk for at least 5 minutes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Energy cost (J·kg(-1)·m(-1)) and temporal gait parameters (walking speed, mean and coefficient of variation of stride time, and symmetry index) were obtained during 4 walking trials at preferred walking speed: overground with and without a cane and on a treadmill with and without handrail support. RESULTS: On the treadmill, handrail support resulted in a significant decrease in energy cost of 16%, independent of the group. Although walking aid dependent ambulators had on average a larger reduction in energy cost than walking aid independent ambulators (19% vs 14%), this interaction did not reach statistical significance (P=.11). Interestingly, overground walking with support resulted in an 8% reduction in energy cost for walking aid dependent ambulators, but a 6% increase for walking aid independent ambulators. The reduction in energy cost with support was accompanied by changes in temporal gait parameters, most notably an increase in stride time and symmetry and a decrease in stride time variability. CONCLUSIONS: Balance support can result in a significant reduction in the energy cost of walking in stroke patients, the magnitude of which depends on walking ability and the walking task. Impaired balance control should not be overlooked as a contributing factor to the increased energy cost of walking in patients with stroke, and improving or assisting balance control should be considered to reduce the energy cost of hemiplegic gait.