The determination of sarcopenia in older adults using a practical measure.

BACKGROUND: Many older adults are at risk of sarcopenia, a gradual loss of muscle mass affecting muscle strength and physical function, which can lead to adverse health consequences deteriorating their independence. However, the detection could be delayed due to the requirement of many measures, including a complex imaging modality. Thus, an exploration for a practical community- or home-based measure would be helpful to identify at-risk older adults and begin the timely management. OBJECTIVE: To explore the ability of the upper limb loading during a seated push-up test (ULL-SPUT) to determine the presence of sarcopenia in community-dwelling older adults. METHODS: Older adults (n= 110; 62 females, average age approximately 77 years) were cross-sectionally assessed for sarcopenia using standard measures (handgrip strength, appendicular skeletal muscle mass, and walking speed) and the ULL-SPUT. RESULTS: Data from standard measures indicated that 44 participants had sarcopenia. The ULL-SPUT index of < 16.9 kg/m2 for females (sensitivity = 86%, specificity = 78%, area under the receiver operating characteristic curve [AUC] = 0.85) and < 19.7 kg/m2 for males (sensitivity = 73%, specificity = 69%, AUC = 0.83) could optimally identify participants with sarcopenia. CONCLUSION: The ULL-SPUT index could be used to screen and monitor older adults with sarcopenia in various clinical, community, and home settings. This practical measure may be accomplished using a digital bathroom scale on a hard, even surface. Outcomes would identify an adult who should undergo further confirmation of sarcopenia through standard measures or the initiation of timely management to promote treatment effectiveness.

The seventh cervical vertebra is an appropriate landmark for thoracic kyphosis measures using distance from the wall.

Background: Hyperkyphosis is frequently found nowadays due to the change in current lifestyles and age-related system decline. A simple hyperkyphosis measurement can be made easily using the perpendicular distance from the landmark to the wall. However, the existing evidence applied two different landmarks [occiput and the seventh cervical vertebra (C7)] and the measurement using rulers was susceptible to error due to their misalignment. Objective: To assess an appropriate landmark for thoracic kyphosis measurement using distance from the wall (KMD), by comparing between occiput and C7, as measured using rulers and verified using data from a specially developed machine, the so-called infrared-gun kyphosis wall distance tool (IG-KypDisT), and the Cobb angles. Methods: Community-dwelling individuals with a risk of thoracic hyperkyphosis (age ≥10 years, n=43) were cross-sectionally assessed for their thoracic hyperkyphosis using the perpendicular distance from the landmarks, occiput and C7, to the wall using rulers and IG-KypDisT. Then the Cobb angles of these participants were measured within seven days. Results: The outcomes from both landmarks differed by approximately 0.8 cm (p= 0.084). The outcomes derived from C7 were more reliable (ICCs>0.93, p<0.001), with greater concurrent validity with the radiologic data (r= 0.738, p<0.001), with the overall variance predicted by the regression models for the Cobb angles being higher than that from the occiput (47-48% from C7 and 38-39% from occiput). The outcomes derived from rulers and IG-KypDisT showed no significant differences. Conclusion: The present findings support the reliability and validity of KMD assessments at C7 using rulers as a simple standard measure of thoracic hyperkyphosis that can be used in various clinical, community, and research settings.

Ability of the Seventh Cervical Vertebra Wall Distance to Determine Mobility Deficits of Older Adults.

Thoracic hyperkyphosis could affect mobility and independence of older adults. However, there was no clear evidence on the use of the seventh cervical vertebra wall distance (C7WD), a practical measure for thoracic hyperkyphosis, to indicate mobility deficits relating to independence of these individuals. This study explored the ability of C7WD to determine mobility impairments in 104 older adults. Participants (average age of 74.1 ± 7.4 years) with various degree of thoracic kyphosis were cross-sectionally measured for their C7WD, mobility, and Cobb angle. The findings indicate that participants with thoracic hyperkyphosis (Cobb angle = 46.1 ± 5.2°) had significantly poorer mobility than those without thoracic hyperkyphosis (Cobb angle = 32.8 ± 5.9°, p < .05). A C7WD of ≥7.8 cm could indicate mobility deficits of the participants (sensitivity = 71%-92%, specificity = 75%-94%, and area under the curve >0.80). The findings confirm the ability of C7WD that could be clinically measured using rulers to indicate mobility deficits of older adults.

Ability to detect history of falls among individuals with spinal cord injury using upper limb loading during a seated push-up test.

BACKGROUND: A history of falls is an important risk factor for future falls, including for individuals with spinal cord injury (SCI) who often experience falls and subsequent injuries. This may be even more pronounced during the current COVID-19 pandemic because of the extreme shortage of hospital admission and restricted access to important services. Therefore, the ability of detecting a history of falls that can be applied to wheelchair users and ambulatory individuals with SCI in various settings are essential. AIM: To investigate the discriminative ability of three clinical measures-the handgrip (HG) test, Spinal Cord Independence Measure (SCIM) III and Upper Limb Loading During a Seated Push-Up Test (ULL-SPUT)-in discriminating individuals with SCI with and without a history of falls over the past six months. DESIGN: A 6-month retrospective observational cohort study. SETTING: Inpatient tertiary rehabilitation center. POPULATION: One hundred and fourteen wheelchair users and ambulatory individuals with SCI. METHODS: The participants were interviewed and assessed for their demographics, SCI characteristics and fall data over the past six months, with data confirmation from related events, their caregivers and medical records. Subsequently, they were assessed using the HG test, SCIM III, and ULL-SPUT. RESULTS: In total, 29 participants (25%) fell during the past six months (with the number of falls ranging from 1-20, with minor consequences after the falls). Among the three clinical measures assessed in this study, the ULL-SPUT data of faller participants were significantly higher than those of non-fallers (P<0.05). CONCLUSIONS: The limited rehabilitation length and increased staying home and social isolation prompted by the COVID-19 pandemic may have reduced the fall rates of the participants. The findings suggest a higher likelihood of falls among wheelchair users and ambulatory individuals with SCI who have good mobility as determined using ULL-SPUT data. CLINICAL REHABILITATION IMPACT: Apart from being an important rehabilitation strategy, the present findings suggest an additional benefit of ULL-SPUT to identify individuals with SCI with a likelihood of future falls. The measurement can be done easily using digital bathroom scales placing over a flat and smooth surface. Therefore, it would enable the timely initiation of fall prevention strategies in various clinical, community, home and research settings; particularly in this COVID-19 pandemic of limited beds and hospital services for these individuals.

The use of simple muscle strength tests to reflect body compositions among individuals with spinal cord injury.

STUDY DESIGN: A cross-sectional study. OBJECTIVES: To investigate the correlation between simple muscle strength tests (including handgrip test and upper limb loading during a seated push-up test [ULL-SPUT]) and body compositions among individuals with spinal cord injury (SCI). SETTING: A tertiary rehabilitation center. METHODS: Twenty-four participants with SCI (average age of 40 years) were cross-sectionally assessed using handgrip test, ULL-SPUT, and body compositions (including skeletal muscle mass, bone mineral content, and fat mass) using dual-energy X-ray absorptiometry scan. RESULTS: The handgrip data had low-to-moderate correlation to body compositions of the arms (rs = 0.474-0.515, p < 0.05), while the ULL-SPUT data were low-to-excellently correlated to all body compositions of the arms, legs, and trunk (rs, r = 0.467-0.921, p < 0.05). CONCLUSIONS: The findings extend clinical benefit of a SPUT apart from being a rehabilitation strategy to promote mobility of individuals with SCI. Simple measurement of the ULL-SPUT, which can be done using digital bathroom scales placed on a hard and even surface, appears to be strongly correlated with body compositions in a small sample of predominantly middle age, normal weight, men with paraplegia. More research is required to understand whether this test can be used clinically to assess body compositions in a more diverse SCI population, and whether it is responsive to changes in body compositions over time.

The utility of upper limb loading device in determining optimal walking ability in ambulatory individuals with spinal cord injury.

BACKGROUND: Walking devices are frequently prescribed for many individuals, including those with spinal cord injury (SCI), to promote their independence. However, without proper screening and follow-up care, the individuals may continue using the same device when their conditions have progressed, that may possibly worsen their walking ability. OBJECTIVE: This study developed an upper limb loading device (ULLD), and assessed the possibility of using the tool to determine the optimal walking ability of ambulatory participants with SCI who used a walking device daily ( n = 49 ). METHODS: All participants were assessed for their optimal walking ability, i.e., the ability of walking with the least support device or no device as they could do safely and confidently. The participants were also assessed for their amount of weight-bearing on the upper limbs or upper limb loading while walking, amount of weight-bearing on the lower limbs or lower limb loading while stepping of the other leg, and walking performance. RESULTS: The findings indicated that approximately one third of the participants (31%) could progress their walking ability from their current ability, whereby four participants could even walk without a walking device. The amount of upper limb loading while walking, lower limb loading ability, and walking performance were significantly different among the groups of optimal walking ability ( p < 0 . 05 ). Furthermore, the amount of upper limb loading showed negative correlation to the amount of lower limb loading and walking performance ( ρ =- 0 . 351 to - 0.493, p < 0 . 05 ). CONCLUSION: The findings suggest the potential benefit of using the upper limb loading device and the amount of upper limb loading for walking device prescription, and monitoring the change of walking ability among ambulatory individuals with SCI.

Immediate effects of lower limb loading exercise during stepping with and without augmented loading feedback on mobility of ambulatory individuals with spinal cord injury: a single-blinded, randomized, cross-over trial.

STUDY DESIGN: Single-blinded, randomized, cross-over design. OBJECTIVES: To compare the immediate effects of bodyweight shifting and lower limb loading (LLL) exercise during stepping with and without augmented loading feedback, followed by overground walking, on the mobility of ambulatory individuals with spinal cord injury (SCI). SETTING: Academic laboratory center. METHODS: Thirty participants with SCI were trained using a single intervention session consisting of repetitive bodyweight shifting and LLL exercises during stepping with or without external feedback (10 min/leg) followed by overground walking (10 min) with a 2-week washout period, in a random sequence. The timed up-and-go test (TUG) (primary outcome), 10-m walk test (10MWT), five times sit-to-stand test (FTSST), and maximal LLL were measured 1 day before and immediately after each training session. RESULTS: Significant improvement was found following both training sessions, excepting the TUG and LLL of the less-affected leg, where improvement was found only after training using augmented feedback. Moreover, the improvement following the training with feedback was significantly greater than that after training without feedback. The mean (95% CI) between-group differences for the TUG = 1.9 [0.6-3.3]s, 10MWT = 0.1 [0.0-0.1]m/s, FTSST = 1.0 [1.5-4.8]s, LLL = 3.1 [1.5-4.8]-2.8 [0.8-4.9]%bodyweight, p < 0.05. CONCLUSIONS: The training programs immediately enhanced the mobility of ambulatory individuals with chronic SCI (post-injury time >6 years), particularly the training with augmented loading feedback. The findings offer another effective rehabilitation strategy that can be applied in various clinical and home-based settings.

Stepping training with external feedback relating to lower limb support ability effectively improved complex motor activity in ambulatory patients with stroke: a randomized controlled trial.

BACKGROUND: Lower limb support ability is important for steady and efficient mobility, but previous data commonly involved training during double stance positions, with or without external feedback, using a complex and costly machine. AIM: To compare the effects of stepping training with or without external feedback in relation to the lower limb support ability of the affected limb on the functional ability necessary for independence in individuals with stroke. DESIGN: A single-blinded, randomized controlled trial. SETTING: Tertiary rehabilitation centers. POPULATION: Ambulatory participants with stroke who walked independently over at least 10 meters with or without walking devices. METHODS: Thirty-six participants were randomly arranged to be involved in a program of stepping training with or without external feedback related to the lower limb support ability of the affected limb (18 participants/group) for 30 minutes, followed by overground walking training for 10 minutes, 5 days/week over 4 weeks. The outcomes, including the lower limb support ability of the affected legs during stepping, functional ability and spatial walking data, were assessed prior to training, immediately after the first training session, and after 2- and 4-week training. RESULTS: Participants demonstrated significant improvement in the amount of lower limb support ability, immediately after the first training with external feedback. Then, these participants showed further improvement in both the amount and duration of lower limb support ability, as well as the Timed Up and Go data after 2 and 4 weeks of training (P<0.05). This improvement was not found following control training. CONCLUSIONS: The external feedback relating to lower limb support ability during stepping training effectively improved the movement stability and complex motor activity of ambulatory individuals with stroke who had long post-stroke time (approximately 3 years). CLINICAL REHABILITATION IMPACT: Stepping training protocols and feedback can be easily applied in various settings using the amount of body weight from an upright digital bathroom scale. Thus, the findings offer an alternative rehabilitation strategy for clinical, community and home-based settings for stroke individuals.

Hyperkyphotic measures using distance from the wall: validity, reliability, and distance from the wall to indicate the risk for thoracic hyperkyphosis and vertebral fracture.

C7WD is a practical, valid, and reliable measure that could clearly indicate a risk of hyperkyphosis and vertebral fracture in the elderly. The findings might be particularly of use in regions difficult to access radiology or for the determination of those who need further invasive radiologic examination and therapy. PURPOSE: To investigate psychometric properties of the 7th cervical vertebra wall distance (C7WD) to determine the risk of thoracic hyperkyphosis and spinal fracture, as compared to a standard radiologic Cobb's method. METHODS: Community-dwelling elderly (n = 104), aged at least 60 years with occiput-wall distance > 0 cm, were assessed for their C7WD using rulers and a specially developed tool for an accurate perpendicular distance from C7 to the wall: infrared-gun kyphosis wall distance tool (IG-KypDisT). The first 15 participants were also involved in the reliability tests by a healthcare professional, village health volunteer, and caregiver. Within 7 days, all participants were at a hospital to complete a lateral plain radiograph (Cobb's method). RESULTS: Outcomes of C7WD had excellent correlation to the Cobb angles (r = 0.87 for rulers and r = 0.92 for IG-KypDisT), with excellent reliability when used by all three raters (ICC3,3 = 0.85-0.99). The C7WD of at least 7.5 and 9.5 cm had the best diagnostic properties to determine the risk of thoracic hyperkyphosis and vertebral fracture, respectively. CONCLUSION: C7WD is valid and reliable with good diagnostic properties for thoracic hyperkyphosis and vertebral fracture. The findings confirm the use of C7WD using traditional ruler-based method as a practical tool to screen and monitor severity of thoracic hyperkyphosis in clinics and communities. In addition, the measurement using the IG-KypDisT provided accurate data that can be saved for further analysis; it is therefore suggested for research settings. The findings would promote the standardization of hyperkyphosis measurements in various settings.

Is walking symmetry important for ambulatory patients with spinal cord injury?

PURPOSE: To assess and compare the levels of walking symmetry in ambulatory participants with spinal cord injury (SCI) who had different degrees of lesion severity, levels of walking ability, and fall history. In addition, the study explored the relationship between the levels of walking symmetry and variables related to the ability of well-controlled walking of the participants. STUDY DESIGN: Cross-sectional study. METHODS: Sixty-six eligible participants were assessed and interviewed for levels of walking symmetry, walking speed, functional endurance, symmetrical lower limb support ability, balance control, and fall history over the last 6 months. RESULTS: Participants walked asymmetrically (85%) similar to those with unilateral impairments (i.e., patients with stroke and amputee, 79-93%). The levels of walking symmetry were significantly correlated to walking speed, functional endurance and balance ability of the participants (p < 0.05). The problem and correlation were particularly apparent in those with the history of multiple falls (79%, r = 0.613-0.765, p < 0.005) Conclusions: The findings confirm problems of asymmetrical walking and the importance of walking symmetry for the ability of well-controlled walking and a risk of multiple falls in ambulatory participants with SCI. Therefore, apart from the levels of independence, the improvement of walking symmetry is crucial for these individuals. Implications for Rehabilitation: Ambulatory individuals with spinal cord injury walked asymmetrically at the same level as those with unilateral impairments such as patients with stroke and amputee. Their levels of walking symmetry were significantly related to the ability of well-controlled walking, particularly in those with the history of multiple falls. The finding confirmed the importance of walking symmetry as a crucial parameter to detect walking improvement and fall risk reduction. Apart from the levels of independence, rehabilitation professionals also need to emphasize on the improvement of symmetrical walking for these patients.

Ability of sit-to-stand with hands reflects neurological and functional impairments in ambulatory individuals with spinal cord injury.

STUDY DESIGN: A cross-sectional study. OBJECTIVES: To explore the need of upper limb contribution during sit-to-stand (STS) in ambulatory participants with spinal cord injury (SCI) and compare the lower limb loading during the sit-to-stand (LLL-STS) in those with SCI who performed the task with or without hands as compared to able-bodied individuals. In addition, the study assessed the correlation between the LLL-STS, and sensorimotor scores and functional ability in ambulatory participants with SCI. SETTING: A tertiary rehabilitation center and community hospitals, Thailand. METHODS: Forty-three participants with SCI who could perform STS with or without hands, and 10 able-bodied individuals were interviewed and assessed for their demographics, STS, and LLL-STS ability. Moreover, participants with SCI were assessed for SCI characteristics, sensorimotor scores, and functional ability relating to independent walking. RESULTS: More than half of participants with SCI (58%) performed STS using hands. Their LLL-STS, sensorimotor, and functional ability were significantly lower than those with SCI who performed the task without hands. The LLL-STS of participants with SCI, particularly amount, was significantly associated with their sensorimotor scores and functional ability (P < 0.05). CONCLUSIONS: The findings indicated that those with marked lower limb muscle weakness and sensory impairments used their hands during STS. As such, the use of the hands during STS can be used as an indicator of neurological and functional impairments in ambulatory individuals with SCI.

Importance of independent sit-to-stand ability in ambulatory patients with spinal cord injury.

BACKGROUND: Sit-to-stand (STS) is an important and basic activity for daily living. However, a few studies have reported information relating to STS ability in ambulatory patients with spinal cord injury (SCI). AIM: To investigate factors associated with the ability of independent sit-to-stand (iSTS) among ambulatory patients with SCI. DESIGN: Cross-sectional cohort study. SETTING: Inpatient tertiary rehabilitation center and communities. POPULATION: Ambulatory patients with SCI. METHODS: Sixty-nine independent ambulatory individuals with SCI who walked with or without a walking device were cross-sectionally interviewed and assessed for their demographics, SCI characteristics, iSTS ability (pass or fail), types of walking device used, balance ability, and lower limb support capability during STS. RESULTS: Forty-six subjects (67%) successfully performed iSTS ability (pass). The ability of iSTS was significantly associated with lower extremity muscle strength, lower limb support ability, balance control, and ability of walking with a single cane and without a walking device (P<0.01). CONCLUSIONS: The ability of iSTS is important for ambulatory patients with SCI as it related to ability of walking with minimal use of the upper extremities. Other significant associated factors provided important clue to promote ability of iSTS. CLINICAL REHABILITATION IMPACT: The findings imply the use of iSTS ability as a simple and practical screening or monitoring tool for the ability of walking at least with a single cane. The improvement of lower extremity muscle strength, lower limb support ability, and balance control could improve iSTS ability of these individuals.

Validity and reliability of a thoracic kyphotic assessment tool measuring distance of the seventh cervical vertebra from the wall.

BACKGROUND: In primary healthcare (PHC) service, community residents, village health volunteers (VHVs), and healthcare professionals need to work in partnership to facilitate universal and equitable healthcare services. However, these partnerships may need an appropriate tool helping them to execute an effective health-related activity. OBJECTIVES: To investigate the reliability and validity of a simple kyphosis measure using a perpendicular distance from the seventh cervical vertebra (C7) to the wall (C7WD). METHODS: Elderly people with different degrees of kyphosis (n = 179) were cross-sectionally investigated for the intra- and interrater reliability of the measurement by a physical therapist (PT), VHV, and caregiver. The validity was assessed in terms of concurrent validity as compared with the Flexicurve, and discriminative validity for functional deterioration in participants with mild, moderate, and severe kyphosis. RESULTS: The method showed excellent reliability among PT, VHV, and caregivers (ICC > 0.90, p < 0.001), and excellent correlation to the data from the Flexicurve. Results of the assessment were greater than a level of minimal detectable change and could clearly discriminate functional deterioration in participants with different severity of kyphosis (p < 0.001). CONCLUSION: C7WD is valid and reliable, thus it can be used to promote the standardisation of kyphosis measures among PHC members.

Visuotemporal cues clinically improved walking ability of ambulatory patients with spinal cord injury within 5 days.

BACKGROUND/OBJECTIVE: The human movement system uses a variety of inputs to produce movements. The concurrent use of external information, specifically visutemporal cues, while walking could promote the walking ability of ambulatory patients with spinal cord injury (SCI). This study explored the use of visutemporal cues in rehabilitation training by subjecting ambulatory individuals with SCI to walking training with or without visuotemporal cues and then assessing the effects on their functional ability. DESIGN: Quasi-experimental study. SETTING: A tertiary rehabilitation center. PARTICIPANTS: Thirty-two participants were randomly assigned to the experimental or control groups using stage of injury, severity of SCI, and baseline walking ability as criteria for group arrangement (16 participants/group). INTERVENTIONS: The participants were trained to walk over level ground at their fastest safe speed with or without a visuotemporal cue, 30 minutes/day, for 5 consecutive days. OUTCOME MEASURES: The 10-meter walk test, 6-minute walk test, timed up and go test, and five times sit-to-stand test. RESULTS: The participants demonstrated significant improvement in all functional tests after the 5 days of training (P < 0.001). In addition, the improvement in the group trained using the visuotemporal cue was significantly better than that trained without using the cue. CONCLUSIONS: Most of these participants were at a chronic stage of SCI, so the findings supported a benefit for incorporating visuotemporal cues in rehabilitation practice, particularly today when the length of rehabilitation has dramatically decreased.