Three-Dimensional Instrumented Gait Analysis for Children With Cerebral Palsy: An Evidence-Based Clinical Practice Guideline.

BACKGROUND: Children with cerebral palsy (CP) who walk have complex gait patterns and deviations often requiring physical therapy (PT)/medical/surgical interventions. Walking in children with CP can be assessed with 3-dimensional instrumented gait analysis (3D-IGA) providing kinematics (joint angles), kinetics (joint moments/powers), and muscle activity. PURPOSE: This clinical practice guideline provides PTs, physicians, and associated clinicians involved in the care of children with CP, with 7 action statements on when and how 3D-IGA can inform clinical assessments and potential interventions. It links the action statement grades with specific levels of evidence based on a critical appraisal of the literature. CONCLUSIONS: This clinical practice guideline addresses 3D-IGA's utility to inform surgical and non-surgical interventions, to identify gait deviations among segments/joints and planes and to evaluate the effectiveness of interventions. Best practice statements provide guidance for clinicians about the preferred characteristics of 3D-IGA laboratories including instrumentation, staffing, and reporting practices.Video Abstract: Supplemental digital content available at http://links.lww.com/PPT/A524.

Instrumented Gait Analysis (IGA) for Management of Children With Cerebral Palsy: A Needs Assessment Survey.

PURPOSE: This needs assessment survey identifies the priorities of the clinical and research communities involved with the use of instrumented gait analysis (IGA) for a clinical practice guideline on IGA use with children with cerebral palsy (CP). METHODS: Thirteen Likert scale questions asked about the importance of topics related to IGA. Other questions addressed respondents' demographics, experience with IGA, patient populations, and gait laboratory characteristics. Several open-ended questions were included and analyzed. RESULTS: The survey was completed by 43 physical therapists and 53 non-physical therapists involved with IGA. More than 90% rated the following as critically or highly important: reliability and validity of IGA to identify gait pathology (94%); ability to longitudinally track gait pathology (93%); use in planning interventions (93%); use in evaluating outcomes (93%); and definition of IGA (90%). CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE: This needs assessment survey identified the topic priorities of clinicians and practitioners who use IGA for the management of children with CP. These results will guide the development of a clinical practice guideline on the use of IGA for the management of CP.

The Relationship Between Performance of Sit-To-Stand From a Chair and Getting Down and Up From the Floor in Community-Dwelling Older Adults.

BACKGROUND AND PURPOSE: The ability to perform sit-to-stand from a chair and getting down and up from the floor, or the ability to safely perform a floor transfer are important transitional activities for independent living. The sit-to-stand maneuver is frequently performed by community-dwelling older adults and is routinely evaluated as a part of geriatric physical therapy assessment. Conversely, a floor transfer is rarely performed by older adults or addressed by clinicians, even when working with frail patients who live alone and are at high risk for falls. Accordingly, the specific aim of this cross-sectional study was to determine the concurrent, predictive, and discriminant validity of the five times sit-to-stand (5xSTS) test against 3-point floor transfer performance. METHODS: A total of 46 community-dwelling adults, ages 65-96 years, were recruited using a stratified sampling technique based on self-reported levels of floor transfer ability: independent (n = 16); assisted (n = 15); and dependent (n = 15). Forty-five of the 46 participated in the data collection process. Participants were first assessed for the 5xSTS test and were categorized based on performance as unable to perform (n = 14), poor performance (>13.6 seconds), or good performance (≤13.6 seconds). Participants then performed the 3-point floor transfer test and were classified based on results as independent (n = 18), assisted (n = 10), or dependent (n = 17). Spearman correlations were calculated to assess the concurrent validity for the 5xSTS testing procedure against 3-point floor transfer performance. The Kruskal-Wallis test was used to: 1) determine the discriminant validity of 5xSTS test outcome performance among groups that differ in 3-point floor transfer test performance; and 2) examine the significance level of the socio-demographic data. RESULTS: Moderate to strong positive correlations were found between the 3-point floor transfer test and the categorical performance outcomes of the 5xSTS test (rho ranged from 0.67 to 0.88, p < .001). A strong negative correlation was found between 5xSTS scores and the 3-point floor transfer test (rho = 0.86, p < .001). There was moderate sensitivity (71%) and strong specificity (93%) for the 5xSTS test to predict floor transfer performance. The outcomes of 5xSTS performance differed significantly among 3-point floor transfer performance outcome groups. Older adults who were unable to perform 5xSTS test were also dependent in floor transfer performance. In contrast, older adults who demonstrated good performance in the 5xSTS test were independent in floor transfer performance (p ≤ 0.012). CONCLUSION: Floor transfer is a highly important safety maneuver for older adults, although it is rarely performed and assessed. This study documents that the 5xSTS test displays concurrent, predictive, and discriminative validity properties, making it a potentially useful initial screening tool to predict floor transfer ability. Failure to complete the 5xSTS test may also be a reliable indicator of floor transfer performance dependency among community-dwelling older adults.

Instrumented gait analysis for management of gait disorders in children with cerebral palsy: A scoping review.

BACKGROUND: The use of Instrumented Gait Analysis (IGA) for the clinical management of individuals with cerebral palsy (CP) has increased in recent years. Previous systematic reviews have been completed to evaluate and summarize the evidence related to the efficacy of IGA in general. However, a focused summary of research studies on IGA for children with CP related gait disorders is needed. RESEARCH QUESTION: The purpose of the current work was to perform a scoping review to describe and categorize the range of existing literature about IGA as applied to the clinical management of children with CP related gait disorders. METHOD: A health sciences librarian developed a search strategy to include four key inclusion criteria of original research study, population included children with CP, study employed IGA, available in English. The available literature was organized into six study categories: reliability and validity, documentation of subgroups or model development, IGA for clinical decision making, effectiveness of treatments that depend on IGA, cost effectiveness, IGA used to evaluate the outcome of surgical, medical or rehabilitation treatment. RESULTS: 909 studies met the inclusion criteria and were placed into the six study categories. 14 % of studies were in reliability and validity, 33 % in subgroups or modeling, 2% in IGA for clinical decision making, 2% in treatments that depend on IGA, 1% in cost effectiveness, and 49 % of studies had IGA used as an outcome measure for treatment. SIGNIFICANCE: This scoping review has documented the wide range, diversity and extent of original research studies investigating the use of IGA for the clinical management of children with CP related gait disorders. The large volume of studies provides a basis for future work to develop a CPG about the use of IGA for the clinical management of children with CP related gait disorders.

Parkinson's Disease: Exploring Motives for Long-Term Adherence to a Group Exercise Program.

PURPOSE: The aim of this study was to explore why people with Parkinson's disease maintained attendance at a community group exercise program. DESIGN: Qualitative design was used for this study. METHODS: A purposive sample was used to recruit participants. Interviews with individual and focus groups collected narrative data that were interpreted using content analysis. FINDINGS: Eighteen participants enrolled in the study. Four themes emerged: (1) changing and challenging workout; (2) gaining strength, inspiration, and knowledge and doing it among friends; (3) professionals, not amateurs; and (4) holistic lasting benefit. CONCLUSIONS: For the participants in this study, exercising in a group among peers in an enjoyable, varied, and challenging program that was structured, socially supportive, and supervised provided incentive for maintaining attendance. CLINICAL RELEVANCE: Exercise is a life-long recommendation for everyone, including people with Parkinson's disease, for whom maintaining attendance is more challenging. The words of these participants encourage healthcare providers to consider the relevance of socialization, supervision, and structure when developing exercise programs for this population.

Characteristics of Older Adults Who Are Unable to Perform a Floor Transfer: Considerations for Clinical Decision-Making.

BACKGROUND AND PURPOSE: The ability to get down to and up from the floor or to perform a floor transfer (FT) is a vital and useful skill for older adults at risk of falling. Little is known about the health-related factors that separate older adults who can perform FT independently from those who cannot. Therefore, the specific aims of this cross-sectional study are to (1) describe and compare health-related factors among older adults who were independent, assisted, or dependent in FT performance; and (2) establish the parallel reliability between self-reported and actual performance of FT. METHODS: A total of 46 community-dwelling adults ages 65 to 96 years were recruited using a stratified sampling technique based on self-reported levels of FT ability: independent (n = 15), assisted (n = 15), or dependent (n = 15). Participants were asked to perform the actual FT test and were categorized according to test result as independent (n = 18), assisted (n = 10), or dependent (n = 17). Sociodemographic and health-related factors of participants were separated into the 3 FT test outcome groups. The Kruskal-Wallis test was used to compare these factors across the 3 FT test outcome groups. The quadratic-weighted κ coefficient was calculated to determine the agreement between self-reported FT ability and FT test performance. RESULTS: Significant differences were observed among the FT test outcome groups based on all sociodemographic and health-related factors (P < .05). Older adults who were dependent in FT were older and dependent in instrumental activities of daily living (IADL, 100%). Also, this group required some type of help during basic activities of daily living (ADL, 35.3%), which reflected a homebound status and the need for caregiver support, including the use of 2-handed assistive devices during ambulation. More than half the participants in this category had fallen at least once in the past 6 months. Conversely, older adults who were independent in FT were younger and living independently in the community (83.3%). The parallel reliability between the self-reported FT ability and actual FT test performance was 0.92 (95% confidence interval, 0.88-0.97). CONCLUSION: Sociodemographic and health-related factors were significantly different among older adults who demonstrated varying abilities on the FT test. This study has shown that the self-reported FT ability and actual FT test performance represented reliable alternative forms to assess the ability to transfer from a standing to a supine position on the floor and then back to an erect position. Evaluation of FT ability and/or performance is recommended as a standard component of geriatric functional assessment to make more informed clinical decision in providing effective physical therapy interventions.

Reliability and Validity of the Floor Transfer Test as a Measure of Readiness for Independent Living Among Older Adults.

BACKGROUND AND PURPOSE: The ability to get up from the floor after a fall is a basic skill required for functional independence. Consequently, the inability to safely get down to and up from the floor or to perform a floor transfer (FT) may indicate decreased mobility and/or increased frailty. A reliable and valid test of FT ability is a critical part of the clinical decision-making process. The FT test is a simple, performance-based test that can be administered quickly and easily to determine a patient's ability to safely and successfully get down and up from the floor using any movement strategy and without time restriction. The primary purpose of this cross-sectional study was to determine the intrarater reliability and validity of the FT test as a practical alternative to several widely used yet time-consuming measures of physical disability, frailty, and functional mobility. METHODS: A total of 61 community-dwelling older adults (65-96 years of age) participated in the study, divided into 2 separate subsamples: intrarater reliability was studied with 15 participants, while concurrent validity was studied with the remaining 46 participants. In both subsamples, the participants were stratified on the basis of the self-reported levels of FT ability as independent, assisted, and dependent. Intrarater reliability was assessed on 2 separate occasions and scores were analyzed by intraclass correlation coefficient and κ statistics. Concurrent validity of the FT test was assessed against the self-reported FT ability questionnaire, Physical Functioning Scale, Phenotype of Physical Frailty, and the Short Physical Performance Battery. Known-groups validity was tested by determining whether the FT test distinguished between (1) community-dwelling older adults with physical disabilities versus those without physical disabilities; and (2) community-dwelling older adults who were functionally dependent versus those who were independent. Participants were also categorized on the basis of FT test outcome as independent, assisted, or dependent. The Spearman correlation coefficients were calculated to examine the strength of the relationships between the FT test and physical status measures. The Kruskal-Wallis test was used to determine whether the FT test significantly discriminated between groups as categorized by the Physical Functioning Scale and Short Physical Performance Battery, and to examine the significance level of the sociodemographic data across the 3 FT test outcome groups. RESULTS: The intrarater reliabilities of the measures were good (0.73-1.00). There were statistically positive and strong correlations between the FT test and all physical status measures (ρ ranged from 0.86 to 0.93, P < .001). Older adults who passed the FT test were collectively categorized as those without physical disabilities and functionally independent, whereas older adults who failed the FT test were categorized as those with physical disabilities and functionally dependent (P < .001). CONCLUSION: The FT test is a reliable and valid measure for screening for physical disability, frailty, and functional mobility. It can determine which older adults have physical disabilities and/or functional dependence and hence may be useful in assessing readiness for independent living. Inclusion of the FT test at initial evaluation may reveal the presence of these conditions and address the safety of older adults in the community.

What makes a group fitness program for people with Parkinson's disease endure? A mixed-methods study of multiple stakeholders.

OBJECTIVE: Identify key features of an enduring group exercise program for people with Parkinson's disease (PD) by exploring experiences of participants, student assistants and the exercise instructor through a convergent mixed methods design. METHODS: Fourteen people with PD (modified Hoehn & Yahr: 1-3.5) who regularly participated in a group exercise program (≥ 50% of classes for ≥ 1 year) were interviewed to explore their perceptions of the program. The exercise instructor was also interviewed and weekly written reflections were collected from 18 undergraduate student assistants. Using a grounded theory approach, interviews and written reflections were thematically analyzed via qualitative content analysis. Quantitative data from the Physical Fitness and Exercise Activity Levels of Older Adults Scale were used as part of a convergent mixed-methods design to move towards theory formation. RESULTS: Thematic analysis of the PD participant interviews revealed 4 themes: 1) Quality of the program, 2) Social interactions, 3) Facilitators to exercise, 4) Barriers to exercise. The exercise instructor interview revealed 2 themes: individualization and functionality of exercises, and creating a nurturing atmosphere. Themes from students' data included student learning, and positive in-class experiences. Means (sd) were 1.6 (0.5) for facilitators and 3.0 (0.5) for barriers subscales (1=strongly agree to 4=strongly disagree). CONCLUSION: These varied sources of data converge to identify and characterize key features of an enduring group exercise program for people with PD: a positive and nurturing environment, varied and individually tailored exercise content, and the importance of social cohesion. These findings also highlight the critical role of multiple stakeholders in fostering an environment that facilitates long-term adherence to group exercise.

Physical Functioning After 1, 3, and 5 Years of Exercise Among People With Parkinson's Disease: A Longitudinal Observational Study.

BACKGROUND AND PURPOSE: Regular physical activity is thought to be crucial to maintaining optimal physical function in people with Parkinson's disease (PWP), and it may have neuroprotective effects. As with many medical treatments, exercise is most effective when performed consistently over a period of years. The primary aim of this study was to examine multiyear adherence to a community-based group exercise program for PWP. A secondary aim was to document how physical functioning progressed after 1, 3, and 5 years for participants who consistently attended a community-based, group, exercise program. METHODS: Forty-six individuals with idiopathic Parkinson's disease, who were at modified Hoehn and Yahr stage I, II, or III and were community ambulators, were recruited on a rolling basis between 2008 and 2013. Each provided yearly medical clearance to exercise. Participants engaged in a free, community-based, group exercise program offered 2 days per week, 1 hour per day, for three 10-week sessions per year. The program included supervised floor exercises for balance, coordination, strength, and flexibility along with resistance training on dual-action exercise machines. Participants who attended more than half the classes for 1, 3, or 5 years (n = 27, n = 14, n = 7, respectively) were considered to have completed the fitness program (consistent exercisers) and were included in the longitudinal data analysis; participants who either dropped out or attended less than half the classes (n = 19) were not included. Physical functioning was evaluated at baseline for all participants and yearly thereafter for consistent exercisers. Wilcoxon signed rank tests were used to compare baseline data with data collected after 1, 3, and 5 years of consistent exercise. RESULTS AND DISCUSSION: Over half of the participants initially evaluated completed at least 1 year of the fitness program (27 of the 46 = 59%) and a proportion completed 3 years (14 of the 39 = 39%), and 5 years (7 of the 24 = 29%). At baseline, consistent exercisers were younger than those who dropped out (63.9 vs 69.9 years, P < .05), but had similar modified Hoehn and Yahr medians (2.0 vs 2.3), and similar time since diagnosis (8.0 vs 5.6 years). Consistent exercisers showed small statistically significant improvements in grip strength (8.9% change), Berg Balance scores (5.1% change), and 6-minute walk test (11% change) from baseline to year 1. No significant differences were found in these variables after 3 or 5 years, or for gait speed and timed up and go after 1, 3, or 5 years. CONCLUSION: Despite the progressive nature of Parkinson's disease, many PWP can sustain a regular program of varied modes of community-based, group exercise over a period of years. Participants who did so maintained initial performance levels on key measures of physical functioning. By working with an interprofessional team in a supportive community-based exercise program, physical therapists can help many PWP engage in consistent and sustained exercise activity over multiyear periods.

Long-term group exercise for people with Parkinson's disease: a feasibility study.

BACKGROUND AND PURPOSE: Aerobic and strengthening exercises have been shown to benefit people with Parkinson's disease (PD) on the basis of highly structured, short-term, clinical protocols. This study extended previous research by investigating feasibility of an ongoing, community-based, group exercise program for people with PD on the basis of short-term (10 weeks) and long-term (14 months) data. METHODS: Twenty people with PD (Hoehn and Yahr stages I to III) participated in at least one of four 10-week sessions. Classes were held twice weekly for 1 hour and included strength, flexibility, and balance and walking exercises. Evaluations were done 1.5 hours after medication intake 1 week before and 1 week after each session. Gait speed, 6-Minute Walk test (6MWT), "Timed Up and Go" test, and grip strength were used to assess physical function. Analysis of short-term results were based on 18 participants (2 dropped out prior to posttest), and long-term results were based on 8 participants who started in the first session continued through the 14-month period. RESULTS: Attendance rates were moderate to high (73% overall). No injuries were reported. Wilcoxon signed ranks tests based on each participant's first 10-week session demonstrated significant improvements in 6MWT, and grip strength. Long-term participants showed significant improvements in grip strength, and a trend toward improved 6MWT. Gait speed and Timed Up and Go test did not change significantly in the short or long terms. DISCUSSION/CONCLUSIONS: Our community-based group exercise program was safe, feasible, and appears to be effective. While some measures showed no improvement, there was no evidence of decline. This is an important outcome for persons with progressive neurological disorders, and suggests community-based group exercise is a promising option for people with PD.

Overground physical therapy gait training for chronic stroke patients with mobility deficits.

BACKGROUND: Overground gait training forms a major part of physical therapy services for chronic stroke patients in almost every setting. Overground gait training refers to physical therapists' observation and cueing of the patient's walking pattern along with related exercises, but does not include high-technology aids such as functional electrical stimulation or body weight support. OBJECTIVES: To assess the effects of overground physical therapy gait training on walking ability for chronic stroke patients with mobility deficits. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched March 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2008), MEDLINE (1966 to May 2008), EMBASE (1980 to May 2008), CINAHL (1982 to May 2008), AMED (1985 to March 2008), Science Citation Index Expanded (1981 to May 2008), ISI Proceedings (Web of Science, 1982 to May 2006), Physiotherapy Evidence Database (http://www.pedro.org.au/) (May 2008), REHABDATA (http://www.naric.com/research/rehab/) (1956 to May 2008), http://www.clinicaltrials.gov (May 2008), http://www.controlled-trials.com/ (May 2008), and http://www.strokecenter.org/ (May 2008). We also searched reference lists of relevant articles, and contacted authors and trial investigators. SELECTION CRITERIA: Randomised controlled trials comparing overground physical therapy gait training with a placebo intervention or no treatment for chronic stroke patients with mobility deficits. DATA COLLECTION AND ANALYSIS: Pairs of authors independently selected trials. Three authors independently extracted data and assessed quality. We contacted study authors for additional information. MAIN RESULTS: We included nine studies involving 499 participants. We found no evidence for a benefit on the primary variable, post-test gait function, based on three studies with 269 participants. Uni-dimensional performance variables did show significant effects post-test. Gait speed increased by 0.07 metres per second (95% confidence interval (CI) 0.05 to 0.10) based on seven studies with 396 participants, timed up-and-go (TUG) test improved by 1.81 seconds (95% CI -2.29 to -1.33), and six-minute-walk test (6MWT) increased by 26.06 metres (95% CI 7.14 to 44.97) based on four studies with 181 participants. We found no significant differences in deaths/disabilities or in adverse effects, based on published reports or personal communication from all of the included studies. AUTHORS' CONCLUSIONS: We found insufficient evidence to determine if overground physical therapy gait training benefits gait function in patients with chronic stroke, though limited evidence suggests small benefits for uni-dimensional variables such as gait speed or 6MWT. These findings must be replicated by large, high quality studies using varied outcome measures.

Overground gait training for individuals with chronic stroke: a Cochrane systematic review.

BACKGROUND AND PURPOSE: : Overground gait training-observation and cueing of patient's walking pattern along with related exercises-forms a major part of rehabilitation services for individuals with chronic stroke in almost every setting. This report of a Cochrane systematic review assessed the effects of overground gait training on walking ability for individuals with mobility deficits subsequent to chronic stroke. DATA SOURCES: : We searched the Cochrane Stroke Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Science Citation Index Expanded, http://www.clinicaltrials.gov, among other databases through spring 2008. We also searched reference lists and contacted authors and trial investigators. REVIEW METHODS: : Only randomized controlled trials comparing overground physical therapy gait training with a placebo or no treatment condition were included. RESULTS: : Nine studies involving 499 participants were included. We found no evidence of a benefit on walking function, the primary variable, based on three studies (n = 269). Some performance variables did show significant effects. Walking speed increased by 0.07 m/sec [95% confidence interval (CI), 0.05-0.10] based on seven studies (n = 396), Timed Up and Go test improved by 1.81 seconds (95% CI, -2.29 to -1.33) based on three studies (n = 118), and six-minute walk test increased by 26.06 m (95% CI, 7.14-44.97) based on four studies (n = 181). CONCLUSIONS: : We found insufficient evidence to determine whether overground physical therapy gait training benefits walking function in individuals with chronic stroke, although limited evidence suggests potential benefits for some performance variables. High-quality randomized controlled trials are needed to replicate and extend these findings.

Community health education: reaching ethnically diverse elders.

To address disparities in access to health care information, we developed a model program of community-based, health education workshops to be delivered in English and Spanish to older urban adults from diverse ethnic, cultural, and language backgrounds. The workshops were created through an interdisciplinary collaboration among faculty from seven health care professions and focused on three healthcare topics identified in Healthy People 2010: dementia and depression, stress reduction, and physical activity. The development of workshop content and structure, including didactic and interactive components, an approach to interdisciplinary student involvement, and program evaluation by clients and community center staff, are presented as a model for other educators. The workshops presented at five senior centers were attended by 1110 mostly female clients with an average age of 74 yrs and with a large proportion self-identified as of minority background. One hundred seven students from seven healthcare programs helped deliver the workshops. Interviews and surveys of the clients demonstrated that most had a positive learning experience, whereas the evidence of intent to take action on health care issues was less definitive. Analysis of student essays demonstrated increased student understanding of older adults and of community services. A website, Geriatric Educational Resources for Instructors and Elders (www.GERIE.org), was created to provide access to the instructional and resource materials used for the workshops, including presentation materials in Spanish. This model program may help address the substantial health education needs of a growing population of older adults from diverse ethnic, cultural, and language minorities.

Two simple methods for improving the reliability of joint center locations.

OBJECTIVE: A clinically oriented technique is proposed for evaluating the reliability of methods for estimating joint center locations from surface markers, as is an optimization method for estimating joint center locations during planar movements. DESIGN: Segment length variability is used as a measure of reliability, and three simple methods for locating joint centers are compared via repeated measures analysis. Rigorous evaluation is achieved by applying adjustment parameters to a data set, other than the one from which parameters were derived. BACKGROUND: Although more sophisticated techniques are available, many clinical and experimental studies use visual observation and palpation to locate joint centers. This study offers a simple means to evaluate the reliability of that method, and it offers two simple post-hoc methods to improve reliability. METHODS: Single-joint movements are used to generate adjustment parameters from three-dimensional (3D) measurements of surface markers; these are applied to multi-joint movement trials. Segment length variability is compared before and after adjustment with each of two post-hoc methods. RESULTS: As shown by lowered segment length standard deviations, the proposed optimization technique improved reliability compared to the observational and the two-dimensional (2D) post-hoc methods. CONCLUSIONS: The segment length technique offers a simple means to evaluate the reliability with which joint centers are located, and the new optimization method improves reliability for planar multi-joint movements. RELEVANCE: These improvements in reliability are easily implemented within settings where sophisticated technical support may be unavailable.