Arve Opheim

Simultaneous estimation of effects of gender, age and walking speed on kinematic gait data

Analysis of variations in normal gait has received considerable attention over the last years. However, most such analyses are carried out on one explanatory variable at a time, and adjustments for other possibly influencing factors are often done using ad hoc methods. As a result, it can be difficult to know whether observed effects are actually a result of the variable under study. We wanted to simultaneously statistically test the effect of gender, age and walking speed on gait in a normal population, while also properly adjusting for the possibly confounding effects of body height and weight. Since point-by-point analysis does not take into account the time dependency in the data, we turned to functional data analysis (FDA). In FDA the whole gait curve is represented not by a set of points, but by a mathematical function spanning the whole gait cycle. We performed several multiple functional regression analyses, and the results indicate that walking speed is the main factor influencing gait in the reference material at our motion analysis laboratory. This effect is also largely unaffected by the presence of other variables in the model. A gender effect was also apparent in several planes and joints, but this effect was often more outspoken in the multiple than in the univariate regression analyses, highlighting the importance of adjusting for confounders like body height and weight.

Evaluating the properties of the coefficient of multiple correlation (CMC) for kinematic gait data

When assessing reliability of three dimensional gait analysis, the coefficient of multiple correlation (CMC), a measure of similarity of waveforms, is frequently used. Several shortcomings of the method have been reported. It is strongly related to the range of motion (ROM); it is supposed to take values from 0 to 1, but is known to obtain complex values and break down. Removing offset before calculations appears to make it insensitive to apparent differences in gait. In the present work we use stochastic simulations to demonstrate why all of this happens, and the consequences thereof. We also demonstrate other, lesser-known, issues with the method, such as the strong dependency on number of subjects and test situations. The results are demonstrated on real data from an inter-rater repeatability study. We conclude that the CMC in its current form is generally unsuitable as a tool for assessing reliability in kinematic gait data.

Upper-limb spasticity during the first year after stroke: stroke arm longitudinal study at the University of Gothenburg.

ObjectiveThe aims of this study were to describe the prevalence and the severity of upper-limb spasticity during the first year after stroke and to analyze sensorimotor function, pain, reduced range of motion, and sensibility in persons with and without spasticity. DesignThis is a longitudinal design with assessments at days 3 and 10; week 4; and mos 3, 6, and 12. A total of 117 patients with first-ever stroke and arm paresis on day 3 were consecutively included. Sixty-five percent were assessed at 12 mos. Upper-limb spasticity was assessed with the Modified Ashworth Scale, and a score of 1 or greater was considered spastic. Sensorimotor function, pain, sensibility, and joint range of motion were assessed with the Fugl-Meyer Assessment. Impairment was defined as a score of less than maximum on the motor and nonmotor domains of the Fugl-Meyer Assessment. ResultsSpasticity was present in 25% of the patients at day 3 and in 46% at 12 mos. In most patients with spasticity, the severity increased during the first year after stroke. Spasticity appeared first in the elbow flexors and later in the elbow extensors and the wrist flexors. The patients with spasticity had significantly worse sensorimotor function and more pain, reduced joint range of motion, and reduced sensibility. ConclusionsSpasticity developed in almost half of the assessed patients, and the severity of spasticity increased over time. Because spasticity and impairments related to spasticity, such as pain and limitation in joint range of motion, influence upper extremity function negatively, early identification and treatment of spasticity may be warranted.

Early prediction of long-term upper limb spasticity after stroke Part of the SALGOT study

Objective: To identify predictors and the optimal time point for the early prediction of the presence and severity of spasticity in the upper limb 12 months poststroke. Methods: In total, 117 patients in the Gothenburg area who had experienced a stroke for the first time and with documented arm paresis day 3 poststroke were consecutively included. Assessments were made at admission and at 3 and 10 days, 4 weeks, and 12 months poststroke. Upper limb spasticity in elbow flexion/extension and wrist flexion/extension was assessed with the modified Ashworth Scale (MAS). Any spasticity was regarded as MAS ≥1, and severe spasticity was regarded as MAS ≥2 in any of the muscles. Sensorimotor function, sensation, pain, and joint range of motion in the upper limb were assessed with the Fugl-Meyer assessment scale, and, together with demographic and diagnostic information, were included in both univariate and multivariate logistic regression analysis models. Seventy-six patients were included in the logistic regression analysis. Results: Sensorimotor function was the most important predictor both for any and severe spasticity 12 months poststroke. In addition, spasticity 4 weeks poststroke was a significant predictor for severe spasticity. The best prediction model for any spasticity was observed 10 days poststroke (85% sensitivity, 90% specificity). The best prediction model for severe spasticity was observed 4 weeks poststroke (91% sensitivity, 92% specificity). Conclusions: Reduced sensorimotor function was the most important predictor both for any and severe spasticity, and spasticity could be predicted with high sensitivity and specificity 10 days poststroke.

No effect on gait function of progressive resistance exercise in adults with cerebral palsy – A single-blind randomized controlled trial

Muscular weakness has long been recognized as a problem in individuals with cerebral palsy (CP), but has been ignored therapeutically until recently. The purpose of this study was to examine the effects of a progressive resistance exercise (PRE) programme of seated leg press (SLP) on gait function in adults with spastic diplegic CP, Gross Motor Function Classification System (GMFCS) level II and III, who experience reduced walking ability, using a single-blind randomized controlled trial. Twelve individuals were included, 6 in the training and 6 in the control group. The training group completed a PRE programme consisting of a 10-min warm-up, followed by SLP 12–15 repetitions maximum (RM) in 4 sets, 3 days a week, for the first 2 weeks, progressing to 6RM in 4 sets, 3 days a week, for the following 6 weeks. Six-RM tests in the SLP machine were performed to determine the training load. The control group continued individual treatment or training as usual. The primary outcome measure was the 6-Minute Walk Test (6MWT). Secondary outcome measures were the Ten-meter Walk Test (10 m), stair climbing, the Timed Stands Test (TST) and isokinetic muscle strength of the quadriceps. There was no significant change, or difference in change between the groups, in any of the outcome measures from baseline to 8 weeks. Adults with CP, participating in an 8-week PRE, did not improve their walking, functional lower limb strength or isokinetic strength. The training group did improve their performance in SLP.

Comparison of the Berg Balance Scale and the Mini-BESTest for Assessing Balance in Ambulatory People With Spinal Cord Injury: Validation Study

Background The Berg Balance Scale (BBS) has several constraints-ceiling effect, low responsiveness, and uncertain predictability of falls-in neurological populations. The Mini-BESTest, which has not yet been validated in spinal cord injury (SCI) populations, has shown no ceiling effect, slightly better responsiveness, and could in some neurological populations predict falls. Objective Validate and compare psychometric performances of the BBS and Mini-BESTest in individuals with chronic SCI. Design Cross-sectional validation study. Methods Forty-six individuals able to walk 10 meters (85% American Spinal Injury Association Impairment Scale grade D) with mean age of 55±17 years and median 7 years (range: 1-41) postinjury were included. Floor/ceiling effects were inspected; internal consistency, construct validity, and receiver operating characteristics were analyzed. Results The Mini-BESTest had no ceiling effect; 28% of participants achieved the maximum score on the BBS. Both scales showed excellent internal consistency (α > .93). Strong correlations between both scales (r s = 0.90, P < .001) and between both scales and Timed Up and Go (r s > .70), Spinal Cord Independence Measure-mobility items (r s > .80), and 10-Meter Walk Test (r s > .80) support high construct validity. Both scales could differentiate community walkers without walking aids from participants using aids (AUC > .86) and individuals with low/high concerns about falling (AUC > 0.79) but not recurrent (>2 falls/year) and infrequent fallers (AUC < 0.55). The BBS and Mini-BESTest separated 2 and more than 3 different levels of balance control, respectively. Limitations Small sample. Conclusions Both the BBS and Mini-BESTest were found to be valid scales for assessing balance control in individuals with chronic SCI. The Mini-BESTest may be preferable for this group primarily due to the lack of a ceiling effect.

Falls and fear of falling predict future falls and related injuries in ambulatory individuals with spinal cord injury: a longitudinal observational study

QUESTIONS What is the 1-year incidence of falls and injurious falls in a representative cohort of community-dwelling ambulatory individuals with chronic spinal cord injury? What are the predictors of recurrent falls (more than two/year) and injurious falls in this population? DESIGN One-year longitudinal observational multi-centre study. PARTICIPANTS A representative sample of 68 (of 73 included) community-dwelling ambulatory individuals with traumatic SCI attending regular follow-up programs at rehabilitation centres. OUTCOME MEASURES Primary outcome measures were incidence and predictors of recurrent falls (more than two/year) and injurious falls reported every 2 weeks for 1year. RESULTS A total of 48% of participants reported recurrent falls. Of the 272 reported falls, 41% were injurious. Serious injuries were experienced by 4% of participants, all of whom were women. Multivariate logistic regression analysis showed that recurrent falls in the previous year (OR=111, 95% CI=8.6 to 1425), fear of falling (OR=6.1, 95% CI=1.43 to 26) and longer time taken to walk 10m (OR=1.3, 95% CI=1.0 to 1.7) were predictors of recurrent falls. Fear of falling (OR=4.3, 95% CI=1.3 to 14) and recurrent falls in the previous year (OR=4.2, 95% CI=1.2 to 14) were predictors of injurious falls. CONCLUSION Ambulatory individuals have a high risk of falling and of fall-related injuries. Fall history, fear of falling and walking speed could predict recurrent falls and injurious falls. Further studies with larger samples are needed to validate these findings. [Jørgensen V, Butler Forslund E, Opheim A, Franzén E, Wahman K, Hultling C, Seiger Å, Ståhle A, Stanghelle JK, Roaldsen KS (2017) Falls and fear of falling predict future falls and related injuries in ambulatory individuals with spinal cord injury: a longitudinal observational study. Journal of Physiotherapy 63: 108-113].

Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics

Study designProspective quasi-experimental study, pre- and post-design.ObjectivesAssess safety, feasibility, training characteristics and changes in gait function for persons with spinal cord injury (SCI) using the robotic exoskeletons from Ekso Bionics.SettingNine European rehabilitation centres.MethodsRobotic exoskeleton gait training, three times weekly over 8 weeks. Time upright, time walking and steps in the device (training characteristics) were recorded longitudinally. Gait and neurological function were measured by 10 Metre Walk Test (10 MWT), Timed Up and Go (TUG), Berg Balance Scale (BBS), Walking Index for Spinal Cord Injury (WISCI) II and Lower Extremity Motor Score (LEMS).ResultsFifty-two participants completed the training protocol. Median age: 35.8 years (IQR 27.5–52.5), men/women: N = 36/16, neurological level of injury: C1-L2 and severity: AIS A–D (American Spinal Injury Association Impairment Scale). Time since injury (TSI) < 1 year, N = 25; > 1 year, N = 27.No serious adverse events occurred. Three participants dropped out following ankle swelling (overuse injury). Four participants sustained a Category II pressure ulcer at contact points with the device but completed the study and skin normalized. Training characteristics increased significantly for all subgroups. The number of participants with TSI < 1 year and gait function increased from 20 to 56% (P = 0.004) and 10MWT, TUG, BBS and LEMS results improved (P < 0.05). The number of participants with TSI > 1 year and gait function, increased from 41 to 44% and TUG and BBS results improved (P < 0.05).ConclusionsExoskeleton training was generally safe and feasible in a heterogeneous sample of persons with SCI. Results indicate potential benefits on gait function and balance.

High incidence of falls and fall-related injuries in wheelchair users with spinal cord injury: A prospective study of risk indicators.

OBJECTIVE To identify risk indicators for, and incidence of, recurrent falls and fall-related injuries in wheelchair users with traumatic spinal cord injury. DESIGN Prospective multi-centre study. SUBJECTS One hundred and forty-nine wheelchair users with spinal cord injury attending follow-up in Sweden and Norway. METHODS Inclusion criteria: wheelchair users ≥ 18 years old with traumatic spinal cord injury ≥ 1 year post-injury. EXCLUSION CRITERIA individuals with motor complete injuries above C5. Falls were prospectively reported by text message every second week for one year and were followed-up by telephone interviews. Outcomes were: fall incidence, risk indicators for recurrent (> 2) falls and fall-related injuries. Independent variables were: demographic data, quality of life, risk willingness, functional independence, and exercise habits. RESULTS Of the total sample (n = 149), 96 (64%) participants fell, 45 (32%) fell recurrently, 50 (34%) were injured, and 7 (5%) severely injured. Multivariate logistic regression analysis showed that reporting recurrent falls the previous year increased the odds ratio (OR) of recurrent falls (OR 10.2, p < 0.001). Higher quality of life reduced the OR of fall-related injuries (OR 0.86, p = 0.037). CONCLUSION Previous recurrent falls was a strong predictor of future falls. The incidence of falls, recurrent falls and fall-related injuries was high. Hence, prevention of falls and fall-related injuries is important.

Temporal and spatial gait parameters in patients dependent on walking assistance after stroke: Reliability and agreement between simple and advanced methods of assessment

The aim of this study was to investigate the reliability of temporal and spatial gait parameters in patients dependent on walking assistance after severe stroke, and to examine agreement between simple and advanced methods. Twenty-one patients, admitted for in-patient multidisciplinary rehabilitation, were assessed repeatedly for walking function, both in a test corridor and a gait laboratory (3D camera system) before and after 11 weeks of rehabilitation. The test-retest reliability was examined using intraclass correlation (ICC1.1), and measurement error was reported by within-subject standard deviation (Sw). The agreement between different methods for assessing walking speed, cadence and step length was explored by Bland-Altman plots. High to excellent test-retest reliability was found between trials, both when assessed in the corridor (ICC: 0.93-0.99) and in the laboratory (ICC: 0.88-0.99). Agreement between methods was satisfactory at baseline and was higher after the rehabilitation period. Agreement was found to be slightly better at lower walking speeds and for shorter step lengths. The results implicate that temporal-spatial gait parameters may be measured reliably by both simple and advanced methods in dependent walkers after stroke. A high level of agreement was found between the two methods for walking speed, cadence and average step length at both test points.