Danny Rafferty

Walking and talking: an investigation of cognitive—motor dual tasking in multiple sclerosis

Background: Deficits in motor functioning, including walking, and in cognitive functions, including attention, are known to be prevalent in multiple sclerosis (MS), though little attention has been paid to how impairments in these areas of functioning interact. Objectives: This study investigated the effects of performing a concurrent cognitive task when walking in people with MS. Level of task demand was manipulated to investigate whether this affected level of dual-task decrement. Method: Eighteen participants with MS and 18 healthy controls took part. Participants completed walking and cognitive tasks under single- and dual-task conditions. Results: Compared to healthy controls, MS participants showed greater decrements in performance under dual-task conditions in cognitive task performance, walking speed and swing time variability. In the MS group, the degree of decrement under dual-task conditions was related to levels of fatigue, a measure of general cognitive functioning and self-reported everyday cognitive errors, but not to measures of disease severity or duration. Conclusions: Difficulty with walking and talking in MS may be a result of a divided attention deficit or of overloading of the working memory system, and further investigation is needed. We suggest that difficulty with walking and talking in MS may lead to practical problems in everyday life, including potentially increasing the risk of falls. Clinical tools to assess cognitive—motor dual-tasking ability are needed.

The effect of functional electrical stimulation on the physiological cost of gait in people with multiple sclerosis

Objective Functional electrical stimulation (FES) is used clinically in the management of drop foot in people suffering from neurological conditions. The aim of the study was to investigate the effects of FES, in terms of speed and physiological cost of gait, in people with multiple sclerosis (pwMS). Methods Twelve pwMS and 12 healthy matched controls walked at their own preferred walking speed (PWS) for 5 min around a 10 m elliptical course. Subjects with MS completed the protocol with and without using their FES. In addition, control subjects completed the protocol twice more walking at the same PWS of the pwMS to which they were matched. Results Wearing FES lead to a significant improvement in walking speed (0.49 ms−1 and 0.43 ms−1 with and without their FES respectively; P < 0.001) and a significant reduction in the physiological cost of gait (0.41 mL min−1 kg−1 m−1 and 0.46 mL min−1 kg−1 m−1 with and without FES respectively; P = 0.017) in pwMS. The speed of walking, oxygen uptake, and physiological cost were significantly different between pwMS and controls both at preferred and matched speeds. Although pwMS exhibit a higher physiological cost of walking, FES offers an orthotic benefit to pwMS and should be considered as a possible treatment option.

Tibialis posterior tenosynovitis and associated pes plano valgus in rheumatoid arthritis : electromyography, multisegment foot kinematics, and ultrasound features

To compare electromyographic (EMG), kinematic, kinetic, and ultrasound (US) features of pes plano valgus associated with US‐confirmed tibialis posterior (TP) tenosynovitis in rheumatoid arthritis (RA) and healthy control subjects.

The effect of cueing therapy on single and dual-task gait in a drug naïve population of people with Parkinson's disease in northern Tanzania†

The incidence of Parkinsons disease (PD) in sub‐Saharan Africa (SSA) is greater than thought however, is largely undiagnosed and untreated. This study aimed to evaluate a nonpharmacological approach using cueing therapy to improve gait in drug‐naïve PD and the feasibility of delivering rehabilitation in northern Tanzania. In this study, twenty‐one people with PD aged 76.4 years (12.9 SD) with varying disease severity participated. They received 9 × 30 min sessions of cueing therapy for gait problems over 3 weeks from a trained therapist delivered in their home environment. Cueing therapy consisted of walking in time to a metronome beat to correct step amplitude and step frequency during a range of functional activities. Gait was recorded on video before and after therapy, and videos were analyzed in the UK by an assessor not involved in data collection. Disease severity (UPDRS) and balance were also measured. Patients were assessed in their nearest clinic. Data were analyzed in Minitab and a P value of 0.05 was considered significant. Cueing therapy significantly improved single and dual task walking speed, step amplitude, and single task step frequency. There was also a significant improvement in motor impairment (UPDRS III) and activities of daily living (UPDRS II). The results provide promising evidence for the role of cueing therapy in PD for symptom management to reduce or delay medication onset. This study also supports the feasibility of rehabilitation in PD in community environments in SSA, which may be applicable to other developing regions.

Low back pain and physiotherapy use of red flags: the evidence from Scotland

BACKGROUND Red flags are recognised as indicators of possible serious spinal pathology, and their use is indicated by numerous guidelines. Similar to other countries worldwide, Scotland lacked a national view about the overall quality of the physiotherapy management of low back pain and the use of red flags. Anecdotal evidence suggested that practice varied considerably. AIM To improve the use and documentation of red flags by physiotherapists during the assessment and management of low back pain. DESIGN Prospective, multicentred, national data collection and improvement initiative. SETTING National Health Service (NHS) health boards in Scotland (n=14) plus two private provider sites. PARTICIPANTS One hundred and eighty-six individual NHS provider sites and two private provider sites, with in excess of 360 physiotherapists providing services to low back pain patients. METHOD Measurement of documented practice in line with evidence- and consensus-based recommendations from guidelines collected via a web-based tool over two 5-week audit cycles interspersed with an improvement phase over 1 year (2008-2009). RESULTS Data from 2147 patients showed improvement in the documentation of all red flags assessed from 33% (n=709) to 65% (n=1396), and improvement in the documentation of cauda equina syndrome from 60% (n=1288) to 84% (n=1804) over the two cycles. Only two regions provided evidence of 100% documentation of all components of cauda equina syndrome, with wide variation across the country. CONCLUSION This national initiative resulted in considerable improvement in the documentation of red flags. Despite this, however, one in five patients did not receive optimal management as recommended by guidance. This has significant implications for patient safety and highlights the need for ongoing education of physiotherapists in this area.

Relationship between isokinetic muscle strength and exercise capacity in chronic heart failure

The exercise intolerance and excessive ventilatory response to exercise of chronic heart failure is associated with abnormalities of skeletal muscle function, in particular a reduction in muscle strength. Isometric and isokinetic leg muscle strength were measured in 10 patients with chronic heart failure and 10 age-matched controls. Each subject undertook maximal exercise testing to measure peak oxygen consumption (V(O2)) and the ventilatory response to exercise as measured by the slope of the relation between ventilation and carbon dioxide production (V(E)/V(CO2) slope). Quadriceps strength (mean (S.D.)) was reduced in heart failure as measured by isometric (444.9 (129.6) N vs. 556.0 (136.0); P<0.01) and isokinetic (123.6 (30.2) Nm vs. 146.8 (40.0); P=0.04). Hamstring strength was also reduced as measured by isokinetic testing (53.6 (15.6) Nm vs. 71.1 (28.1); P=0.02). Isokinetic and isometric strengths correlated, but not closely (r=0.52, P<0.001). There were negative correlations between the V(E)/V(CO2) slope, and isokinetic measures: with average torque, r=-0.62, P<0.004; with peak torque, r=-0.64, P=0.002. We have found evidence for reduced muscle function affecting both knee flexors and extensors. This reduction in muscle strength correlates with the ventilatory response to exercise. These observations lend support to the muscle hypothesis of the generation of symptoms in chronic heart failure.

Increasing physical activity in stroke survivors using STARFISH, an interactive mobile phone application: a pilot study

Background: Following stroke, people are generally less active and more sedentary which can worsen outcomes. Mobile phone applications (apps) can support change in health behaviors. We developed STARFISH, a mobile phone app-based intervention, which incorporates evidence-based behavior change techniques (feedback, self-monitoring and social support), in which users’ physical activity is visualized by fish swimming. Objective: To evaluate the potential effectiveness of STARFISH in stroke survivors. Method: Twenty-three people with stroke (12 women; age: 56.0 ± 10.0 years, time since stroke: 4.2 ± 4.0 years) from support groups in Glasgow completed the study. Participants were sequentially allocated in a 2:1 ratio to intervention (n = 15) or control (n = 8) groups. The intervention group followed the STARFISH program for six weeks; the control group received usual care. Outcome measures included physical activity, sedentary time, heart rate, blood pressure, body mass index, Fatigue Severity Scale, Instrumental Activity of Daily Living Scale, Ten-Meter Walk Test, Stroke Specific Quality of Life Scale, and Psychological General Well-Being Index. Results: The average daily step count increased by 39.3% (4158 to 5791 steps/day) in the intervention group and reduced by 20.2% (3694 to 2947 steps/day) in the control group (p = 0.005 for group–time interaction). Similar patterns of data and group–time interaction were seen for walking time (p = 0.002) and fatigue (p = 0.003). There were no significant group–time interactions for other outcome measures. Conclusion: Use of STARFISH has the potential to improve physical activity and health outcomes in people after stroke and longer term intervention trials are warranted.

Physical activity profiles and sedentary behaviour in people following stroke: a cross-sectional study

Abstract Purpose: To measure and compare physical activity profiles and sedentary time between community dwelling stroke survivors and healthy volunteers. Methods: Twenty-two stroke survivors (10 men, age 55.3 ± 9.9 years; 4.2 ± 4.0 years since their stroke) were recruited from local stroke support groups, and 22 controls were matched for sex, age and body mass index (BMI). All participants wore an ActivPAL™ physical activity monitor for seven days and from these data activity profiles, including the number of steps per day, time spent sedentary and time in different cadence bands, were recorded. Results: Stroke survivors took significantly fewer steps per day than the controls (4035 ± 2830 steps/day versus 8394 ± 2941 steps/day, p < 0.001) and sedentary time (including sleep time) was significantly higher for stroke participants compared to the controls (20.4 ± 2.7 h versus 17.5 ± 3.8 h, p < 0.001). People with stroke spent a significantly higher proportion of their walking time in lower self-selected cadences compared to the controls. Conclusions: Community dwelling stroke survivors spent more time sedentary, took fewer steps and walked at a slower self-selected cadence. Interventions to increase walking and reduce sedentary time following stroke are required which may have the added benefit of reducing cardiovascular risk in this group. Implications for Rehabilitation Stroke survivors are predisposed to reduced physical activity and increased cardiovascular risk. This study showed that community dwelling stroke survivors spent more time sedentary, took fewer steps and walked at a slower self-selected cadence. Interventions are required which focus on reducing sedentary time as well as increasing step counts in people following stroke.

Dose–response effects of customised foot orthoses on lower limb muscle activity and plantar pressures in pronated foot type

Customised foot orthoses (FOs) featuring extrinsic rearfoot posting are commonly prescribed for individuals with a symptomatic pronated foot type. By altering the angle of the posting it is purported that a controlled dose-response effect during the stance phase of gait can be achieved, however these biomechanical changes have yet to be characterised. Customised FOs were administered to participant groups with symptomatic pronated foot types and asymptomatic normal foot types. The electromyographic (EMG) and plantar pressure effects of varying the dose were measured. Dose was varied by changing the angle of posting from 6° lateral to 10° medial in 2° steps on customised devices produced using computer aided orthoses design software. No effects due to posting level were found for EMG variables. Significant group effects were seen with customised FOs reducing above knee muscle activity in pronated foot types compared to normal foot types (biceps femoris p=0.022; vastus lateralis p<0.001; vastus medialis p=0.001). Interaction effects were seen for gastrocnemius medialis and soleus. Significant linear effects of posting level were seen for plantar pressure at the lateral rearfoot (p=0.001), midfoot (p<0.001) and lateral forefoot (p=0.002). A group effect was also seen for plantar pressure at the medial heel (p=0.009). This study provides evidence that a customised FOs can provide a dose response effect for selected plantar pressure variables, but no such effect could be identified for muscle activity. Foot type may play an important role in the effect of customised orthoses on activity of muscles above the knee.

A reliability study of biomechanical foot function in psoriatic arthritis based on a novel multi-segmented foot model

The objective of this study was to determine the within-and between-day reliability of spatio-temporal, plantar pressure, kinematic and kinetic measurements based on a novel, seven segment foot model applied in patients with Psoriatic Arthritis (PsA). Nine PsA patients and matched healthy adult controls underwent three-dimensional gait analysis on two occasions, one week apart using a seven segment foot model. A core-set of functional variables including inter-segment kinematics, kinetics, spatio-temporal and plantar pressure distribution were analysed using the coefficient of multiple correlation (CMC), Bland-Altman plots, intraclass correlation coefficients (ICC) and the standard error of measurement (SEM). Results showed excellent within- and between-day reliability for intersegment kinematic and kinetic data patterns with CMC values typically greater than 0.950 in a clinically stable cohort of PsA patients. Between-day reliability ranged from poor to excellent for absolute CMC values. Corrected CMC values were consistently higher across all variables ranging from fair-to-good to excellent. ICC values indicated excellent reliability for discrete spatio-temporal, plantar pressure, and ankle moment and power variables for both groups. Reliability for ground reaction forces and kinematic discrete variables ranged from fair-to-good to excellent. Standard error of measurement values ranged from 0.7° to 3.0° for discrete kinematic variables across both groups with greater variability in the PsA patients. In conclusion, intersegment kinematics and kinetics as well as spatio-temporal and plantar pressure can be reliably measured in PsA patients using a novel seven segment foot model. Some discrete kinematic variables have poor reliability and should not be used in prospective cohort and intervention studies.