Hélène Corriveau

Gait in the elderly

Abstract Walking is one of the most common of all human movements. It exists to transport the body safely and efficiently across ground level, uphill or downhill. Walking is learned during the first year of life and reaches maturity around 7 until 60 years. Elderly walking performance then starts to decline and the elderly slow down gradually. Falls are a major cause of morbidity in the elderly and in almost all incidences of falls, some aspects of locomotion have been implicated. With the increased life expectancy of the elderly and their more active lifestyle there is now an emphasis on determining any changes that occur in their gait patterns in order to reduce the frequency of falls, to identify diagnostic measures that are reliable predictors of fall-prone elderly and finally to develop programs for preventing such falls. This review addresses the gait related changes in the elderly in order to pinpoint the effect of normal aging for comparison with different gait deviations related to some pathologies. Spatio-temporal, kinematics, kinetics and EMG data will be reviewed as well as the physiological changes associated with gait and aging. Finally, the selection criteria will be reviewed and recommendation on the urgent need of a valid healthy elderly database will be addressed.

Screening older adults at risk of falling with the Tinetti balance scale

In a prospective study of 225 community dwelling people 75 years and older, we tested the validity of the Tinetti balance scale to predict individuals who will fall at least once during the following year. A score of 36 or less identified 7 of 10 fallers with 70% sensitivity and 52% specificity. With this cut-off score, 53% of the individuals were screened positive and presented a two-fold risk of falling. These characteristics support the use of this test to screen older people at risk of falling in order to include them in a preventive intervention.

A randomized controlled trial of home telerehabilitation for post-knee arthroplasty

We compared the effectiveness of home telerehabilitation with conventional rehabilitation following knee replacement surgery (total knee arthroplasty, TKA). Forty-eight patients (mean age 66 years) who received TKA were recruited prior to discharge from hospital after surgery and were randomly assigned to telerehabilitation or usual care. Telerehabilitation sessions (16 per participant over two months) were conducted by trained physiotherapists using videoconferencing to the patients home via an Internet connection (512 kbit/s upload speed). Disability and function were measured using standardized outcome measures in face-to-face evaluations at three times (prior to and at the end of treatment, and four months after the end of treatment). Clinical outcomes improved significantly for all subjects in both groups between endpoints. Some variables showed larger improvements in the usual care group two months post-discharge from therapy than in the telerehabilitation group. Home telerehabilitation is at least as effective as usual care, and has the potential to increase access to therapy in areas with high speed Internet services.

Effectiveness of unilateral and symmetrical bilateral task training for arm during the subacute phase after stroke: a randomized controlled trial

Objective: To evaluate the effect of an arm training programme combining repetition of unilateral and symmetrical bilateral tasks for people in the subacute phase after stroke. Design: Randomized controlled trial. Setting: Inpatient functional rehabilitation unit. Subjects: Forty-one people who had had a stroke, in the subacute phase, receiving conventional arm occupational and physical therapy, were randomized to an experimental group (n=20) and a control group (n=21). Interventions: In addition to the usual arm therapy in the rehabilitation unit, the experimental group received an arm therapy programme (15-20 45-min sessions) based on repetition of unilateral and symmetrical bilateral tasks. The control group received additional usual arm therapy of a similar duration and frequency to the experimental treatment. Main measures: The effect of the programme was judged on the basis of: (1) arm impairments (motor function, grip strength, gross and fine manual dexterity and motor co-ordination), (2) arm disabilities in tasks related to daily activities, and (3) functional independence in activities of daily living (ADL) and instrumental ADL (IADL). Results: Although both experimental and control groups of participants improved similarly during the study period, the statistical analyses did not show any difference between the groups at the end of the treatment for the different dependent variables evaluated: (1) arm impairments: p=0.43-0.79; (2) arm disabilities: p=0.16-0.90; and (3) functional independence: p=0.63 and 0.90. Conclusions: An arm training programme based on repetition of unilateral and symmetrical bilateral practice did not reduce impairment and disabilities nor improve functional outcomes in the subacute phase after stroke more than the usual therapy.

Moving Forward in Fall Prevention: An Intervention to Improve Balance Among Older Adults in Real-World Settings

OBJECTIVES We investigated the effectiveness of a group-based exercise intervention to improve balancing ability among older adults delivered in natural settings by staff in local community organizations. METHODS The main component of the intervention consisted of biweekly group-based exercise sessions conducted over 12 weeks by a professional, coupled with home-based exercises. In a quasiexperimental design, 10 community organizations working with older adults offered the intervention to groups of 5 to 15 persons concerned about falls, while 7 organizations recruited similar groups to participate in the control arm of the study. Participants (98 experimental and 102 control) underwent balance assessments by a physiotherapist at registration and 3 months later. RESULTS Eighty-nine percent of participants attended the 3-month measurement session (n=177). A linear regression analysis showed that after adjusting for baseline levels of balance and demographic and health characteristics, the intervention significantly improved static balance and mobility. CONCLUSION Structured, group-based exercise programs offered by community organizations in natural settings can successfully increase balancing ability among community-dwelling older adults concerned about falls.

A qualitative study of in-home robotic telepresence for home care of community-living elderly subjects.

We examined the requirements for robots in home telecare using two focus groups. The first comprised six healthcare professionals involved in geriatric care and the second comprised six elderly people with disabilities living in the community. The concept of an in-home telepresence robot was illustrated using a photograph of a mobile robot, and participants were then asked to suggest potential health care applications. Interview data derived from the transcript of each group discussion were analyzed using qualitative induction based on content analysis. The analyses yielded statements that were categorized under three themes: potential applications, usability issues and user requirements. Teleoperated mobile robotic systems in the home were thought to be useful in assisting multidisciplinary patient care through improved communication between patients and healthcare professionals, and offering respite and support to caregivers under certain conditions. The shift from a traditional hospital-centred model of care in geriatrics to a home-based model creates opportunities for using telepresence with mobile robotic systems in home telecare.

In home telerehabilitation for older adults after discharge from an acute hospital or rehabilitation unit: A proof-of-concept study and costs estimation

Purpose.The purpose of this study is to investigate rehabilitation through teletreatment as an alternative to a physical home-care visit to deliver services to individuals at home following discharge from an acute hospital or rehabilitation unit. Method.Four community-living elderly people were recruited for telerehabilitation services prior being discharged from an acute-care hospital and a geriatric rehabilitation unit. Once the patient returned home, an appointment was made for the assessing therapist to take the clinical measurements (T1) in a face-to-face session. Four clinical variables were used (functional autonomy, balance, locomotor performance in walking and lower-body strength). Telerehabilitation sessions with the participants were conducted with trained personnel in the individuals home. The system used to support telerehabilitation services for this proof of concept was built around network-attached remotely-controlled pan/tilt/zoom cameras with MJPEG compression, media displays and hands-free phones. Before the patient was discharged from the physiotherapy program, the same assessing therapist visited the subject again to take the T2 measurements in a face-to-face session. The satisfaction of the health-care professional was determined for each session with the homemade questionnaire. Costs related to telerehabilitation were compared to theoretically home visits. Results.All four subjects improved on the four clinical variables. Mean costs for the telerehabilitation program, comprising 12 sessions over 4 weeks was

In-Home Telerehabilitation Compared with Face-to-Face Rehabilitation After Total Knee Arthroplasty: A Noninferiority Randomized Controlled Trial.

487. Conclusion.Telerehabilitation seems to be a practical alternative for dispensing rehabilitation services after patients are discharged from an acute hospital or rehabilitation unit.

Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial

BACKGROUND The availability of less resource-intensive alternatives to home visits for rehabilitation following orthopaedic surgeries is important, given the increasing need for home care services and the shortage of health resources. The goal of this trial was to determine whether an in-home telerehabilitation program is not clinically inferior to a face-to-face home visit approach (standard care) after hospital discharge of patients following a total knee arthroplasty. METHODS Two hundred and five patients who had a total knee arthroplasty were randomized before hospital discharge to the telerehabilitation group or the face-to-face home visit group. Both groups received the same rehabilitation intervention for two months after hospital discharge. Patients were evaluated at baseline (before total knee arthroplasty), immediately after the rehabilitation intervention (two months after discharge), and two months later (four months after discharge). The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire at the last follow-up evaluation. Secondary outcome measures included the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, functional and strength tests, and knee range of motion. The noninferiority margin was set at 9% for the WOMAC. RESULTS The demographic and clinical characteristics of the two groups of patients were similar at baseline. At the last follow-up evaluation, the mean differences between the groups with regard to the WOMAC gains, adjusted for baseline values, were near zero (for 182 patients in the per-protocol analysis): -1.6% (95% confidence interval [CI]: -5.6%, 2.3%) for the total score, -1.6% (95% CI: -5.9%, 2.8%) for pain, -0.7% (95% CI: -6.8%, 5.4%) for stiffness, and -1.8% (95% CI: -5.9%, 2.3%) for function. The confidence intervals were all within the predetermined zone of noninferiority. The secondary outcomes had similar results, as did the intention-to-treat analysis, which was conducted afterward for 198 patients. CONCLUSIONS Our results demonstrated the noninferiority of in-home telerehabilitation and support its use as an effective alternative to face-to-face service delivery after hospital discharge of patients following a total knee arthroplasty. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Effects of orthopaedic immobilization of the right lower limb on driving performance: an experimental study during simulated driving by healthy volunteers.

Purpose: To compare the effectiveness of supervised Tai Chi exercises versus the conventional physical therapy exercises in a personalized rehabilitation program in terms of the incidence and severity of falls in a frail older population. Method: The participants were frail older adults living in the community, admitted to the day hospital program in Sherbrooke, Quebec, Canada (n = 152). They were randomized to receive a 15-week intervention, either by supervised Tai Chi exercises (n = 76) or conventional physical therapy (n = 76). Fall incidence and severity were assessed using both the calendar technique and phone interviews once a month during 12 months following the end of the intervention. Other variables were collected at baseline to compare the two groups: age, comorbidity, balance, sensory interaction on balance, and self-rated health. Results: Both interventions demonstrated a protective effect on falls but Tai Chi showed a greater one (RR = 0.74; 95% CI = 0.56–0.98) as compared to conventional physical therapy exercises. Conclusions: Supervised Tai Chi exercises as part of a rehabilitation program seem to be a more effective alternative to the conventional physical therapy exercises for this specific population. Implications for Rehabilitation Seniors who have fallen have a 50% chance of falling again during the following year, leading them to reduce their outings and thus decrease their social activities. Frail older people could benefit more from an individualized intervention than the regular group program generally used in a Tai Chi intervention. Tai Chi exercises seems to be a good alternative to regular physiotherapy exercises as a part of a multidisciplinary intervention in preventing a subsequent fall over a 12-month period.