Helene Henson

Performance-based gait tests for acute stroke patients

OBJECTIVE Qualitative measures may not differentiate severity of deficits after an acute or subacute stroke. The aim of this study was to contrast the utility of performance-based gait tests with qualitative measures in a sample of acute stroke patients. DESIGN Twenty acute stroke subjects had their performance-based gait measured by gait speed, walking distance, gait energy expenditure, and gait energy cost. They were also qualitatively evaluated for cognition, functional outcomes, motor impairment, and Functional Ambulation Category. RESULTS Strong and significant correlations were observed among performance-based gait tests. Qualitative scales indicated moderate to minimal deficits in each domain evaluated, although they were not correlated among themselves, except for Functional Ambulation Category and FIM and FIM and Mini-Mental State Exam. Functional Ambulation Category correlated with performance-based gait tests. CONCLUSIONS Performance-based gait tests are feasible to conduct during early recovery after a stroke and allow better discrimination among the patients than qualitative measures.

Reliability of measures of gait performance and oxygen consumption with stroke survivors.

The measurement of physical activity, especially walking activity, is important for many outcome studies. In many investigations, the Physical Activity scale of the short-form-36 (SF-36) health assessment questionnaire is used in lieu of an actual physical measurement of walking. This study determined the relationship between the SF-36 questionnaire and the Step Activity Monitor (SAM), a real-world performance-based tool that counts the actual number of steps taken during daily activities. We studied the physical activity of 57 men with diabetes using step count monitoring and the SF-36 questionnaire. The subjects averaged 3,293 steps/day, but had a very wide range (111-11,654) and a large standard deviation (SD = 2,037). The correlations between total daily steps and the SF-36 Physical Component Summary score, and the Physical Function, Bodily Pain, and Vitality scales of the SF-36 were only fair (Pearsons r = 0.376, 0.488, 0.332, 0.380, respectively). The corresponding coefficients of determination range from only 7.7% to 23.8%. Physical activity is a complex concept not completely represented by either the SF-36 or the step counts. The correlation between actual walking activity and the SF-36 is not as strong as many researchers believe. Caution should be exercised with the use of the SF-36 to specifically measure walking activity.This study assessed the reliability of gait performance with concurrent measures of oxygen consumption (VO2) in stroke survivors (SS). Nine male SS (60.00 +/- 15.08 yr) had a recent history of stroke (44.56 +/- 51.35 days since the stroke) and were receiving rehabilitation. Four had a right cerebrovascular accident (CVA), and five had a left CVA. Subjects walked without assistance, although three used a single cane to complete the test. Within 30 minutes, subjects completed two trials of a 5 min walk while walking back and forth on a 5 m walkway wearing a portable gas analyzer to collect samples of gases. The intraclass correlation coefficient (ICC) was used to assess reliability. The ICC for gait energy expenditure, walk distance, gait speed, and gait energy cost were 0.64, 0.97, 0.95, and 0.97, respectively. Assessment of gait performance with concurrent measures of VO2 is a reliable procedure with SS.

Differential responses to measures of gait performance among healthy and neurologically impaired individuals

OBJECTIVES To compare gait during a 5-minute walk among healthy individuals, persons with spinal cord injury (SCI), and stroke survivors and to investigate whether simultaneous measures of oxygen consumption enhance information about performance. DESIGN Descriptive study. SETTING Veterans Affairs medical center. PARTICIPANTS Thirty-nine healthy individuals, 10 persons with SCI, and 20 stroke survivors. INTERVENTIONS Participants were fitted with a portable gas analyzer and walked on a 5-m walkway for 5 minutes. MAIN OUTCOME MEASURES Measures of walk distance, gait speed, gait energy expenditure (GEE), and gait cost were obtained, along with measures of ventilation (.Ve), ventilation and carbon dioxide production slope (.Ve . .VCo2), oxygen pulse, and heart rate. RESULTS The SCI group (127.65+/-81.74m) walked less than the stroke survivors (148.80+/-64.3m) or the healthy group (268.90+/-35.01m) but had higher energy demands, as shown by GEE (SCI group, 13.28+/-3.23mL.kg(-1).min(-1); stroke group, 10.18+/-2.14mL.kg(-1).min(-1); healthy group, 9.61+/-1.90mL.kg(-1).min(-1)) and by gait cost (SCI group,.57+/-.40 mL.kg(-1).m(-1); stroke group,.40+/-.52mL.kg(-1).m(-1); healthy group,.18+/-.02mL.kg(-1).m(-1)). Compared with the healthy group, the stroke group had higher .Ve (stroke group, 22.34+/-5.20L/min vs healthy group, 16.11+/-3.22L/min) and .Ve . .VCo2 slope (24.22+/-8.80 vs 18.73+/-5.44, respectively). CONCLUSION Use of metabolic assessment during the 5-minute walk was feasible and provided further information for evaluating gait performance with the subjects studied.

Telerehabilitation for veterans with a lower-limb amputation or ulcer: Technical acceptability of data

A study was undertaken to determine the technical acceptability of information available via a customized telerehabilitation system regarding patients with lower-limb ulcers or recent lower-limb amputations receiving care at a Veterans Affairs Medical Center. Among the 54 participants, 57 wounds (39 ulcers, 19 amputation incisions) were evaluated by means of still photographs and skin temperature data sent via ordinary telephone lines. Three experienced clinicians served as raters. Intrarater agreements and McNemar chi(2) tests were assessed between decisions made after telerehabilitation sessions and decisions made by the same rater after in-person sessions. Interrater agreements and kappa coefficients were assessed between two raters for both telerehabilitation and in-person sessions. The intrarater agreement on 57 wounds for the primary rater was 93%, and the McNemar test indicated no significant difference in the ratings (p < 0.63). Interrater agreement on 18 wounds was 78% (kappa = 0.55, p < 0.02) for the telerehabilitation sessions and 89% (kappa = 0.77, p < 0.001) for the in-person sessions. Most qualitative comments by three clinicians on picture quality (54/63 = 86%) and temperature data (39/44 = 88%) were favorable (good to excellent). The information yielded from this study provides evidence that the telerehabilitation system has the potential to present sufficient information to experienced clinicians so they can make informed decisions regarding wound management. The next phase of the study will include in-home trials and improvements in the technology.

Association of hemoglobin levels, acute hemoglobin decrease, age, and co-morbidities with rehabilitation outcomes after total knee replacement.

Wang X, Rintala DH, Garber SL, Henson H: Association of hemoglobin levels, acute hemoglobin decrease, age, and co-morbidities with rehabilitation outcomes after total knee replacement. Am J Phys Med Rehabil 2005;84:451–456. Objective:A study was undertaken to assess the association of preoperative and postoperative hemoglobin levels with rehabilitation outcomes, age, and selected co-morbidities Design:Charts of 49 patients admitted to rehabilitation after total knee arthroplasty due to degenerative joint disease were reviewed. Outcome measures included rehabilitation admission and discharge motor FIM™ scores, motor FIM gain, and rehabilitation length of stay. Results:Patients with higher preoperative hemoglobin levels had higher rehabilitation admission motor FIM scores (r = 0.38, P < 0.01) and lower motor FIM gains (r = −0.45, P < 0.001). Patients who had higher hemoglobin levels at rehabilitation admission had higher admission motor FIM scores and shorter length of stay. Patients with diabetes had lower preoperative hemoglobin levels. Patients with hypertension had longer length of stay. Older patients had lower admission and discharge motor FIM scores and longer length of stay. Conclusions:Patients admitted to rehabilitation after total knee replacement have the potential to improve motor function, regardless of their preoperative and rehabilitation admission hemoglobin levels and the decrease in hemoglobin levels. However, those admitted to rehabilitation with lower hemoglobin levels, those with lower admission motor FIM scores, those who are older, and those who have hypertension may expect longer hospital stays to reach their functional goals.

Combat Exposure, PTSD Symptoms, and Cognition Following Blast-Related Traumatic Brain Injury in OEF/OIF/OND Service Members and Veterans

Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are frequently documented among the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans. This study will investigate both combat exposure and PTSD as factors that may influence objective cognitive outcomes following blast-related mild TBI (mTBI). Participants included 54 OEF/OIF/OND veterans who had been exposed to blast and reported symptoms consistent with mTBI and 43 combat-deployed control participants who had no history of blast exposure or TBI. Raw scores from the Controlled Oral Word Association Test, Trail Making Test, Color-Word Interference Test, and Verbal Selective Reminding Test were used to measure cognitive functioning. All participants demonstrated adequate effort on the Word Memory Test. Demographics, injury characteristics, overall intellectual functioning, and total scores from the PTSD Checklist-Civilian Version (PCL-C) and Combat Exposure Scale (CES) were used as the predictors for each cognitive measure. History of mTBI was significantly associated with higher PCL-C and CES scores. Multivariable linear regression, however, showed no significant differences in cognitive performance between groups. The absence of effect of mTBI, PTSD, and combat exposure on cognitive functioning noted in this study may be partially explained by the inclusion of only those participants who passed performance validity testing.

Cost-effectiveness of Revascularization for Limb Preservation in Patients with Marginal Functional Status

BACKGROUND Revascularization and limb salvage attempts are often offered to patients with foot wounds and chronic limb ischemia who are thought to be good-risk candidates, but some skepticism remains about the utility of these efforts for elderly patients with marginal functional status. We sought to determine whether limb preservation efforts in this population could be justified from a patient-centered, cost-effectiveness perspective. METHODS A probabilistic Markov model was used to simulate the clinical outcomes, health utilities, and costs over a 10-year period with various management strategies. Clinical parameter estimates were obtained from previous clinical trials and large observational series. Cost estimates were obtained from cost literature and also a single-center study that reviewed total costs accumulated (including secondary amputations, wound care, outpatient nursing care, and nursing home costs). Cost (in 2011 U.S. dollars) per year of ambulation (with limb preservation or with a prosthesis after amputation) was the primary measure of cost-effectiveness. RESULTS The total 10-year costs of revascularization--either endovascular or surgical--were lower than the costs of either local wound care alone or primary amputation. Revascularization strategies also produced more health benefits as measured in terms of years of ambulatory ability, years of limb salvage, or quality-adjusted life-years. In none of the scenarios modeled in deterministic sensitivity analyses did primary amputation prove to be cost-effective. CONCLUSIONS Revascularization and limb preservation attempts appear less costly and provide more health benefits than wound care alone or primary amputation, even among patients with marginal functional status at baseline.

Acute and Long-Term Effects of Multidirectional Treadmill Training on Gait and Balance in Parkinson Disease

Treadmill training has been shown to be a promising rehabilitation strategy for improving gait and balance in persons with Parkinson disease (PD). Most studies have involved only forward walking as an intervention. The effects of multidirectional treadmill (forward, backward, and left and right sideways) on gait and balance have not been reported.

Ambulation and independence among Veterans with nontraumatic bilateral lower-limb loss.

In describing functional outcomes and independent living in a cohort of bilateral major amputees, we sought to provide current estimates of function and independence after a second major amputation in an elderly Veteran population with peripheral arterial disease and/or diabetes. After retrospectively reviewing and excluding the electronic health records of those failing to meet the inclusion criteria, we identified 40 patients with a history of unilateral major amputation who underwent a second major amputation during the defined study period. Of these, 43% (17) were bilateral transfemoral amputations (TFAs); bilateral transtibial amputations (TTAs) and TFA-TTA accounted for the rest (33% and 25%, respectively). Of the 19 (48%) patients who were ambulatory prior to bilateral amputation, only 2 (11%) remained ambulatory after the second amputation, while 17 (89%) patients lost ambulatory capabilities. Compared with those who were </=65 yr, those between 66 and 79 yr were 18% less likely to ambulate precontralateral amputation (p = 0.03). All patients with bilateral TFA were nonambulatory. Independence postcontralateral amputation decreased from 88% (35) to 53% (21). When data were available (58%), pre and post Functional Independence Measure scores showed a decrease in 74% of patients, while 22% showed an increase. In conclusion, bilateral lower-limb amputation among dysvascular Veterans is highly associated with a loss of ambulation.

Reliability of a portable gas analyzer during a 5-min walk test.

Cunha-Filho IT, Henson H, Protas EJ: Reliability of a portable gas analyzer during a 5-min walk test. Am J Phys Med Rehabil 2007;86:469–473. Objective:To determine the reliability of a gas analyzer while assessing oxygen consumption (&OV0312;O2) during a 5-min walking test. Design:Forty healthy participants were connected to the KB1-C and walked for 5 mins on a 5-m walkway. Total &OV0312;O2 or energy expenditure (EE) was obtained by averaging the samples for each minute for 5 mins of walking. Walk distance (D), gait speed (S), and gait energy cost (C) were also evaluated. Results:The ICC2,1 for EE, D, S, and C were 0.88, 0.92, 0.92, and 0.67, respectively. The coefficient of variation across trials for each variable was 7.4, 3.6, 3.2, and 9%, respectively. Conclusion:All but C generated high coefficients of reliability. All variables demonstrated acceptable test–retest variability. There was low variability between participants for C.