Jaclyn Megan Sions

Age- and stroke-related skeletal muscle changes: a review for the geriatric clinician.

Independently, aging and stroke each have a significant negative impact on skeletal muscle, but the potential cumulative effects of aging and stroke have not been explored. Optimal interventions for individuals post stroke may include those that specifically target skeletal muscle. Addressing changes in muscles may minimize activity limitations and enhance participation post stroke. This article reviews the impact of aging and stroke on muscle morphology and composition, including fiber atrophy, reductions in muscle cross-sectional area, changes in muscle fiber distributions, and increases in intramuscular fat. Relationships between changes in muscle structure, muscle function, and physical mobility are reviewed. Clinical recommendations that preserve and enhance skeletal muscle in the aging adult and individuals post stroke are discussed. Future research directions that include systematic comparison of the differences in skeletal muscle between younger and older adults who have sustained a stroke are suggested.

Trunk Muscle Training Augmented With Neuromuscular Electrical Stimulation Appears to Improve Function in Older Adults With Chronic Low Back Pain: A Randomized Preliminary Trial.

Objectives:To assess the feasibility of a trial to evaluate a trunk muscle training program augmented with neuromuscular electrical stimulation (TMT+NMES) for the rehabilitation of older adults with chronic low back pain (LBP) and to preliminarily investigate whether TMT+NMES could improve physical function and pain compared with a passive control intervention. Materials and Methods:We conducted a single-blind, randomized feasibility trial. Patients aged 60 to 85 years were allocated to TMT+NMES (n=31) or a passive control intervention (n=33), consisting of passive treatments, that is, heat, ultrasound, and massage. Outcomes assessed 3- and 6-month postrandomization included Timed Up and Go Test, gait speed, pain, and LBP-related functional limitation. Results:Feasibility was established by acceptable adherence (≥80%) and attrition (<20%) rates for both interventions. Both groups had similar, clinically important reductions in pain of >2 points on a numeric pain rating scale during the course of the trial. But, only the TMT+NMES group had clinically important improvements in both performance-based and self-reported measures of function. In terms of the participants’ global rating of functional improvement at 6 months, the TMT+NMES group improved by 73.9% and the passive control group improved by 56.7% compared with baseline. The between-group difference was 17.2% (95% confidence interval, 5.87-28.60) in favor of TMT+NMES. Discussion:It seems that a larger randomized trial investigating the efficacy of TMT+NMES for the purpose of improving physical function in older adults with chronic LBP is warranted.

Trunk Muscle Size and Composition Assessment in Older Adults with Chronic Low Back Pain: An Intra-Examiner and Inter-Examiner Reliability Study.

OBJECTIVE To evaluate intra- and inter-examiner reliability for the assessment of relative cross-sectional area, muscle-to-fat infiltration indices, and relative muscle cross-sectional area, i.e., total cross-sectional area minus intramuscular fat, from T1-weighted magnetic resonance images obtained in older adults with chronic low back pain. DESIGN Reliability study. SUBJECTS n = 13 (69.3 ± 8.2 years old) METHODS After lumbar magnetic resonance imaging, two examiners produced relative cross-sectional area measurements of multifidi, erector spinae, psoas, and quadratus lumborum by tracing regions of interest just inside fascial borders. Pixel-intensity summaries were used to determine muscle-to-fat infiltration indices; relative muscle cross-sectional area was calculated. Intraclass correlation coefficients were used to estimate intra- and inter-examiner reliability; standard error of measurement was calculated. RESULTS Intra-examiner intraclass correlation coefficient point estimates for relative cross-sectional area, muscle-to-fat infiltration indices, and relative muscle cross-sectional area were excellent for multifidi and erector spinae across levels L2-L5 (ICC = 0.77-0.99). At L3, intra-examiner reliability was excellent for relative cross-sectional area, muscle-to-fat infiltration indices, and relative muscle cross-sectional area for both psoas and quadratus lumborum (ICC = 0.81-0.99). Inter-examiner intraclass correlation coefficients ranged from poor to excellent for relative cross-sectional area, muscle-to-fat infiltration indices, and relative muscle cross-sectional area. CONCLUSIONS Assessment of relative cross-sectional area, muscle-to-fat infiltration indices, and relative muscle cross-sectional area in older adults with chronic low back pain can be reliably determined by one examiner from T1-weighted images. Such assessments provide valuable information, as muscle-to-fat infiltration indices and relative muscle cross-sectional area indicate that a substantial amount of relative cross-sectional area may be magnetic resonance-visible intramuscular fat in older adults with chronic low back pain.

Criterion Validity of Ultrasound Imaging: Assessment of Multifidi Cross-sectional Area in Older Adults With and Without Chronic Low Back Pain.

Background and Purpose: Ultrasound (US) imaging may be a cost-conscious alternative to magnetic resonance imaging (MRI), which is the criterion standard for muscle cross-sectional area (CSA) assessment. Within the trunk, when compared with MRI, US has been shown to be valid for assessing lumbar multifidi CSA in younger, asymptomatic individuals. To date, there are no studies validating US for multifidi CSA assessment in older adults or individuals with low back pain. Given age- and pain-related muscle changes, validation of US is needed in these populations. If valid for multifidi CSA assessment, US may be used to evaluate short-term changes in muscle size in response to exercise-based interventions among older adults. The primary objective of this study was to evaluate the validity of US for multifidi CSA assessment as compared with MRI in older adults with and without chronic low back pain (CLBP). The secondary objective was to determine whether a single US image was valid for assessment of multifidi CSA or whether the average of 3 US images should be recommended. Methods: Twenty community-dwelling older adults (ie, 10 with and 10 without CLBP), ages 60 to 85 years, were recruited. US images and MRI slices of multifidi muscle were obtained and L4 multifidi CSAs were measured. Intraclass correlation coefficients (ICCs) were calculated to assess agreement between MRI measures and a single US image and MRI measures and the average of 3 US images. Results and Discussion: ICC point estimates were excellent for older adults with CLBP for a single US image (ICCs = 0.90-0.97), but ICC point estimates for participants without CLBP ranged from fair to excellent (ICCs = 0.48-0.86). ICC point estimates for the average of 3 US images for both groups were better than for a single image (ICCs = 0.95-0.99). Conclusions: For assessment of L4 multifidi CSA, US is a valid alternative to MRI for older adults with and without CLBP. However, limitations of US, such as the inability to quantify intramuscular fat, which may be increased with aging and CLBP, should be considered. CSA measurement of 3 US images, rather than a single image, is recommended.

Step count accuracy of StepWatch and FitBit One™ among individuals with a unilateral transtibial amputation

Background: Step counts, obtained via activity monitors, provide insight into activity level in the free-living environment. Accuracy assessments of activity monitors are limited among individuals with lower-limb amputations. Objectives: (1) To evaluate the step count accuracy of both monitors during forward-linear and complex walking and (2) compare monitor step counts in the free-living environment. Study design: Cross-sectional study. Methods: Adult prosthetic users with a unilateral transtibial amputation were equipped with StepWatch and FitBit One™. Participants completed an in-clinic evaluation to evaluate each monitor’s step count accuracy during forward linear and complex walking followed by a 7-day step count evaluation in the free-living environment. Results: Both monitors showed excellent accuracy during forward, linear walking (intraclass correlation coefficients = 0.97–0.99, 95% confidence interval = 0.93–0.99; percentage error = 4.3%–6.2%). During complex walking, percentage errors were higher (13.0%–15.5%), intraclass correlation coefficients were 0.88–0.90, and 95% confidence intervals were 0.69–0.96. In the free-living environment, the absolute percentage difference between monitor counts was 25.4%, but the counts had a nearly perfect linear relationship. Conclusion: Both monitors accurately counted steps during forward linear walking. StepWatch appears to be more accurate than FitBit during complex walking but a larger sample size may confirm these findings. FitBit consistently counted fewer steps than StepWatch during free-living walking. Clinical relevance The StepWatch and FitBit are acceptable tools for assessing forward, linear walking for individuals with transtibial amputation. Given the results’ consistenty in the free-living enviorment, both tools may ultimiately be able to be used to count steps in the real world, but more research is needed to confirm these findings.

Balance-confidence is associated with community participation, perceived physical mobility, and performance-based function among individuals with a unilateral amputation

ABSTRACT Objective To explore relationships between balance-confidence and: 1) community participation; 2) self-perceived mobility; and 3) performance-based physical function among individuals with a lower-limb amputation using a prosthetic. Design: Retrospective, cross-sectional study. Setting: Outpatient, multidisciplinary amputee clinic. Participants: Patients (n = 45) using a prosthesis, aged ≥ 18 years, with a unilateral transfemoral or transtibial amputation of ≥1 year, were included. Methods: Participants completed the following self-report measures: Activities-Specific Balance Confidence Scale (ABC); Community Integration Questionnaire (CIQ); Locomotor Capabilities Index (LCI); and two performance-based measures (i.e. Timed Up and Go and 6 Minute Walk Test). Linear regression modeling was used to explore relationships between balance-confidence (i.e. ABC) and self-report (i.e. CIQ and LCI) and performance-based measures (p ≤ 0.0125). Results: After controlling for potential covariates (i.e. age, sex, and body mass index), balance-confidence explained 47.4% of the variance in CIQ (p = 0.000), 53.0% of the variance in LCI (p = 0.000), 20.3% of the variance in Timed Up and Go (p = 0.001), and 18.2% of the variance in 6 Minute Walk Test (p = 0.001). Conclusion: Lower balance-confidence is associated with less community participation, lower self-perceived mobility, and poorer performance among patients with a unilateral lower-limb amputation.

Self-Reported Functional Mobility, Balance Confidence, and Prosthetic Use Are Associated With Daily Step Counts Among Individuals With a Unilateral Transtibial Amputation

BACKGROUND Adults postamputation are not meeting physical activity recommendations. Physical activity is an important consideration in prosthetic prescription. The objective of this study was to determine if functional mobility, balance confidence, and prosthetic use are associated with physical activity among adults with a lower-limb amputation. METHODS This study recruited patients aged 18-85 years with unilateral transtibial amputations. The Cumulative Illness Rating Scale was used to determine comorbidity burden. Participants completed the Prosthetic Evaluation Questionnaire-Mobility Section, Activities-specific Balance Confidence Scale, and Houghton Scale of Prosthetic Use and wore a StepWatch monitor for 7 days to obtain daily step counts. Linear regression was used to evaluate relationships between each self-report measure and step counts after controlling for covariates, that is, sex, age, time since initial amputation, and comorbidity burden. RESULTS Forty-seven participants had ≥5 days of step data and were included in this analysis. The Prosthetic Evaluation Questionnaire-Mobility Section [mean (SD): 35.0 (9.6) points] and Activities-specific Balance Confidence Scale [79.2% (15.9%)] each explained 13% of the variance in step count [5491 (4043) steps], whereas the Houghton Scale of Prosthetic Use [10.3 (1.2) points] explained 10% of the variance. CONCLUSION Self-reported functional mobility, balance confidence, and prosthetic use predict short-term average daily step counts as determined from research-grade accelerometers.

Differences in Physical Performance Measures Among Patients With Unilateral Lower-Limb Amputations Classified as Functional Level K3 Versus K4

OBJECTIVE To determine whether differences in physical function, assessed via self-report questionnaires and physical performance tests, exist between individuals with lower-limb loss using a prosthetic device classified as a K3 versus a K4 functional level. DESIGN Cross-sectional study. SETTING A university physical therapy amputee clinic. PARTICIPANTS Participants (N=55) were included if they (1) were aged ≥18 years with a unilateral transfemoral or transtibial amputation; (2) were classified as K3 or K4 functional level; (3) completed all relevant outcome measures; and (4) were currently using a prosthesis. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Locomotor Capabilities Index (LCI), Prosthetic Evaluation Questionnaire-Mobility Section (PEQ-MS), Timed Up and Go (TUG), 10-Meter Walk Test (10MWT), Amputee Mobility Predictor (AMPPRO), and 6-Minute Walk Test (6MWT). K level was determined by group consensus based on a standardized clinical evaluation. RESULTS After controlling for covariates, patients classified as K3 had slower TUG times (P=.002) and self-selected and fast gait speeds (P<.001), lower AMPPRO scores (P<.001), and walked shorter distances during the 6MWT (P=.003) when compared with patients classified as K4. No significant between-group differences for the LCI or PEQ-MS were found. CONCLUSIONS Clinicians involved in prosthetic prescription may consider including the TUG, 10MWT, AMPPRO, and 6MWT during their clinical evaluations to help differentiate between individuals of higher functional mobility. The LCI and PEQ-MS may be less useful in classifying individuals as K3 versus K4 because of a ceiling effect.