Karl Schurr

Observation and analysis of hemiplegic gait: stance phase

People with hemiplegia resulting from cerebrovascular accident commonly demonstrate one or more deviations from the kinematics of normal gait. This paper presents a list of common kinematic deviations for which physiotherapists might look when making clinical observations of hemiplegic gait. A number of likely causes of those kinematic deviations are described, based on a review of the literature, biomechanical considerations and clinical observations. Particularly common and significant stance phase deviations are a decreased peak hip extension in late stance, increased or decreased peak lateral pelvic displacement, increased or decreased knee extension in early or mid stance and decreased plantarflexion at toe-off. The causes of these kinematic deviations lie in the inability to appropriately activate muscles and in the adaptive muscle shortening which commonly occurs following stroke.

Barriers and enablers to implementing multiple stroke guideline recommendations: a qualitative study

BackgroundTranslating evidence into practice is an important final step in the process of evidence-based practice. Medical record audits can be used to examine how well practice compares with published evidence, and identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit.MethodsA qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a group or individual interview. These interviews occurred after staff had received audit feedback and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations about management of: upper limb sensory impairments, mobility including sitting balance; vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and colleagues (2005).ResultsSix group and two individual interviews were conducted, involving six disciplines. Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills required to implement best practice; (5) Intention and motivation to implement best practice, and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists generally knew how to implement best-practice mobility rehabilitation (an enabler).ConclusionsFindings add to current knowledge about barriers to change and implementation of multiple guideline recommendations. Major challenges included sexuality education and depression screening. Limited knowledge and skills was a common barrier. Knowledge about specific interventions was needed before implementation could commence, and to maintain treatment fidelity. The provision of detailed online intervention protocols and manuals may help clinicians to overcome the knowledge barrier.

A novel weight-bearing strengthening program during rehabilitation of older people is feasible and improves standing up more than a non-weight-bearing strengthening program: a randomised trial

QUESTION What is the feasibility and effectiveness of a novel weight-bearing strengthening program compared with that of a traditional non-weight-bearing strengthening program for older inpatients undergoing rehabilitation? DESIGN Randomised, controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS Eighty-eight inpatients (11% loss to follow-up) aged on average 82 years old from three rehabilitation units with no contraindications to exercise. INTERVENTION Both the weight-bearing and non-weight-bearing strengthening programs were supervised by physiotherapists and were of similar intensities (10 to 15 RM) for two weeks. OUTCOME MEASURES The primary outcomes were standing up performance measured as minimum chair height, and strength measured as maximum isometric knee extensor force of both legs. The secondary outcomes were other mobility measures such as standing-up rate, walking, standing and overall mobility, and other strength measures such as maximum isometric hip extensor, hip abductor, and knee flexor force of both legs. RESULTS After the two-week intervention, the weight-bearing strengthening group had decreased their minimum chair height by 5.3 cm (95% CI 0.7 to 9.8) and increased their hip extensor strength on the weaker leg by 9 N (95% CI 1 to 17) more than the non-weight-bearing strengthening group. There were no clinically-worthwhile or statistically-significant differences between the groups for any other measures. CONCLUSION This novel weight-bearing strengthening program was feasible and safe in an inpatient rehabilitation setting and had some additional benefits over a traditional non-weight-bearing strengthening program.

Effect of affordable technology on physical activity levels and mobility outcomes in rehabilitation: a protocol for the Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial

Introduction People with mobility limitations can benefit from rehabilitation programmes that provide a high dose of exercise. However, since providing a high dose of exercise is logistically challenging and resource-intensive, people in rehabilitation spend most of the day inactive. This trial aims to evaluate the effect of the addition of affordable technology to usual care on physical activity and mobility in people with mobility limitations admitted to inpatient aged and neurological rehabilitation units compared to usual care alone. Methods and analysis A pragmatic, assessor blinded, parallel-group randomised trial recruiting 300 consenting rehabilitation patients with reduced mobility will be conducted. Participants will be individually randomised to intervention or control groups. The intervention group will receive technology-based exercise to target mobility and physical activity problems for 6 months. The technology will include the use of video and computer games/exercises and tablet applications as well as activity monitors. The control group will not receive any additional intervention and both groups will receive usual inpatient and outpatient rehabilitation care over the 6-month study period. The coprimary outcomes will be objectively assessed physical activity (proportion of the day spent upright) and mobility (Short Physical Performance Battery) at 6 months after randomisation. Secondary outcomes will include: self-reported and objectively assessed physical activity, mobility, cognition, activity performance and participation, utility-based quality of life, balance confidence, technology self-efficacy, falls and service utilisation. Linear models will assess the effect of group allocation for each continuously scored outcome measure with baseline scores entered as a covariate. Fall rates between groups will be compared using negative binomial regression. Primary analyses will be preplanned, conducted while masked to group allocation and use an intention-to-treat approach. Ethics and dissemination The protocol has been approved by the relevant Human Research Ethics Committees and the results will be disseminated widely through peer-reviewed publication and conference presentations. Trial registration number ACTRN12614000936628. Pre-results.

The Time Use and Activity Levels of Inpatients in a Co-located Acute and Rehabilitation Stroke Unit: An Observational Study

Abstract Purpose: Stroke patients spend a large proportion of their day alone and inactive. In one rehabilitation unit, practice changes had been implemented over several years to improve patient activity levels and practice, yet measures of patient activity had not been recorded. The aim of this study was to obtain baseline measures of the time use and activity levels of inpatients in that co-located acute and rehabilitation stroke unit. Methods: A quantitative observational design was used. The behavior of 11 inpatients was mapped at 15-minute intervals over 4 days between 7 am and 7 pm. Observations were recorded across 7 categories, including physical activity, location and person(s) present, and 42 possible subcategories. Thirteen allied health and nursing professionals were trained to record these observations and interrater reliability was examined. Frequencies, cross-tabulations, and t tests were used for data analysis. Results: Stroke patients spent a large proportion of the day in their bedroom, engaged in solitary behavior and being inactive (76%, 44% and 62% of observed time, respectively). Patients spent 11% of their weekday with an allied health or nursing professional. Good interrater agreement was achieved between raters for 41 of the 42 observational categories. Conclusions: These data provide a baseline for comparison following implementation of more practice change. A trained team of health professionals was able to reliably collect data.

Exercise dose and mobility outcome in a comprehensive stroke unit: description and prediction from a prospective cohort study.

OBJECTIVE To describe the dose of lower limb exercise completed during admission to a stroke unit, establish predictors of dose and explore the relationship between dose and walking outcomes. DESIGN Inception cohort study. PARTICIPANTS Two hundred consecutively-admitted people with stroke. METHODS Repetitions of exercise completed throughout the admission were tallied. Possible predictors of exercise dose were recorded within 48 h of admission. Walking velocity was assessed at the beginning and end of the hospital stay. RESULTS Data were available for 191 (96%) participants on discharge. The mean daily dose of lower limb exercise was 288 repetitions (standard deviation (SD) 242), the variability in dose was best explained by age and disability level. The mean improvement in walking velocity was 0.43 m/s (SD 0.46), 26% of variability in walking improvement was explained by exercise repetitions and 29% was explained by a multivariable model including significant contributions from exercise repetitions (p < 0.01) and age (p = 0.03). After controlling for other factors, for every 100 daily repetitions of lower limb exercise there was an additional change in walking velocity of 0.08 m/s (95% CI 0.05 to 0.11, p < 0.01). CONCLUSION Exercise dose in a stroke unit is variable and can be predicted by age and disability. Increased exercise dose is associated with improved mobility outcomes.

Validity of Different Activity Monitors to Count Steps in an Inpatient Rehabilitation Setting

Background Commonly used activity monitors have been shown to be accurate in counting steps in active people; however, further validation is needed in slower walking populations. Objectives To determine the validity of activity monitors for measuring step counts in rehabilitation inpatients compared with visually observed step counts. To explore the influence of gait parameters, activity monitor position, and use of walkers on activity monitor accuracy. Methods One hundred and sixty-six inpatients admitted to a rehabilitation unit with an average walking speed of 0.4 m/s (SD 0.2) wore 16 activity monitors (7 different devices in different positions) simultaneously during 6-minute and 6-m walks. The number of steps taken during the tests was also counted by a physical therapist. Gait parameters were assessed using the GAITRite system. To analyze the influence of different gait parameters, the percentage accuracy for each monitor was graphed against various gait parameters for each activity monitor. Results The StepWatch, Fitbit One worn on the ankle and the ActivPAL showed excellent agreement with observed step count (ICC 2,1 0.98; 0.92; 0.78 respectively). Other devices (Fitbit Charge, Fitbit One worn on hip, G-Sensor, Garmin Vivofit, Actigraph) showed poor agreement with the observed step count (ICC 2,1 0.12-0.40). Percentage agreement with observed step count was highest for the StepWatch (mean 98%). The StepWatch and the Fitbit One worn on the ankle maintained accuracy in individuals who walked more slowly and with shorter strides but other devices were less accurate in these individuals. Limitations There were small numbers of participants for some gait parameters. Conclusions The StepWatch showed the highest accuracy and closest agreement with observed step count. This device can be confidently used by researchers for accurate measurement of step counts in inpatient rehabilitation in individuals who walk slowly. If immediate feedback is desired, the Fitbit One when worn on the ankle would be the best choice for this population.

Amount of Exercise in the First Week After Stroke Predicts Walking Speed and Unassisted Walking

Background. Predicting walking outcomes poststroke is a challenge for clinicians. Objective. To identify the extent to which exercise dose (repetitions of leg movements) in the first week of a comprehensive stroke unit stay predicts discharge mobility. Methods. A cohort study was conducted on 200 consecutive people admitted to a comprehensive stroke unit who required physical therapy. Results. Discharge and predictor data were available for 191 survivors (99%). On admission, 86 participants were able to walk, and the average walking velocity was 0.42 m/s. On discharge, the average walking velocity was 0.77 m/s, and 152 participants were able to walk. A discharge walking velocity of greater than 0.8 m/s was predicted by the exercise dose achieved in the first week after admission. Adding other predictors did not significantly increase the predictive ability of the model. Completion of more than the median number of exercise repetitions (703) in the first week of admission was associated with a quicker recovery of unassisted walking. This effect persisted after adjustment for walking velocity on admission, cognition, and comorbidity. Conclusion. Exercise dose in the first week after admission for stroke is an important indicator of walking speed at discharge and the time to achieve unassisted walking.

The minimum sit-to-stand height test: reliability, responsiveness and relationship to leg muscle strength

Objective: To determine the reliability of the minimum sit-to-stand height test, its responsiveness and its relationship to leg muscle strength among rehabilitation unit inpatients and outpatients. Design: Reliability study using two measurers and two test occasions. Secondary analysis of data from two clinical trials. Setting: Inpatient and outpatient rehabilitation services in three public hospitals. Subjects: Eighteen hospital patients and five others participated in the reliability study. Sevety-two rehabilitation unit inpatients and 80 outpatients participated in the clinical trials. Methods: The minimum sit-to-stand height test was assessed using a standard procedure. For the reliability study, a second tester repeated the minimum sit-to-stand height test on the same day. In the inpatient clinical trial the measures were repeated two weeks later. In the outpatient trial the measures were repeated five weeks later. Knee extensor muscle strength was assessed in the clinical trials using a hand-held dynamometer. Results: The reliability for the minimum sit-to-stand height test was excellent (intraclass correlation coefficient (ICC) 0.91, 95% confidence interval (CI) 0.81–0.96). The standard error of measurement was 34 mm. Responsiveness was moderate in the inpatient trial (effect size: 0.53) but small in the outpatient trial (effect size: 0.16). A small proportion (8–17%) of variability in minimum sit-to-stand height test was explained by knee extensor muscle strength. Conclusions: The minimum sit-to-stand height test has excellent reliability and moderate responsiveness in an inpatient rehabilitation setting. Responsiveness in an outpatient rehabilitation setting requires further investigation. Performance is influenced by factors other than knee extensor muscle strength.

Making inferences about muscle forces from clinical observations

The analysis of movement dysfunction often requires that inferences be made about the muscle forces which occur during motor task performance. Physiotherapists probably use a range of different models of analysis to make inferences about such forces. These models differ in the degree to which they invoke simplifying assumptions about the non-muscle forces acting on body segments. In some circumstances even the most simple models of analysis will enable reasonable inferences to be made about muscle forces, but in other situations it may be very difficult to make reasonable inferences about muscle forces from clinical observations alone.