Kristin E. Musselman

Physical Function and Health Status among Seniors with and without a Fear of Falling

Background: Fear of falling (FF) is pervasive among older people and is an independent risk factor for decreased mobility and loss of quality of life. Although it is a serious health concern, little is known about the severity of the physical and health-related deficits in high-functioning fearful seniors. Objective: This study examined the physical correlates of FF in community-dwelling seniors in relation to their non-fearful counterparts and also explored the relevance of recent fall history. Subjects: Twenty-five volunteers who stated that they had curtailed their activities due to a FF and who reported themselves to be healthy participated. Non-fearful, age- and gender-matched subjects were also recruited and served as a comparison group. Methods: This cross-sectional study had participants come to the laboratory on one occasion for about 1.5 h. Limits of balance stability, walking speed, and lower limb muscle strength were measured in random order. In addition, the SF-36, the Activities-specific Balance Confidence (ABC) scale and the Human Activity Profile questionnaires were completed to provide measures of heath status, FF and activity levels, respectively. Results: Subjects with a FF had lower ABC scores (69.8 ± 10.2) than controls (90.2 ± 7.9; p < 0.001), and although they reported activity curtailment, the groups presented similar activity profiles (p > 0.05). Balance ability was not compromised in seniors with a FF, although their walking speed was slower than that of control subjects (p < 0.004). Lower limb weakness was significant in the FF group, which also reported low physical health. Perceived physical health, activity and hip flexor torque in combination accounted for almost 62% of the variance in ABC scores. Secondary analysis of the data from the FF group revealed a tendency for those who had fallen in the past year to restrict their limits of stability compared to those who had not fallen; though generally the effect sizes were small to moderate. Conclusions: The marked deficits in strength and health status found among seniors living independently in the community, who are in good health, but report being fearful of falling underscores the seriousness of FF as a potential health risk factor in the well elderly.

Training of Walking Skills Overground and on the Treadmill: Case Series on Individuals With Incomplete Spinal Cord Injury

Background and Purpose: Walking in the home and community is an important goal for individuals with incomplete spinal cord injury (iSCI). Walking in the community requires various skills, such as negotiating curbs, doors, and uneven terrain. This case report describes the use of a method to retrain walking overground that is intensive, variable, and relevant to daily walking (skill training). The aims of this case series were to determine the effectiveness of skill training in a small group of people with iSCI and to compare skill training with body-weight–supported treadmill training (BWSTT) in the same individuals. Case Description: Four individuals who were a median of 2.7 years (interquartile range [IQR]=12.8) after iSCI participated in alternating phases of intervention, each 3 months long. All patients started with BWSTT. Two patients subsequently engaged in skill training while the other 2 patients engaged in BWSTT, after which a third phase of intervention (opposite to the second) was repeated. Outcomes: The Modified Emory Functional Ambulation Profile, the 10-Meter Walk Test, the 6-Minute Walk Test, the Berg Balance Scale, and the Activities-specific Balance Confidence Scale were administered before training, monthly throughout training, and 3 months after training. Discussion: Overall improvements in walking speed met or exceeded the minimal clinically important difference for individuals with iSCI (≥0.05 m/s), particularly during the skill training phase (skill training: median=0.09 m/s, IQR=0.13; BWSTT: median=0.01 m/s, IQR=0.07). Walking endurance, obstacle clearance, and stair climbing also improved with both types of intervention. Three of the 4 patients had retained their gains at follow-up (retention of walking speed: median=92%, IQR=63%). Thus, the findings suggest that skill training was effective in this small group of individuals.

Clinical significance testing in rehabilitation research : What, why, and how?

Abstract Rehabilitation research often uses statistical significance to demonstrate the effectiveness of an intervention. This practice may produce misleading results as statistical significance does not imply clinical significance. An intervention that impacts the well-being and function of clients is clinically significant. How is clinical significance evaluated, and how can it be incorporated into rehabilitation research? This paper addresses these questions by using a combination of distribution- and anchor-based approaches to determine the clinical impact of treadmill training on comfortable walking speed in individuals with incomplete spinal cord injuries. Effect size, standard error of measurement, and the Walking Index for Spinal Cord Injury are used to estimate clinically significant change in walking speed. The results from these three methods are combined into a robust and interpretable conclusion regarding clinical significance. Such conclusions will facilitate knowledge transfer between research and practice.

Spinal Cord Injury Functional Ambulation Profile A New Measure of Walking Ability

Background. Objective measures of functional walking remain scarce for individuals with incomplete spinal cord injury (ISCI). Hence, the authors developed the Spinal Cord Injury Functional Ambulation Profile (SCI-FAP), which encompasses the timed performance of 7 tasks, such as walking and negotiating obstacles, doors, and stairs. Objective. To assess the reliability and validity of the SCI-FAP. Methods. A total of 32 individuals with ISCI attended 2 testing sessions separated by 1 to 2 weeks. At the first session, participants performed the SCI-FAP, the 10-m walk test (10MW), the 6-minute walk test (6MW), and the Walking Index for Spinal Cord Injury (WISCI II); 3 raters scored the participants’ performances on the SCI-FAP to assess interrater reliability. To establish convergent validity, SCI-FAP scores were compared with scores on the 10MW, 6MW, and WISCI II. At the second session, participants completed the SCI-FAP to assess test-retest reliability. To establish discriminative validity, SCI-FAP scores were compared between participants with ISCI and 60 able-bodied adults, who were scored on the SCI-FAP in a single session. Results. Internal consistency (α = .95), interrater reliability (intraclass correlation coefficient [ICC] = 1.00), and test-retest reliability (ICC = 0.98) of the SCI-FAP were high. SCI-FAP scores were moderately correlated with results from the 10MW (r = −0.59), 6MW (r = −0.59), and WISCI II (M = −0.68). Performance on the SCI-FAP was significantly poorer among participants with ISCI compared with their able-bodied counterparts (P = .002). Conclusions. The findings support the SCI-FAP as a valid and reliable measure of walking skill for individuals with ISCI.

Training to achieve over ground walking after spinal cord injury: A review of who, what, when, and how

Abstract Objectives (1) To provide clinicians with the best evidence for effective retraining of walking after spinal cord injury (SCI) to achieve over ground walking. (2) To identify gaps in our knowledge to guide future research. Methods Articles that addressed the retraining of walking in adults with SCI and reported outcome measures of over ground walking ability were identified through a non-systematic search of the PubMed, Scopus, and CINAHL databases. No restriction was applied to the method of training. Selected articles were appraised using the Physiotherapy Evidence Database scale. Information was synthesized to answer who best responds to what type of treatment, how that treatment should be delivered, and at what stage after injury. Results Individuals with motor incomplete SCI (American Spinal Injury Association (ASIA) Impairment scale (AIS) C and D) are most likely to regain walking over ground. The effective methods of training all involved a substantial component of walking in the training, and if assistance was provided, partial assistance was more effective than total assistance. Walking training resulted in a change in over ground walking speed of 0.06–0.77 m/s, and 6 minute walk distance of 24–357 m. The effective training schedules ranged from 10 to 130 sessions, with a density of sessions ranging from 2 per week to 5 per week. Earlier training led to superior results both in the subacute (<6 months) and chronic phases (>6 months) after injury, but even individuals with chronic injuries of long duration can improve. Conclusions Frequent, early treatment for individuals with motor incomplete SCI using walking as the active ingredient whether on the treadmill or over ground, generally leads to improved walking over ground. Much work remains for the future, including better quantification of treatment intensity, better outcome measures to quantify a broader range of walking skills, and better ways to retrain individuals with more severe lesions (AIS A and B).

Unique characteristics of motor adaptation during walking in young children

Children show precocious ability in the learning of languages; is this the case with motor learning? We used split-belt walking to probe motor adaptation (a form of motor learning) in children. Data from 27 children (ages 8-36 mo) were compared with those from 10 adults. Children walked with the treadmill belts at the same speed (tied belt), followed by walking with the belts moving at different speeds (split belt) for 8-10 min, followed again by tied-belt walking (postsplit). Initial asymmetries in temporal coordination (i.e., double support time) induced by split-belt walking were slowly reduced, with most children showing an aftereffect (i.e., asymmetry in the opposite direction to the initial) in the early postsplit period, indicative of learning. In contrast, asymmetries in spatial coordination (i.e., center of oscillation) persisted during split-belt walking and no aftereffect was seen. Step length, a measure of both spatial and temporal coordination, showed intermediate effects. The time course of learning in double support and step length was slower in children than in adults. Moreover, there was a significant negative correlation between the size of the initial asymmetry during early split-belt walking (called error) and the aftereffect for step length. Hence, children may have more difficulty learning when the errors are large. The findings further suggest that the mechanisms controlling temporal and spatial adaptation are different and mature at different times.

Prevalence of ataxia in children: A systematic review

Objective: To estimate the prevalence of childhood ataxia resulting from both genetic and acquired causes. Methods: A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement. Five databases were searched for articles reporting a frequency measure (e.g., prevalence, incidence) of ataxia in children. Included articles were first grouped according to the World Health Organization (WHO) regions and subsequently classified according to etiology (genetic, acquired, or mixed). Each article was assessed for its risk of bias on the domains of sampling, measurement, and analysis. Incidence values were converted to prevalence estimates whenever possible. European prevalence estimates for different etiologies of ataxia were summed to gauge the overall prevalence of childhood ataxia. Results: One hundred fifteen articles were included in the review. More than 50% of the data originated from the Europe WHO region. Data from this region also showed the least susceptibility to bias. Little data were available for Africa and Southeast Asia. The prevalence of acquired ataxias was found to vary more greatly across regions than the genetic ataxias. Ataxic cerebral palsy was found to be a significant contributor to the overall prevalence of childhood ataxia across WHO regions. The prevalence of childhood ataxias in Europe was estimated to be ∼26/100,000 children and likely reflects a minimum prevalence worldwide. Conclusions: The findings show that ataxia is a common childhood motor disorder with a higher prevalence than previously assumed. More research concerning the epidemiology, assessment, and treatment of childhood ataxia is warranted.

Walking tasks encountered by urban-dwelling adults and persons with incomplete spinal cord injuries.

OBJECTIVE Gait retraining should target the walking skills most needed for independence in the home and community. The main objective of this study was to document the walking tasks most commonly encountered in daily life by able-bodied adults. The study also compared participation in walking tasks between able-bodied adults and persons with incomplete spinal cord injuries. PARTICIPANTS Convenience sample of 50 able-bodied adults and 16 ambulatory, community-dwelling persons with incomplete spinal cord injuries. METHODS A walking survey was developed, and its content validity and concurrent validity confirmed. Participants used the survey to document the frequency with which walking tasks were encountered during a full waking day. RESULTS Frequently encountered tasks included walking on smooth and rough surfaces, opening/closing doors and carrying objects. Tasks encountered more than once per day by the majority of able-bodied participants included negotiating obstacles, walking on uneven and sloped surfaces, in crowded environments, narrow spaces, and on steps and stairs. Participants with spinal cord injuries encountered fewer tasks, including many of those frequently encountered by able-bodied participants. CONCLUSION The findings identify the important walking tasks for ambulation in the home and community. These tasks should be included in therapy programs aiming to retrain functional walking.

Repetitive Mass Practice or Focused Precise Practice for Retraining Walking After Incomplete Spinal Cord Injury? A Pilot Randomized Clinical Trial

Background. Retraining walking following spinal cord injury using visually guided tasks may be especially efficacious because it engages the motor cortex, whose input may facilitate improvements in functional walking. Objectives. To contrast 2 methods of retraining, one emphasizing precise, visually guided walking over obstacles and on targets (Precision Training), the other emphasizing mass practice of walking on a treadmill (Endurance Training). Methods. A randomized, single-blind, crossover design was used. Twenty-two participants, ≥7 months postinjury, were randomly allocated to start with Precision or Endurance Training. Each phase of training was 5 times per week for 2 months, followed by a 2-month rest. Measures of walking speed, distance, skill, confidence, and depression were obtained before training, then monthly thereafter. Results. Both forms of training led to significant improvements in walking, with Endurance Training inducing bigger improvements in walking distance than Precision Training, especially for high-functioning walkers who had initial walking speeds >0.5 m/s. The largest improvements in walking speed and distance occurred in the first month of Endurance Training, with minimal changes in the second month of training. In contrast, improvements in walking skill occurred over both months during both types of training. Retention of over ground walking speed, distance, and skill was excellent for both types of training. Conclusions. Intensive walking training in the chronic phase after spinal cord injury is effective in improving over ground walking. Visually guided tasks for training individuals with chronic spinal cord injury were not superior to mass practice on a treadmill.

Interlimb coordination in rhythmic leg movements: spontaneous and training-induced manifestations in human infants.

Different rhythmic leg movements in vertebrates can share coordinating neural circuitry. These movements are often similar kinematically, and smooth transitions between the different movements are common. We focused on interlimb coordination of the legs in young infants to determine whether weight bearing and non-weight bearing movements might share coordinating circuitry. If interlimb coordination is controlled by the same circuitry, the same coordination (i.e., either synchronous or alternate) should be seen in different rhythmic movements. Moreover, if we altered the interlimb coordination in one movement through exercise, it should translate to a change in coordination in another rhythmic movement that received no exercise. Video and electrogoniometry were recorded while 46 infants (age, 6.2+/-1.4 mo) performed non-weight bearing and weight bearing movements. Interlimb coordination was quantified by the phase lag between the movement cycles of each leg. Most infants (83%) showed the same coordination in weight bearing and non-weight bearing movements. Ten infants practiced the form of coordination they did not exhibit in the first visit, in weight bearing for 4 wk. Following practice, 8 of 10 infants changed their interlimb coordination in weight bearing to that practiced. Some who practiced synchronous coordination also changed their coordination in non-weight bearing activity. More infants showed both forms of coordination after practice and smooth transitions between the two forms. The results suggest that interlimb coordination is malleable in infants, and there is a partial sharing of the neural substrates for interlimb coordination between different rhythmic leg movements in infants.