Mary Cramp

Effectiveness of a community-based low intensity exercise programme for ambulatory stroke survivors

Purpose. To establish the feasibility and effectiveness of a community-based exercise programme for ambulatory patients with stroke discharged from rehabilitation Method. Eighteen participants were recruited 3–12 months after onset of first stroke. Using a time series experimental design, the group completed a baseline period of 4 weeks (A1), a group exercise programme of low-intensity progressive resistive exercise and functional tasks for lower limb muscles (B) and repeat assessment after cessation of exercise (A2). Fitness instructors delivered sessions at Leisure Centres twice weekly for 14 weeks with physiotherapy support and the minimum attendance requirement was 16 sessions. Measures included muscle strength, gait velocity, Berg Balance Scale and Nottingham Extended Activities of Daily Living. Results. Lower limb muscle strength improved after training (ANOVA, p < 0.02). Paretic knee extension strength increased from 43.4 ± 5.9 to 60.4 ± 6.8 Nm after 16 exercise sessions. Walking velocity increased significantly (ANOVA, p < 0.001), from 0.54 ± 0.07 to 0.75 ± 0.08 m/s (t = −3.31, p < 0.01). Balance and everyday function were also significantly improved (p < 0.003). There were marked individual variation in the response to training, and those who completed additional training did not show benefit. Conclusions. This community-based exercise programme was feasible and delivered positive improvements in physical function for participants. Further issues raised for investigation include the individual response to training and the benefits of extended training.

Low intensity strength training for ambulatory stroke patients.

Purpose. To investigate feasibility and effectiveness of an individually-directed, group strength-training programme on knee muscle strength after stroke. Method. Ten volunteers (62 ± 11 years, mean ± SD), 6 – 12 months after first-ever unilateral stroke, walking independently with or without aids were recruited. Using an A1-B-A2 design, 3 sets of baseline measures were taken at 2 weekly intervals; volunteers then attended twice weekly sessions of low intensity progressive strengthening exercises and were assessed after each series of 8 sessions to a maximum of 24 sessions; post training, measures were repeated after 4 – 6 weeks. Measures included isometric and concentric knee extensor muscle strength and 10 m walking velocity. Results. Strength of knee extensor muscles was improved after training (ANOVA, p < 0.05). On cessation of training, isometric strength increased by 58 ± 19% and concentric strength at 30°/s by 51 ± 14%; walking velocity quickened from 0.47 ± 0.06 m · s−1 to 0.57 ± 0.08 m · s−1 (t = −3.31, p < 0.01). These gains were maintained 4 – 6 weeks after completion of training. Conclusions. These findings support the use of low intensity strength training after stroke and confirm published evidence. It was feasible for one therapist to deliver the training programmes for 4 – 6 participants at a time; an important feature when resources are limited.

Evaluation of multi-segmental kinematic modelling in the paediatric foot using three concurrent foot models

BackgroundVarious foot models are used in the analysis of foot motion during gait and selection of the appropriate model can be difficult. The clinical utility of a model is dependent on the repeatability of the data as well as an understanding of the expected error in the process of data collection. Kinematic assessment of the paediatric foot is challenging and little is reported about multi-segment foot models in this population. The aim of this study was to examine three foot models and establish their concurrent test-retest repeatability in evaluation of paediatric foot motion during gait.Methods3DFoot, Kinfoot and the Oxford Foot Model (OFM) were applied concurrently to the right foot and lower limb of 14 children on two testing sessions. Angular data for foot segments were extracted at gait cycle events and peaks and compared between sessions by intraclass correlation coefficient (ICC) with 95% confidence intervals (95%CI) and standard error of measurement (SEM).ResultsAll foot models demonstrated moderate repeatability: OFM (ICC 0.55, 95% CI 0.16 to 0.77), 3DFoot (ICC 0.47, 95% CI 0.15 to 0.64) and Kinfoot (ICC 0.43, 95% CI -0.03 to 0.59). On the basis of a cut-off of 5°, acceptable mean error over repeated sessions was observed for OFM (SEM 4.61° ± 2.86°) and 3DFoot (SEM 3.88° ± 2.18°) but not for Kinfoot (SEM 5.08° ± 1.53°). Reliability of segmental kinematics varied, with low repeatability (ICC < 0.4) found for 14.3% of OFM angles, 22.7% of 3DFoot angles and 37.6% of Kinfoot angles. SEM greater than 5° was found in 26.2% of OFM, 15.2% of 3DFoot, and 43.8% of Kinfoot segmental angles.ConclusionFindings from this work have demonstrated that segmental foot kinematics are repeatable in the paediatric foot but the level of repeatability and error varies across the segments of the different models. Information on repeatability and test-retest errors of three-dimensional foot models can better inform clinical assessment and advance understanding of foot motion during gait.

The meaning of spasticity to people with multiple sclerosis: What can health professionals learn?

Purpose: Multiple sclerosis (MS) is the most common disabling neurological condition affecting young adults. One third of people on an American registry of people with MS (PWMS) reported having activities affected by spasticity. The psychosocial effects of spasticity in people with MS have been shown to be distressing and detrimental to emotional and social relationships when investigated from a psychology perspective. This paper investigates the impact of spasticity on the lives of people living with MS from a physiotherapeutic perspective. Method: This study involved 12 semi-structured interviews with individuals experiencing MS-related spasticity. Ten sets of data were analyzed following framework analysis principles. Results: Results suggest spasticity effects life experience of these PWMS in diverse and complex ways. Physical, psychological and social consequences of spasticity are closely linked and can be far reaching. Conclusions: Therapists need to be aware of links between specific physical symptoms and their psychosocial consequences if they want to improve peoples’ quality of life. This paper provides in depth qualitative research evidence for the complexity of the spasticity experience for each individual, strengthening the argument for a patient-centred approach to treatment. These results also support the case for targeted interventions with effectiveness recorded in a patient-centred way. Implications for Rehabilitation Spasticity is suggested here to affect the lives of individuals with multiple sclerosis in diverse and far reaching ways. Therapists need to investigate this fully in subjective assessment to impact on peoples quality of life. Direct links were identified between treatable physical symptoms and far reaching consequences of spasticity. Knowledge about the complexity of the spasticity experience for each individual will allow therapists to target interventions appropriately and accurately record effectiveness in a patient-centred way.

The impact of body fat on three dimensional motion of the paediatric foot during walking.

Childhood obesity is commonly associated with a pes planus foot type and altered lower limb joint function during walking. However, limited information has been reported on dynamic intersegment foot motion with the level of obesity in children. The aim of this study was to explore the relationships between intersegment foot motion during gait and body fat in boys age 7-11 years. Fat mass was measured in fifty-five boys using air displacement plethysmography. Three-dimensional gait analysis was conducted on the right foot of each participant using the 3DFoot model to capture angular motion of the shank, calcaneus, midfoot and metatarsals. Two multivariate statistical techniques were employed; principle component analysis reduced the multidimensional nature of gait analysis, and multiple linear regression analysis accounted for potential confounding factors. Higher fat mass predicted greater plantarflexion of the calcaneus during the first half and end of stance phase and at the end of swing phase. Greater abduction of the calcaneus throughout stance and swing was predicted by greater fat mass. At the midfoot, higher fat mass predicted greater dorsiflexion and eversion throughout the gait cycle. The findings present novel information on the relationships between intersegment angular motion of the foot and body fat in young boys. The data indicates a more pronated foot type in boys with greater body fat. These findings have clinical implications for pes planus and a predisposition for pain and discomfort during weight bearing activities potentially reducing motivation in obese children to be physically active.

Reliability of three foot models to examine paediatric gait

Background A variety of multi-segmental foot models have been produced to examine patterns of foot segmental movement during gait cycle to identify biomechanical differences between normal and pathological foot function[1-3]. The reliability of foot models to accurately describe motion of the foot joints is dependent on the ability of the examiner to repeatedly apply markers to specific landmarks and the relevance of models’ segmental descriptions to underlying anatomy. The aim of this study was to test the reliability of segmental angles measured by three published foot models during paediatric gait. Materials and methods Sixteen children, aged 6 to 12 years old, were recruited to the study. Marker sets for three foot models 3DFoot [1], Oxford Foot Model (OFM)[2], and Kinfoot[3] were applied to their right feet simultaneously which to the authors knowledge, is the first direct comparison of the three models during gait. Each foot model was assessed for repeatability of maximal joint angle and range of motion during the gait cycle between two testing occasions. Absolute angular differences and standard error of measurement (SEM) are reported. Results Repeatability of all maximal segmental angles and range of motions were higher in 3DFoot compared to OFM and Kinfoot (Table 1).

Foot and ankle impairments affect balance and mobility in stroke (FAiMiS): the views and experiences of people with stroke

Abstract Purpose: To explore the nature and impact of foot and ankle impairments on mobility and balance in community-dwelling, chronic stroke survivors. Methods: A qualitative research design using face to face semi-structured, audio recorded interviews. Thirteen community-dwelling stroke survivors, all of whom had self-reported foot and ankle impairments, were interviewed (female n = 6, mean age = 67 years, SD = 12 years, mean time since stroke = 4 years, SD = 6 years, right stroke n = 7, left stroke n = 6). A framework analysis approach was used to analyse and interpret transcribed interviews. Results: Three themes emerged: (1) Impact. The influence of foot and ankle impairments on mobility and balance. (2) Standing out. How participants felt they “stood out” because of their impairments and wanted to be normal. (3) Help. The specific help and advice participants received in managing their problems. Conclusions: Foot and ankle impairments such as pain, altered somatosensory input and weakness significantly contribute to problems with community ambulation, balance and fear of falling in people with chronic stroke. Specific foot and ankle impairments may also negatively contribute to perceptions of physical appearance and self-esteem. Therapeutic management approaches within clinical practice appear to focus mostly on the gross performance of the lower limb with little emphasis on the specific assessment or treatment of the foot or ankle. Implications for Rehabilitation Foot pain, sensory impairments and muscle weakness in the foot and ankle can impact on community ambulation, balance and fear of falling following stroke. Foot and ankle function post-stroke should be routinely assessed and monitored. Clinicians should be aware of the potentially distressing negative perceptions associated with altered gait patterns, footwear and orthotic use.

Identifying biomechanical gait parameters in adolescent boys with haemophilia using principal component analysis

Improvements in the medical management for those with haemophilia have resulted in improved clinical outcomes. However, current treatment regimens do not alleviate all joint haemarthroses with the potential for long‐term joint deterioration remaining. The evaluation of functional activities such as gait, using standardized tools to monitor children with haemophilia is emerging.

Multi-segmental foot modelling during shod activity: study of running shoe integrity

Introduction Multi-segmental foot modelling (MSFM) during shod activity has the potential to enhance our understanding of how footwear influences foot motion. Recent work by Bishop et al. (2015) and Shultz & Jenkyn (2012) has validated the incision parameters to accommodate surface mounted markers for two alternative MSFMs, requiring 7 and 5 incisions respectively, within the shoe. These MSFMs have been sparsely used in contrast to 3DFoot model (Leardini et al. 2007) which would require 10 incisions and has not been used previously to assess in-shoe foot motion. Purpose of the study To determine the influence of incisions to accommodate Jenkyn and Nicol (JN) and 3DFoot MSFMs upon the structural integrity of neutral running shoes. Methods Two procedures were applied to assess shoe deformation. A) Eight males (30±8yrs, 1.78±0.05m, 84±7kg) completed 2 testing sessions. Participants ran at a self-selected pace (3±0.5m.s-1) in standard ASICS running shoes. Baseline shoe deformation data was collected during the first session. Prior to session 2, 25mm incisions were made to accommodate MSFMs: 3DFoot (left shoe) and JN (right shoe). Kinematic data were recorded using a 3D motion analysis system (VICON, Oxford, England) at 200Hz. Three retro-reflective markers (Figure 1) were used to measure as shoe distance and shoe angle at initial contact (IC), heel rise (HR) and toe off (TO). Shoe deformation measures were compared using paired t-tests. B) Material strain of the shoe upper was assessed in 1 male participant (26yrs, 1.80m, 80kgs) using ARAMIS optical system. Material strain patterns were compared between intact and cut conditions using Trend symmetry (TS) analysis (Crenshaw & Richards, 2006). Here Figure 1. Results No significant differences (p > 0.05) in shoe distance were recorded between intact and cut conditions but significant differences (p < 0.05) were reported in shoe angle at all three events of running gait (Table 1). Material strain assessment showed lower TS scores for the lateral aspect of the shoe (TS = 0.81 ± 0.11) than the medial aspect (TS = 0.89 ± 0.12). Symmetry was greater between the intact and JN shoe (TS= 0.88 ± 0.10) than the intact and 3DFoot shoe (TS = 0.82 ± 0.13). Here Table 1. Discussion and Conclusion Analysis of kinematic shoe deformation measures revealed individual responses to incisions made within the upper of a running shoe to accommodate MSFMs. Significant (p < 0.05) changes in shoe angles were noted between the intact and cut conditions at IC and TO for the JN incisions and HR for the 3DFoot incisions. However, while the changes in shoe angle were significant, the mean difference was small (≤ 5°). This value is lower than the minimal important difference proposed by Nester et al. (2007) for comparison of gait kinematics. Thus, it may be argued that the differences in shoes angles between intact and cut conditions were negligible and the results support the use of either MSFM to assess shod foot motion. While the use of kinematic measures to infer the shoes structural integrity have been used previously (Shultz and Jenkyn, 2012), no validation of these measure has been undertaken. The small and non-systematic findings reported in both this study and that of Shultz and Jenkyn (2012), particularly for shoe distance measures; question the sensitivity of kinematic shoe deformation measures to detect changes in structural integrity. Material strain analysis was used to further explore area specific alterations in the running shoes structural integrity from the different incision sets. The material strain analysis supported the use of the JN foot model to assess in-shoe foot kinematics, due to higher symmetry scores and smaller mean differences between the intact and JN shoes. Further exploration of additional means of assessing the influence of incisions to accommodate MSFM upon the shoes structural integrity is warranted. References Bishop, C. et al. (2015). Gait Posture, 41 (1), 295-299. Crenshaw, S. and Richards, J. (2006) Gait Posture, 24 (4), 515-521. Jenkyn, T. and Nicol, A. (2007). J Biomech, 40 (14), 3271-3278. Leardini, A. et al. (2007). Gait Posture, 25 (3), 453-462. Nester, C. et al. (2007). J Biomech, 40 (15), 3412-3423. Shultz, R. and Jenkyn, T. (2012). Med Eng Phys, 34 (1), 118-122.

Biomechanical characteristics of lower limb gait waveforms: Associations with body fat in children

BACKGROUND Childhood obesity is associated with musculoskeletal dysfunction and altered lower limb biomechanics during gait. Few previous studies have explored relationships between childhood obesity measured by body fat and lower limb joint waveform kinematics and kinetics. RESEARCH QUESTION What is the association between body fat and hip, knee and ankle joint angles and moments during gait and in 7 to 11 year-old boys? METHODS Fifty-five boys participated in the study. Body fat was measured by air displacement plethysmography. Hip, knee and ankle 3D waveforms of joint angles and moments were recorded during gait. Principle component analysis was used to reduce the multidimensional nature of the waveform into components representing parts of the gait cycle. Multiple linear regression analysis determined the association between the components with body fat. RESULTS Higher body fat predicted greater hip flexion, knee flexion and knee internal rotation during late stance and greater ankle external rotation in late swing/early stance. Greater hip flexion and adduction moments were found in early stance with higher body fat. In mid-stance, greater knee adduction moments were associated with high body fat. Finally, at the ankle, higher body fat was predictive of greater internal rotation moments. SIGNIFICANCE The study presents novel information on relationships between body fat and kinematic and kinetic waveform analysis of paediatric gait. The findings suggest altered lower limb joint kinematics and kinetics with high body fat in young boys. The findings may help to inform research in to preventing musculoskeletal comorbidities and promoting weight management.