Patricia A. Goldie

Deficit and change in gait velocity during rehabilitation after stroke

OBJECTIVE To quantify the initial deficit, change, and outcome in gait velocity during inpatient rehabilitation following stroke. DESIGN The initial deficit on admission to rehabilitation was quantified by comparing 42 stroke patients with 42 controls matched by gender and age. The change in the stroke patients during the next 8 weeks was quantified and gait outcome was compared with functional and normal criteria. SETTING Patients were referred from four inpatient rehabilitation centers at the time of admission following a median of 16.5 days in the acute hospital. PATIENTS SELECTION CRITERIA ability to give informed consent; unilateral first stroke; ability to walk 10 meters. INTERVENTION Patients participated in a median of 17.38 hours of individual physical therapy including a median of 6.92 hours of gait training during the 8 weeks. MAIN OUTCOME MEASURE Gait velocity. RESULTS Gait velocity was initially 38.6% (26.7m/min SD = 14.9) of the performance of controls and improved to 55.1% (38.1m/min). At outcome only 24% exceeded the 5th percentile of controls (48.1m/min) or the velocity required to cross the typical signalled intersection (46.2m/min). The change was only 26% of the initial deficit. Fifty-five percent of the patients improved beyond the 95% confidence intervals surrounding the error of measuring change. Indices of responsiveness indicated that there was a high signal-to-noise ratio and a robust effect size. CONCLUSION Gait velocity discriminated the effect of stroke and the change during rehabilitation.

Theoretical considerations in balance assessment

Although balance control is an integral component of all daily activities, its complex and flexible nature makes it difficult to assess adequately. This paper discusses balance by examining it in relation to function and the physical environment. Balance is affected by both the task being undertaken and the surroundings in which it is performed. Different tasks and environments alter the biomechanical and information processing needs for balance control. These issues are discussed and a modification of Gentile s Taxonomy of Tasks is suggested for analysis of clinical balance tests, some of which are used as examples.

Falls and injury prevention should be part of every stroke rehabilitation plan

Objective: To evaluate falls incidence, circumstances and consequences in people who return home after stroke rehabilitation, so that appropriate falls and injury prevention strategies can be developed. Design: Prospective cohort study. Setting: Community. Subjects: Fifty-six subjects with stroke who were participating in a rehabilitation programme and returning to live in a community setting completed the study. Main measures: Subjects completed a prospective falls diary for six months after discharge from rehabilitation, and were interviewed after falls. Physical function was measured by the Berg Balance Scale (BBS) and the Functional Independence Measure (FIM). Results: Forty-six per cent of people (26/56) fell, with most falls (63/103 falls) occurring in the two months after discharge from rehabilitation. One subject had 37 similar falls and these falls were excluded from further analysis. Falls occurred more often indoors (50/66), during the day (46/66) and towards the paretic side (25/66). People required assistance to get up after 25 falls (38%) and 36 falls (55%) resulted in an injury. People sought professional health care after only 16 falls, and activity was restricted after 29 falls (44%). The Berg Balance Scale and Functional Independence Measure scores were lower in people who had longer lies after a fall, and who restricted their activity after a fall (p < 0.05). Lower physical function scores were also associated with falling in the morning, wearing multifocal glasses at the time of a fall, and injurious falls (p < 0.05). Conclusion: Falls are common when people return home after stroke. Of concern are the small number seeking health professionals’ assistance after a fall, the high proportion restricting their activity as a result of a fall and the number of falls occurring towards the paretic side.

Maximum voluntary weight-bearing by the affected and unaffected legs in standing following stroke

OBJECTIVE: To compare stroke patients to control subjects for ability to transfer body weight onto the affected and unaffected leg in standing; to investigate intra-session reliability. DESIGN: Comparative clinical study conducted within a single session. BACKGROUND: There is a paucity of quantitative data about maximum voluntary weight-bearing in patients during rehabilitation following stroke. METHODS: A Kistler force platform was used to quantify maximum amount of body weight transferred to a single limb in the lateral and forward directions during weight-shifting. Twelve control subjects matched by gender and age (median 64 years) were compared to 12 inpatient stroke patients after a median of 37 days post-onset. RESULTS: The median score for control subjects was approximately 95% of body weight to each leg in both directions. In contrast, stroke patients transferred less body weight (P<0.01) to the affected leg (65.5% lateral; 54.9% forward) and also to the unaffected leg (85.0% lateral; 80.1% forward). For the stroke patients, transfer of body weight was more challenging in the forward direction than the lateral direction on the affected leg (P<0.05). Relative to individual differences in the stroke group, error due to the repeated measurement process was low. CONCLUSION: The testing procedure was found to discriminate between stroke patients and control patients and had high retest reliability within a single session.

Obstacle crossing in subjects with stroke

OBJECTIVE To study the ability of subjects with stroke to successfully step over an obstacle during ambulation. SETTING A geriatric rehabilitation unit in a tertiary referral hospital. SUBJECTS Twenty-four inpatients with stroke (median time poststroke 27 days, interquartile range 21 to 44.5 days) able to walk 10 m unassisted without walking aids; also, 22 healthy subjects. METHOD Subjects were required to step over obstacles of various heights and widths, ranging from 1cm to 8cm. A fail was scored if the obstacle was contacted by either lower limb or if assistance or upper limb support was required. The choice of leading limb and the presence of visual deficits and neglect were also recorded in the stroke subjects. Subjects were tested on two occasions. RESULTS Significantly more fails were recorded for stroke subjects, with 13 subjects failing at least once. No preference was shown for leading either with the affected or with the unaffected leg. Stroke subjects showed inconsistent performance over the two testing sessions. CONCLUSION The ability to negotiate obstacles was compromised and inconsistent in stroke subjects undergoing inpatient rehabilitation. This suggests that gait safety in this population remains threatened.

Systematic and random error in repeated measurements of temporal and distance parameters of gait after stroke

OBJECTIVE To obtain intersession estimates of error for temporal and distance (TD) parameters of gait in a sample of stroke patients undertaking inpatient rehabilitation. DESIGN Thirty-one stroke patients were measured with an instrumented footswitch system (after a median of 46 days poststroke; interquartile range = 26 to 63) walking over a 10-meter distance a total of four times on 3 consecutive days. Two familiarization walks provided intrasession retest data. RESULTS Metric estimates of systematic and random error have been provided for obtained TD parameters. Proportional indices of reliability (ICC [2,1] and Pearsons r) were generally high, ranging from .72 to .94. CONCLUSION By quantifying systematic and random error associated with the process of repeated measurements, criteria have been provided for evaluating change in TD variables during rehabilitation. Although error for gait velocity was small relative to individual differences in the stroke group, it was large relative to levels of change derived from measurements reported during typical periods of rehabilitation. Serial measurements of gait during rehabilitation may be better than two consecutive measurements. This study highlights the need to interpret estimates of error according to the purpose of measurement.

Neovascularization and pain in abnormal patellar tendons of active jumping athletes

Objective:The aim of this study was to investigate tendon pain in abnormal patellar tendons with and without neovascularization. Study design:Comparative design. Setting:Multidisciplinary tendon study group at a competitive volleyball venue. Participants:One hundred eleven volleyball players volunteered to participate in the study. Main Outcome Measures:Subjects’ patellar tendons were imaged with ultrasound, with and without Doppler. Tendons that were imaging abnormal were categorized according the presence of tendon neovascularization. Subjects completed 3 pain scales that examined function (Victorian Institute of Sport Assessment score, 100-point maximum), pain with tendon load (decline squat, visual analogue scale, 100-mm maximum), and maximum pain for the previous week (visual analogue scale, 100-mm maximum). A 1-tailed Mann-Whitney U test compared pain scores in abnormal tendons without neovascularization to abnormal tendons with neovascularization. Results:Functional scores were lower (Victorian Institute of Sport score, median, 78; P = 0.045) and pain scores under tendon load were greater (decline squat pain, median, 19; P = 0.048) in subjects with abnormal tendons with neovascularization than subjects with abnormal tendons without neovascularization (Victorian Institute of Sport Assessment score, median, 87; decline squat pain, median, 0). Conclusions:This study indicates that the presence of neovascularization in abnormal patellar tendons is associated with greater tendon pain compared with abnormal tendons without neovascularization in active jumping athletes.

The high-level mobility assessment tool (HiMAT) for traumatic brain injury. Part 2: Content validity and discriminability

Primary objectives: (i) To assess the measurement properties of the high-level mobility assessment tool (HiMAT) for people with traumatic brain injury (TBI), (ii) to measure the extent to which the HiMAT is a uni-dimensional, discriminative hierarchical outcome scale. Research design: The content validity was assessed using a three-stage process of investigating internal consistency, factor analysis and Rasch analysis. The uni-dimensionality of the HiMAT items was also tested. Discriminability was investigated by correlating raw and logit scores obtained from Rasch analysis. The study was conducted at a major rehabilitation facility using a convenience sample of 103 adults with TBI. Main outcomes and results: The internal consistency for the high-level items was very high (Cronbachs α = 0.99). Principal axis factoring identified several balance items as belonging to a second factor not related to high-level mobility, hence these items were excluded. Rasch analysis identified several misfitting items, such as walking around a figure of eight and stopping from a run, which were also excluded. Logit scores were used to exclude clustered and, therefore, redundant items. Raw scores correlated very highly (r = 0.98) with logit scores, indicating that raw scores provided good discriminability and were suitable for use by clinicians. Conclusion: The HiMAT, which assesses higher-level mobility requirements of people with TBI for return to pre-accident social, leisure and sporting activities, is a uni-dimensional and discriminative scale for quantifying therapy outcomes.

Falls incidence and factors associated with falling in older, community-dwelling, chronic stroke survivors (>1 year after stroke) and matched controls

Background and aims: Using data from the Australian Longitudinal Study of Ageing, this study aimed at: 1) investigating differences in the incidence of falls between chronic Stroke subjects (n=181) and matched Non-stroke subjects (n=181) who were 65 years or older and community dwellers, and 2) establishing factors associated with falling within chronic Stroke subjects. Methods: Subjects reporting a history of stroke 12 or more months ago, and age- and gender-matched Non-stroke subjects were extracted from the first wave of the Australian Longitudinal Study of Ageing database. Falls incidence and factors associated with falling were examined. Falls data were collected based on recall of the number of falls in the past year, including falls that did not result in injury. Results: Significantly more Stroke subjects reported falling in the previous twelve months than Non-stroke subjects (36 vs 24%, p<0.05). When comparing Stroke Fallers to Stroke Non-fallers within the Stroke group, Stroke Fallers were significantly more likely to report (i) difficulty in stooping or kneeling, (ii) getting up in the night to urinate more than once, and (iii) having a greater number of Instrumental Activities of Daily Living problems (p<0.05). Self-reported difficulty in stooping or kneeling was the most significant factor associated with falling in the Stroke group (OR 2.44, 95% CI 1.30–4.58). Conclusions: Falls are a problem for community dwelling older people with chronic stroke and are associated with physical function difficulties. Factors identified in this and other similar studies should form the basis for targeted falls prevention programs in this high falls risk clinical group.

Angular movements of the pelvis and lumbar spine during self-selected and slow walking speeds

We studied the effect of walking at a self-selected and at a slower speed on the angular movements of the pelvis and lumbar spine. We also studied how interpretation of speed effects on lumbar spine movements was influenced by frame of reference, either relative to the pelvis or relative to a global reference frame. Twenty-seven subjects without pathology walked on a treadmill at either self-selected or 60% of self-selected speed. The movements of the pelvis and lumbar spine, as represented by surface markers, were recorded by videocameras and the three-dimensional angles computed by the PEAK motion measurement system. Results indicated that the amplitudes of pelvic list (P<0.05) and pelvic axial rotation (P<0. 05) were decreased at slow walking speed. Relative to the pelvis, the amplitude of lumbar lateral flexion was decreased with slower walking (P<0.01). In contrast, when lumbar spine movements were measured relative to a global reference frame, no differences were detected due to decreased walking speed. This suggests, firstly, that the effect of walking speed when evaluating the significance of decreased movements of the pelvis and of the lumbar spine (relative to the pelvis) of subjects walking at slower than self-selected speeds should be considered and secondly, that movement of the lumbar spine should be interpreted with respect to a frame of reference.