Sandi J. Spaulding

Cueing and gait improvement among people with Parkinson's disease: a meta-analysis.

OBJECTIVE To compare the relative efficacy of visual versus auditory cueing on gait among individuals with Parkinsons disease (PD). DATA SOURCES A systematic search was completed up to September 2011, using the following databases: EMBASE, Scopus, Medline, CINAHL, and PubMed. STUDY SELECTION Four authors searched the databases using the following terms: Parkinsons disease (including abbreviations), gait, cadence, step, pace, cueing, cues, and prompt. All studies that evaluated the effect of cueing on gait in PD were selected by consensus of 2 pairs of authors who reviewed the titles and abstracts. Each pair of authors then applied the inclusion and exclusion criteria to each study, and 25 articles were chosen. Inclusion criteria were cueing studies that reported pre- and postoutcome measures of gait parameters. Exclusion criteria were lack of data and studies that evaluated gait aids. DATA EXTRACTION Gait measures of cadence, stride length, and velocity, before and after cueing, were collected from each study. If data were represented in graphs, a pair of authors extracted the data points individually, then compared and averaged values. DATA SYNTHESIS The data were synthesized using a meta-analysis based on cue type. Auditory cueing demonstrated significant improvement of cadence (Hedge g=.556; 95% confidence interval [CI], .291-.893), stride length (Hedge g=.497; 95% CI, .289-.696), and velocity (Hedge g=.544; 95% CI, .294-.795). In contrast, visual cueing significantly improved stride length only (Hedge g=.554; 95% CI, .072-1.036). CONCLUSIONS The findings suggest that auditory cueing is more effective for treating gait disorders in PD. Further research is needed to determine the optimum auditory cueing strategy for gait improvements.

Knee bracing after ACL reconstruction : effects on postural control and proprioception

PURPOSE To evaluate the effects an anterior cruciate ligament (ACL) brace has on various measures of knee proprioception and postural control. METHODS Thirty subjects (mean age 27 +/- 11 yr) having undergone unilateral ACL reconstruction were tested with and without wearing their own custom-fit brace on their involved limb. Proprioception was assessed using joint angle replication tests completed on an isokinetic dynamometer. Postural control was assessed using a series of single-limb standing balance tests completed on a force platform. The balance tests included: 1) standing on the stable platform with eyes open, 2) standing on a foam mat placed over the platform with eyes open, 3) standing on the platform with eyes closed, and 4) standing on the platform after landing from a maximal single-limb forward hop. RESULTS The brace provided a small but statistically significant improvement in proprioception (mean reduction in error scores between target and reproduced angles = 0.64 +/- 1.4 degrees, P = 0.02). For the postural control tests, there was a significant brace condition by test situation interaction (P = 0.02), with the brace providing a small but statistically significant improvement during the test completed on the stable platform with eyes open (mean reduction in center of pressure path length = 4.2 +/- 8.4 cm, P = 0.02) but not during the other more challenging test situations. Additional post hoc analyses indicated that the relationship between knee proprioception and postural control measures were low and not significant (r = 0.003 to 0.19, P > 0.32), consistent with the suggestion that changes in knee proprioception can occur in the absence of substantial changes in postural control. Also, standing balance tests that challenged the somatosensory contribution to postural control (i.e., those completed on foam, or with eyes closed) were significantly related to single-limb forward hop distances (r = -0.4, P < 0.05), whereas performance during the proprioception test was not (r = 0.1, P > 0.50). CONCLUSIONS In general, bracing appears to improve performance during tasks characterized by relatively limited somatosensory input but not during tasks characterized by increased somatosenory input. The small magnitude of the improvements, coupled with their apparent lack of carry over to more difficult and functionally relevant tasks, questions the clinical benefit of the present effects of bracing.

Dual-Task Interference: The Effects of Verbal Cognitive Tasks on Upright Postural Stability in Parkinson's Disease

Although dual-task interference has previously been demonstrated to have a significant effect on postural control among individuals with Parkinsons disease, the impact of speech complexity on postural control has not been demonstrated using quantitative biomechanical measures. The postural stability of twelve participants with idiopathic Parkinsons disease and twelve healthy age-matched controls was evaluated under three conditions: (1) without a secondary task, (2) performing a rote repetition task and (3) generating a monologue. Results suggested a significant effect of cognitive load on biomechanical parameters of postural stability. Although both groups increased their postural excursion, individuals with Parkinsons disease demonstrated significantly reduced excursion as compared with that of healthy age-matched controls. This suggests that participants with Parkinsons disease may be overconstraining their postural adjustments in order to focus attention on the cognitive tasks without losing their balance. Ironically, this overconstraint may place the participant at greater risk for a fall.

The influence of external orthotic support on the adaptive gait characteristics of individuals with chronically unstable ankles

External orthotic supports or braces are used clinically to treat individuals with chronically unstable ankles. Braces have efficacious effects on dynamic strength, passive tissue tension, and proprioception, but their effects on gait remains undetermined. The purpose of this study was to determine if overground locomotion, including walking up a step and a curb are influenced by orthotic device use. Twenty subjects, 10 with no previous injury and 10 with chronically unstable ankles, performed with no brace, a flexible brace and a semi-rigid brace while walking on a level surface, up a step and on a ramp. Differences were noted in kinematic and kinetic gait parameters between groups and between step and ramp conditions, suggesting that gait patterns vary between individuals who have had ankle sprain and those who have not. Few differences were noted between the brace and no brace conditions for both groups. Adding to the previously described efficacious benefits, we conclude that bracing does not alter selected gait parameters in individuals who have chronic ankle instability.

Plantar cutaneous sensory stimulation improves single-limb support time, and EMG activation patterns among individuals with Parkinson's disease.

Parkinsons disease is a chronic neurological disorder that results in gait and posture impairment. There is increasing evidence that these motor impairments may be partially due to deficits within the sensory system. In this study, the effects of a facilitatory insole that provides increased plantar sensory stimulation, was evaluated during gait, in a group of individuals with Parkinsons disease in comparison with healthy age-matched controls. Spatial-temporal parameters of gait were evaluated using an instrumented carpet, and muscle activation patterns were evaluated using surface EMG. All participants were tested with both a facilitatory (ribbed) insole and a conventional (flat) insole while walking 20 feet. Results indicated that the use of the facilitatory insole produced a significant increase in single-limb support time. Additionally, the muscle activation sequence of the tibialis anterior was normalized by the facilitatory insole, at the time of initial ground contact. These changes may lead to an overall improvement in gait pattern and stability, and suggest that the use of this type of facilitatory insole may be a useful treatment strategy for improving the gait of individuals with Parkinsons disease. This also provides support for the role of facilitation of the sensory system in improving motor output in individuals with Parkinsons disease.

Effectiveness of External Orthotic Support on Passive Soft Tissue Resistance of the Chronically Unstable Ankle

Functional ankle instability, orthoses, and passive resistive torque tolerated have not been researched. The purpose of the study was to evaluate the passive resistance torque exerted by a flexible and semirigid orthosis for individuals with chronic instability. Twenty-two subjects were evaluated on the passive ankle resistance unit during unbraced, flexible, and semirigid brace conditions. Data from the final three trials for each condition were analyzed using a multiple analysis of variance with repeated measures for resistive torque and inversion range of motion. The semirigid and flexible braces tolerated significantly greater torque forces and less inversion range than the unbraced condition (P < 0.000). External orthotic support, in particular that of a semirigid orthosis, may be beneficial toward reducing injury or be an effective prophylactic for the healthy population.

Predictive Validity of the UPDRS Postural Stability Score and the Functional Reach Test, when Compared with Ecologically Valid Reaching Tasks

Balance problems and falls are a common concern among individuals with Parkinsons disease (PD). Falls frequently occur during daily activities such as reaching into cupboards in the kitchen or bathroom. This study compared the correlation among two standard postural stability tests - the postural stability score on the Unified Parkinsons Disease Rating Scale (UPDRS) and the Functional Reach Test (FRT) - and ecologically valid reaching tasks that correspond to reaching at different cupboard heights among 20 individuals with PD and 20 age-matched controls. Both the FRT and the UPDRS postural stability tests are quick measures that can be performed during the clinical examination. The FRT, but not the postural stability score, demonstrated a significant correlation with the ecologically valid reaching tasks, among individuals with PD. Furthermore the FRT scores did not correlate with the UPDRS postural stability scores, indicating that these are measuring different aspects of balance. This study suggests that the FRT score may better predict the risk of postural instability encountered during daily activities among individuals with PD.

Biomechanical Analysis of Four Supports for the Subluxed Hemiparetic Shoulder

External support systems, such as slings and lapboards, may reduce shoulder subluxation in individuals with hemiplegia. However there is controversy among occupational therapists concerning the most appropriate method to support the affected arm. The purpose of the present paper is to report the biomechanical analysis of four support systems; two shoulder support systems, a Bobath axillary roll, and a laptray. Two dimensional static biomechanical analyses determine the mechanical characteristics of each of these four support systems. The results of the analyses demonstrate the magnitude of the shoulder loading and the effectiveness of the various components of each of the systems. The effect of changing some of the characteristics of the slings is demonstrated. Slings with straps over the unaffected shoulder provide continuous support for the flaccid extremity. The Bobath axillary roll may introduce an unwanted lateral force. Lapboards must be maintained at an appropriate distance from the subluxed shoulder to be effective. This theoretical analysis of supports systems will provide therapists information to help them understand effective supports for subluxation.

Ability of the Functional Independence Measure™ to Predict Rehabilitation Outcomes After Stroke: A Review of the Literature

Objective: A literature review to evaluate the ability of the Functional Independence Measure™ (FIM) to predict functional outcomes following a stroke, including functional performance at discharge, length of rehabilitation stay and discharge destination was completed. Findings: Absolute admission FIM score is a strong predictor of discharge FIM score, outcome disability and discharge destination. Patients with admission FIM scores of less than 50 remain dependent with self-care activities at discharge from rehabilitation. Patients with admission FIM scores equal to or greater than 90 will be independent with most activities of daily living and have a high likelihood of being discharged home.

Waterloo Vision and Mobility Study: Normal gait characteristics during dark and light adaptation in individuals with age-related maculopathy

Abstract The purpose of this study was to evaluate the gait responses of individuals with low vision compared to those of normal-visioned individuals when their vision is challenged by extreme levels of light. Twenty subjects with age-related maculopathy (ARM) and 20 subjects with normal vision first walked along a flat, unobstructed path immediately after the ambient light level was changed from low (5 lux) to high (2500 lux). The procedure was repeated after the light was reduced from the high to the low level. Muscle activity, temporal and kinematic variables, and ground reaction forces were used to detect gait characteristics because of ambient light level changes. Data suggested that ARM subjects walked slower and with more caution than normal subjects but that these differences were not related to ambient light level. Head angle, an estimate of gaze direction, was lower for ARM subjects during high light, but the gaze direction for both groups was low during low light. Among these ARM subjects, extreme levels of ambient light did not affect gait; subjects made adaptations that were reasonable to encourage safe ambulation, despite the direction of light change. Normal-visioned individuals in this study experienced more difficulty in low light than high light situations.