Sandra G. Brauer

Hip strategy for balance control in quiet standing is reduced in people with low back pain.

Study Design. Quiet stance on supporting bases with different lengths and with different visual inputs were tested in 24 study participants with chronic low back pain (LBP) and 24 matched control subjects. Objectives. To evaluate postural adjustment strategies and visual dependence associated with LBP. Summary of Background Data. Various studies have identified balance impairments in patients with chronic LBP, with many possible causes suggested. Recent evidence indicates that study participants with LBP have impaired trunk muscle control, which may compromise the control of trunk and hip movement during postural adjustments (e.g., hip strategy). As balance on a short base emphasizes the utilization of the hip strategy for balance control, we hypothesized that patients with LBP might have difficulties standing on short bases. Methods. Subjects stood on either flat surface or short base with different visual inputs. A task was counted as successful if balance was maintained for 70 seconds during bilateral stance and 30 seconds during unilateral stance. The number of successful tasks, horizontal shear force, and center-of-pressure motion were evaluated. Results. The hip strategy was reduced with increased visual dependence in study participants with LBP. The failure rate was more than 4 times that of the controls in the bilateral standing task on short base with eyes closed. Analysis of center-of-pressure motion also showed that they have inability to initiate and control a hip strategy. Conclusions. The inability to control a hip strategy indicates a deficit of postural control and is hypothesized to result from altered muscle control and proprioceptive impairment.

The influence of a concurrent cognitive task on the compensatory stepping response to a perturbation in balance-impaired and healthy elders

This study investigated the influence of a concurrent cognitive task on the compensatory stepping response in balance-impaired elders and the attentional demand of the stepping response. Kinetic, kinematic and neuromuscular measures of a forward recovery step were investigated in 15 young adults, 15 healthy elders and 13 balance-impaired elders in a single task (postural recovery only) and dual task (postural recovery and vocal reaction time task) situation. Results revealed that reaction times were longer in all subjects when performed concurrently with a compensatory step, they were longer for a step than an in-place response and longer for balance-impaired older adults compared with young adults. An interesting finding was that the latter group difference may be related to prioritization between the two tasks rather than attentional demand, as the older adults completed the step before the reaction time, whereas the young adults could perform both concurrently. Few differences in step characteristics were found between tasks, with the most notable being a delayed latency and reduced magnitude of the early automatic postural response in healthy and balance-impaired elders with a concurrent task.

Patient Education to Prevent Falls Among Older Hospital Inpatients: A Randomized Controlled Trial

BACKGROUND Falls are a common adverse event during hospitalization of older adults, and few interventions have been shown to prevent them. METHODS This study was a 3-group randomized trial to evaluate the efficacy of 2 forms of multimedia patient education compared with usual care for the prevention of in-hospital falls. Older hospital patients (n = 1206) admitted to a mixture of acute (orthopedic, respiratory, and medical) and subacute (geriatric and neurorehabilitation) hospital wards at 2 Australian hospitals were recruited between January 2008 and April 2009. The interventions were a multimedia patient education program based on the health-belief model combined with trained health professional follow-up (complete program), multi-media patient education materials alone (materials only), and usual care (control). Falls data were collected by blinded research assistants by reviewing hospital incident reports, hand searching medical records, and conducting weekly patient interviews. RESULTS Rates of falls per 1000 patient-days did not differ significantly between groups (control, 9.27; materials only, 8.61; and complete program, 7.63). However, there was a significant interaction between the intervention and presence of cognitive impairment. Falls were less frequent among cognitively intact patients in the complete program group (4.01 per 1000 patient-days) than among cognitively intact patients in the materials-only group (8.18 per 1000 patient-days) (adjusted hazard ratio, 0.51; 95% confidence interval, 0.28-0.93]) and control group (8.72 per 1000 patient-days) (adjusted hazard ratio, 0.43; 95% confidence interval, 0.24-0.78). CONCLUSION Multimedia patient education with trained health professional follow-up reduced falls among patients with intact cognitive function admitted to a range of hospital wards. Trial Registration anzctr.org.au Identifier: ACTRN12608000015347.

Differences in postural control and movement performance during goal directed reaching in children with developmental coordination disorder

Poor upper-limb coordination is a common difficulty for children with developmental coordination disorder (DCD). One hypothesis is that deviant muscle timing in proximal muscle groups results in poor postural and movement control. The relationship between muscle timing, arm motion and childrens upper-limb coordination deficits has not previously been studied. The aim of this study was to investigate the relationship between functional difficulties with upper-limb motor skills and neuromuscular components of postural stability and coordination. Sixty-four children aged 8-10 years, 32 with DCD and 32 without DCD, participated in the study. The study investigated timing of muscle activity and resultant arm movement during a rapid, voluntary, goal-directed arm movement. Results showed that compared to children without DCD, children with DCD took significantly longer to respond to visual signals and longer to complete the goal-directed movement. Children with DCD also demonstrated altered activity in postural muscles. In particular, shoulder muscles, except for serratus anterior, and posterior trunk muscles demonstrated early activation. Further, anterior trunk muscles demonstrated delayed activation. In children with DCD, anticipatory function was not present in three of the four anterior trunk muscles. These differences support the hypothesis that in children with DCD, altered postural muscle activity may contribute to poor proximal stability and consequently poor arm movement control when performing goal-directed movement. These results have educational and functional implications for children at school and during activities of daily living and leisure activities and for clinicians assessing and treating children with DCD.

Failure to use movement in postural strategies leads to increased spinal displacement in low back pain

Study Design. Lumbar and hip movements, before and in response to rapid bilateral arm flexion, were evaluated in 10 people with recurrent low back pain (LBP) and 10 matched control subjects when standing on a flat surface or short base. Objective. To evaluate the preparatory movement and resultant displacement of the lumbopelvic region associated with internal perturbation in people with or without LBP. Summary of Background Data. Strategies to control the trunk involve movement. Small spinal movements (preparatory movement), opposite to the direction of reactive moments, precede voluntary arm movements in healthy individuals. However, people with LBP often use less spinal movement. We hypothesized that the tendency to reduce spinal motion in LBP may be associated with decreased preparatory motion, and this may counter intuitively lead to increased displacement of the trunk in response to arm movements. Methods. Movements at the lumbopelvic region before and in response to rapid bilateral arm flexion were examined using electromagnetic motion sensors when subjects were standing on a flat surface or short base. Results. In control subjects, preparatory extension of the lumbar spine preceded a resultant flexion of the region in 88% of trials on the flat surface. People with LBP used preparatory extension less frequently (69%, P = 0.027). Consequently, the spinal displacement (resultant flexion) induced by shoulder flexion was significantly greater in the LBP group (3.2° ± 1.8°) than controls (1.8° ± 1.6°, P = 0.004). There was a significant correlation (r = 0.47) between preparatory and resultant movement of the lumbar spine in the LBP group, which indicates that subjects with reduced preparatory extension were more likely to have a greater resultant displacement. Conclusion. These data suggest that spinal movement is different in people with LBP, and reduced spinal movement in advance of predictable perturbation may be associated with compromised quality of trunk control.

Measuring falls events in acute hospitals - A comparison of three reporting methods to identify missing data in the hospital reporting system

OBJECTIVES: To compare three different methods of falls reporting and examine the characteristics of the data missing from the hospital incident reporting system.

A Specific Inpatient Aquatic Physiotherapy Program Improves Strength After Total Hip or Knee Replacement Surgery: A Randomized Controlled Trial

OBJECTIVE To evaluate the effect of inpatient aquatic physiotherapy in addition to usual ward physiotherapy on the recovery of strength, function, and gait speed after total hip or knee replacement surgery. DESIGN Pragmatic randomized controlled trial with blinded 6-month follow-up. SETTING Acute-care private hospital. PARTICIPANTS People (n=65) undergoing primary hip or knee arthroplasty (average age, 69.6+/-8.2y; 30 men). INTERVENTIONS Participants were randomly assigned to receive supplementary inpatient physiotherapy, beginning on day 4: aquatic physiotherapy, nonspecific water exercise, or additional ward physiotherapy. MAIN OUTCOME MEASURES Strength, gait speed, and functional ability at day 14. RESULTS At day 14, hip abductor strength was significantly greater after aquatic physiotherapy intervention than additional ward treatment (P=.001) or water exercise (P=.011). No other outcome measures were significantly different at any time point in the trial, but relative differences favored the aquatic physiotherapy intervention at day 14. No adverse events occurred with early aquatic intervention. CONCLUSIONS A specific inpatient aquatic physiotherapy program has a positive effect on early recovery of hip strength after joint replacement surgery. Further studies are required to confirm these findings. Our research indicates that aquatic physiotherapy can be safely considered in this early postoperative phase.

Can people with Parkinson's disease improve dual tasking when walking?

BACKGROUND Gait disorders in people with Parkinsons disease (PD) are accentuated when they perform another task simultaneously. This study examines whether practice enables people with PD to walk with large steps while performing added tasks, and to determine if training people with PD to walk with added working memory tasks leads to improvements in gait when walking and performing other tasks simultaneously. METHODS Walking patterns were recorded pre and post a 20min dual task training session in 20 people with PD. Participants performed a series of 10m walking trials under seven conditions: gait only, and with six different added tasks varying by task type (e.g. motor, cognitive), domain (e.g. postural, manual manipulation, language, calculation, auditory, visuospatial), and difficulty level. Dual task training aimed to improve step length while simultaneously undertaking a variety of language and counting working memory tasks that were different to those used in assessment. RESULTS Following training, step length increased when performing five of the six added tasks, indicating transfer of dual task training when walking occurred across task types and domains. Improvements in gait speed occurred in three of the six added tasks. When other gait variables were examined, such as step length variability, few improvements with training were found. CONCLUSIONS Training can lead to larger steps when walking under dual task conditions in people with PD. The gait variable emphasised during dual task training appears to be an important factor in enabling the transfer of training improvements across tasks.

Does the type of concurrent task affect preferred and cued gait in people with Parkinson's disease?

Difficulty performing more than one task at a time is common in people with Parkinsons disease, resulting in interference with one or both tasks. While studies have shown that greater interference in gait occurs with more complex concurrent tasks, the impact of the type of concurrent task is unclear in the Parkinsons population. Thus the first purpose of this study was to investigate the effect of the concurrent task (calculation, language, or motor) on gait in people with Parkinsons disease. As visual cues are commonly used to aid stride regulation in people with Parkinsons disease, the second purpose of this study was to determine whether this method of increasing stride length was still effective if other tasks were performed simultaneously. Sixteen patients with Parkinsons disease and 16 gender- and age-matched controls performed six cognitive and motor concurrent tasks when seated, walking 10 m, and walking over visual cues. Stride length decreased in people with Parkinsons disease when performing the concurrent calculation and language tasks, but not with the motor task. The language task was more complex than the calculation task, thus the effect was not due to task complexity alone. Visual cues were effective in improving stride length whilst maintaining velocity in people with Parkinsons disease, even when performed under dual task conditions. These findings highlight the importance of the task when assessing and retraining dual tasking during gait, and suggest that retraining dual tasking can occur whilst simultaneously using visual aids to regulate stride length.

Training of Reaching in Stroke Survivors With Severe and Chronic Upper Limb Paresis Using a Novel Nonrobotic Device: A Randomized Clinical Trial

Background and Purpose— Severe upper limb paresis is a major contributor to disability after stroke. This study investigated the efficacy of a new nonrobotic training device, the Sensorimotor Active Rehabilitation Training (SMART) Arm, that was used with or without electromyography-triggered electrical stimulation of triceps brachii to augment elbow extension, permitting stroke survivors with severe paresis to practice a constrained reaching task. Methods— A single-blind, randomized clinical trial was conducted with 42 stroke survivors with severe and chronic paresis. Thirty-three participants completed the study, of whom 10 received training using the SMART Arm with electromyography-triggered electrical stimulation, 13 received training using the SMART Arm alone, and 10 received no intervention (control). Training consisted of 12 1-hour sessions over 4 weeks. The primary outcome measure was “upper arm function,” item 6 of the Motor Assessment Scale. Secondary outcome measures included impairment measures; triceps muscle strength, reaching force, modified Ashworth scale; and activity measures: reaching distance and Motor Assessment Scale. Assessments were administered before (0 weeks) and after training (4 weeks) and at 2 months follow-up (12 weeks). Results— Both SMART Arm groups demonstrated significant improvements in all impairment and activity measures after training and at follow-up. There was no significant difference between these 2 groups. There was no change in the control group. Conclusions— Our findings indicate that training of reaching using the SMART Arm can reduce impairment and improve activity in stroke survivors with severe and chronic upper limb paresis, highlighting the benefits of intensive task-oriented practice, even in the context of severe paresis.