Gait Training With Progressive External Auditory Cueing in Persons With Parkinson's Disease

Ford MP, Malone LA, Nyikos I, Yelisetty R, Bickel CS. Gait training with progressive external auditory cueing in persons with Parkinson's disease.

Objective

To investigate the progressively increasing external auditory cues during mobility training with persons with Parkinson's disease (PD).

Design

Experimental.

Setting

General community.

Participants

Convenience sample of persons with PD (N=12) who walked independently.

Interventions

Gait training to external auditory cues was based on a participant's comfortable walking pace. Training external auditory cues rates were increased if patients were able to maintain or increase stride length with increasing external auditory cues rate. Movement synchronization was not monitored during training. Participants trained for 30min/session, 3 sessions/wk, for 8 weeks.

Main Outcome Measures

Walking velocity, stride length, and cadence.

Results

Participants trained at a mean maximal rate of 157bpm. They showed a significant (P<.01) increase in walking velocity, stride length, and cadence after 8 weeks of training.

Conclusions

Walking velocity, stride length, and cadence can significantly improve when community-dwelling persons with PD participate in progressive mobility training.     

Interlimb Muscle and Fat Comparisons in Persons With Lower-Limb Amputation

Sherk VD, Bemben MG, Bemben DA. Interlimb muscle and fat comparisons in persons with lower-limb amputation.

Objectives

To investigate differences in muscle and fat tissue between amputated and intact limbs in subjects with transfemoral and transtibial amputations and to determine the effect of amputation level on limb differences. We hypothesized that the amputated limb would have a higher relative amount of fat than the intact limb, and transfemoral amputees would have greater limb differences in muscle size than transtibial amputees.

Design

Cross-sectional, repeated-measures design.

Setting

Laboratory.

Participants

Subjects included persons with unilateral transfemoral (TF) (n=5) and transtibial (TT) (n=7) amputations and age- and sex-matched nonamputation controls (n=12).

Interventions

Not applicable.

Main Outcome Measures

Muscle cross-sectional areas and fat cross-sectional areas of the end of residual limbs were compared with similar cross-sectional sites of the intact limb by using peripheral quantitative computed tomography scans. Thigh and lower-leg fat mass (FM) and bone-free lean body mass were measured by dual-energy x-ray absorptiometry.

Results

There was a 93% to 117% difference between limbs in muscle cross-sectional areas for TF and TT. TT had a between-limb difference of 39% for fat cross-sectional areas. Thigh bone-free lean body masses and FM were significantly (P<.05) lower for the amputated limb for both TF and TT. Thigh percent fat was significantly (P<.05) higher in the amputated thigh for TF and TT, but limb differences were greater in TF.

Conclusions

Muscle atrophy was prevalent in the residual limb with larger relative amounts of fat in the thighs, especially in TF subjects.     

Feasibility and Outcomes of a Home-Based Exercise Program on Improving Balance and Gait Stability in Women With Lower-Limb Osteoarthritis or Rheumatoid Arthritis: A Pilot Study

Williams SB, Brand CA, Hill KD, Hunt SB, Moran H. Feasibility and outcomes of a home-based exercise program on improving balance and gait stability in women with lower-limb osteoarthritis or rheumatoid arthritis: a pilot study.

Objective

To evaluate the feasibility and gait stability and balance outcomes of a 4-month individualized home exercise program for women with arthritis.

Design

Pre-post interventional study.

Setting

General community.

Participants

Women (N=49) (volunteers) with lower-limb osteoarthritis or lower-limb rheumatoid arthritis were enrolled. Only 39 subjects were eligible and completed the study.

Intervention

After completion of the initial assessment, all participants received home balance exercises from an experienced physiotherapist based on assessment findings and exercises available from commercially available kits. All measures were repeated 4 months later.

Main Outcome Measures

Falls risk (Falls Risk of Older People—Community Setting) and balance measures.

Results

Thirty-nine women (mean age, 69.3y; 95% confidence interval, 65.7-72.9) completed the 4-month program. At baseline, 64% of participants reported falling in the preceding 12 months, and the average falls risk (Falls Risk of Older People—Community Setting) score was 14.5, with 42% rated as moderate risk (16-23). Participants achieved improved performance on most balance and related measures after the exercise program, including falls risk (P=.01), activity levels (P=.015), fear of falling (P=.022), functional reach test (P=.001), rising index for sit to stand (P=.001), step width in walking (P=.001), and body mass index (P=.006).

Conclusions

An individualized balance training home exercise program is feasible for older women with osteoarthritis or rheumatoid arthritis and may improve stability during walking and other functional activities.     

Limits of Stability in Persons With Transtibial Amputation With Respect to Prosthetic Alignment Alterations

Objectives

To evaluate the limits of stability (LOS) in persons with transtibial amputation (TTA), and to determine the effects of prosthetic alignment alterations on motor control strategies.

Design

Before-and-after trial.

Setting

A kinesiology laboratory at a university hospital.

Participants

Male patients with TTA (n=10) and controls (n=17).

Interventions

Prosthetic alignment.

Main Outcome Measures

For the LOS test, the maximum excursion, endpoint excursion, direction control, movement velocity, and reaction time with inclination in the forward direction, toward the amputated leg/right leg, and in the backward direction, and toward the nonamputated leg/left leg. Measurements were performed using the following 5 prosthetic alignments: the optimal alignment, with the prosthesis shorter by 1cm, with the prosthesis longer by 1cm, and with the prosthetic foot in 5° of extra plantar flexion and 5° of extra dorsiflexion.

Results

Compared with the control group, maximum excursion and direction control were lower (P<.05) in patients with TTA with backward body inclination for all tested prosthetic alignments. Direction control in backward inclination was reduced (P<.05) compared with other tested directions for all assessed prosthetic alignments. Differences between the tested alignments were not significant in any of the tested directions.

Conclusions

Patients with TTA have decreased voluntary body inclination backward within the LOS for all tested prosthetic alignments. Compared with controls, changes in prosthetic foot settings by means of rotation in the sagittal plane had a larger impact on movement strategy in patients with TTA than did changes to the length of the prosthesis.     

Walking in an Unstable Environment: Strategies Used by Transtibial Amputees to Prevent Falling During Gait

Objective

To investigate which strategies transtibial amputees use to cope with challenges of gait stability and gait adaptability, and how these strategies differ from strategies used by able-bodied controls.

Design

Cross-sectional study.

Setting

An instrumented treadmill mounted onto a 6°-of-freedom motion platform in combination with a virtual environment.

Participants

Transtibial amputees (n=10) and able-bodied controls (n=9).

Interventions

Mediolateral (ML) translations of the walking surface were imposed to manipulate gait stability. To provoke an adaptive gait pattern, a gait adaptability task was used in which subjects had to hit virtual targets with markers guided by their knees.

Main Outcome Measures

Walking speed, step length, step frequency, step width, and selected measures of gait stability (short-term Lyapunov exponents and backward and ML margins of stability [MoS]).

Results

Amputees walked slower than able-bodied people, with a lower step frequency and wider steps. This resulted in a larger ML MoS but a smaller backward MoS for amputees. In response to the balance perturbation, both groups decreased step length and increased step frequency and step width. Walking speed did not change significantly in response to the perturbation. These adaptations induced an increase in ML and backward MoS. To perform the gait adaptability task, both groups decreased step length and increased step width, but did not change step frequency and walking speed. ML and backward MoS were maintained in both groups.

Conclusions

Transtibial amputees have the capacity to use the same strategies to deal with challenges of gait stability and adaptability, to the same extent as able-bodied people.     

Exergaming With Additional Postural Demands Improves Balance and Gait in Patients With Multiple Sclerosis as Much as Conventional Balance Training and Leads to High Adherence to Home-Based Balance Training

Objective

To assess the effectiveness of and adherence to an exergame balance training program with additional postural demands in patients with multiple sclerosis (MS).

Design

Matched controlled trial, assessment of balance before and after different balance training programs, and adherence to home-based balance exercise in the 6 months after the training.

Setting

A neurorehabilitation facility and center for MS.

Participants

Patients with balance problems (N=70) matched into 1 of the training groups according to age as well as balance and gait performance in 4 tests. Nine patients dropped out of the study because of scheduling problems. The mean age of the 61 remaining participants was 47±9 years, and their Expanded Disability Status Scale score was 3±1.

Interventions

Three weeks of (1) conventional balance training (control), (2) exergame training (playing exergames on an unstable platform), or (3) single-task (ST) exercises on the unstable platform.

Main Outcome Measures

Test scores in balance tests and gait analyses under ST and dual-task (DT) situations. Furthermore, in the 6 months after the rehabilitation training, the frequency and type of balance training were assessed by using questionnaires.

Results

All 3 groups showed significantly improved balance and gait scores. Only the exergame training group showed significantly higher improvements in the DT condition of the gait test than in the ST condition. Adherence to home-based balance training differed significantly between groups (highest adherence in the exergame training group).

Conclusions

Playing exergames on an unstable surface seems to be an effective way to improve balance and gait in patients with MS, especially in DT situations. The integration of exergames seems to have a positive effect on adherence and is thus potentially beneficial for the long-term effectiveness of rehabilitation programs.     

Functional Electrical Stimulation to Dorsiflexors and Plantar Flexors During Gait to Improve Walking in Adults With Chronic Hemiplegia

Embrey DG, Holtz SL, Alon G, Brandsma BA, McCoy SW. Functional electrical stimulation to dorsiflexors and plantar flexors during gait to improve walking in adults with chronic hemiplegia.

Objective

To determine whether functional electrical stimulation (FES) timed to activate the dorsiflexors and plantar flexors during gait improves the walking of adults with hemiplegia.

Design

Randomized crossover trial.

Setting

Outpatient rehabilitation clinic.

Participants

Adults with hemiplegia (N=28) with a mean age ± SD of 60±10.9 years and 4.9±3.8 years postincident.

Interventions

Intervention “A” included 3 months of wearing the FES system, which activated automatically during walking for 6 to 8h/d, 7d/wk, plus walking 1h/d, 6d/wk. Intervention “B” included 3 months of walking 1h/d, 6d/wk without FES. Of the 28 patients who completed the study, 15 were randomly assigned to group A-B, 13 to group B-A. Crossover occurred at 3 months.

Main Outcome Measures

Variables were measured at pretreatment, 3 months, and 6 months. Three primary outcomes were selected a priori and included 2 functional variables, the 6-minute walk test and the Emory Functional Ambulatory Profile, and 1 participation variable, the Stroke Impact Scale. Secondary impairment measures included muscle strength and spasticity. Assessments were done without electrical stimulation.

Results

In phase 1, patients who received treatment A (A-B group) showed improvement compared with patients who received treatment B (B-A group) on the 6-minute walk test (P=.02), Emory Functional Ambulatory Profile (P=.08), and Stroke Impact Scale (P=.03). In phase 2, the A-B group maintained improvement in all 3 primary outcomes even without FES. Both groups improved significantly on all primary outcome measures, comparing 6-month to initial measures (P≤.05).

Conclusions

An FES system that stimulates dorsiflexors and plantar flexors similar to the timing of typical adult gait, combined with daily walking, can improve the walking ability of adults with hemiplegia.     

Effects of Home-Based Locomotor Treadmill Training on Gross Motor Function in Young Children With Cerebral Palsy: A Quasi-Randomized Controlled Trial

Objective

To examine the effects of an intensive home-based program of treadmill training on motor skills related to walking in preambulatory children with cerebral palsy (CP).

Design

Quasi-randomized controlled trial.

Setting

Homes of the participants.

Participants

Children with CP (N=12) with Gross Motor Function Classification System levels I and II were assigned to the intervention group (n=6; mean age ± SD, 21.76±6.50mo) and control group (n=6; 21.25±6.07mo). All children were tested preintervention, postintervention, at a 1-month follow-up, and at a 4-month follow-up.

Interventions

All children received their weekly scheduled physical therapy sessions at their homes. In addition, children in the intervention group walked on a portable treadmill in their homes 6 times per week, twice daily for 10- to 20-minute sessions, for 6 weeks. The intervention was carried out by the children's parents with weekly supervision by a physical therapist.

Main Outcome Measures

Gross Motor Function Measure-66 Dimensions D/E, Peabody Developmental Motor Scales-2 (PDMS-2), Pediatric Evaluation of Disability Inventory (PEDI), timed 10-m walk test (10MWT), and Functional Mobility Scale (FMS). The Friedman test and Mann-Whitney U test were conducted for within-group and between-group differences, respectively.

Results

There was a significant between-group treatment effect for the PDMS-2 at posttest (P=.01) and 1-month postintervention follow-up (P=.09), as well as for the PEDI at posttest (P=.01), the 1-month postintervention follow-up (P=.009), and the 4-month postintervention follow-up (P=.04). The FMS was significant at the posttest (P=.04).

Conclusions

Home-based treadmill training accelerates the attainment of walking skills and decreases the amount of support used for walking in young children with CP.     

The Influence of Applying Additional Weight to the Affected Leg on Gait Patterns During Aquatic Treadmill Walking in People Poststroke

Jung T, Lee D, Charalambous C, Vrongistinos K. The influence of applying additional weight to the affected leg on gait patterns during aquatic treadmill walking in people poststroke.

Objective

To investigate how the application of additional weights to the affected leg influences gait patterns of people poststroke during aquatic treadmill walking.

Design

Comparative gait analysis.

Setting

University-based aquatic therapy center.

Participants

Community-dwelling volunteers (n=22) with chronic hemiparesis caused by stroke.

Interventions

Not applicable.

Main Outcome Measures

Spatiotemporal and kinematic gait parameters.

Results

The use of an ankle weight showed an increase in the stance phase percentage of gait cycle (3%, P=.015) when compared with no weight. However, the difference was not significant after a Bonferroni adjustment was applied for a more stringent statistical analysis. No significant differences were found in cadence and stride length. The use of an ankle weight showed a significant decrease of the peak hip flexion (7.9%, P=.001) of the affected limb as compared with no weight condition. This decrease was marked as the reduction of unwanted limb flotation because people poststroke typically show excessive hip flexion of the paretic leg in the late swing phase followed by fluctuating hip movements during aquatic treadmill walking. The frontal and transverse plane hip motions did not show any significant differences but displayed a trend of a decrease in the peak hip abduction during the swing phase with additional weights. The use of additional weight did not alter sagittal plane kinematics of the knee and ankle joints.

Conclusions

The use of applied weight on the affected limb can reduce unwanted limb flotation on the paretic side during aquatic treadmill walking. It can also assist the stance stability by increasing the stance phase percentage closer to 60% of gait cycle. Both findings can contribute to the development of more efficient motor patterns in gait training for people poststroke. The use of a cuff weight does not seem to reduce the limb circumduction during aquatic treadmill walking.     

Exploratory Study on Oxygen Consumption On-kinetics During Treadmill Walking in Women With Systemic Lupus Erythematosus

Keyser RE, Rus V, Mikdashi JA, Handwerger BS. Exploratory study on oxygen consumption on-kinetics during treadmill walking in women with systemic lupus erythematosus.

Objective

To determine whether oxygen consumption (V˙o₂) on-kinetics differed between groups of women with systemic lupus erythematosus (SLE) and sedentary but otherwise healthy controls.

Design

Exploratory case-control study.

Setting

Medical school exercise physiology laboratory.

Participants

Convenience samples of women with SLE (n=12) and sedentary but otherwise healthy controls (n=10).

Intervention

None.

Main Outcome Measures

V˙o₂ on-kinetics indices including time to steady state, rate constant, mean response time (MRT), transition constant, and oxygen deficit measured during bouts of treadmill walking at intensities of 3 and 5 metabolic equivalents (METs).

Results

Time to steady state and oxygen deficit were increased and rate constant was decreased in the women with SLE compared with controls. At the 5-MET energy demand, the transition constant was lower and MRT was longer in the women with SLE than in controls. For a similar relative energy expenditure that was slightly lower than the anaerobic threshold, the transition constant was higher in controls than in women with SLE.

Conclusion

V˙o₂ on-kinetics was prolonged in women with SLE. The prolongation was concomitant with an increase in oxygen deficit and may underlie performance fatigability in women with SLE.     

Individuals With Chronic Traumatic Brain Injury Improve Walking Speed and Mobility With Intensive Mobility Training

Objective

To determine the feasibility and impact of different dosages of Intensive Mobility Training (IMT) on mobility, balance, and gait speed in individuals with chronic traumatic brain injury (TBI).

Design

Prospective, single group design with 3-month follow-up.

Setting

University research laboratory.

Participants

Volunteer sample of participants with chronic TBI (N=10; ≥3mo post-TBI; able to ambulate 3.05m with or without assistance; median age, 35.4y; interquartile range, 23.5–46y; median time post-TBI, 9.91y; interquartile range, 6.3–14.2y). Follow-up data were collected for all participants.

Interventions

Twenty days (5d/wk for 4wk), with 150min/d of repetitive, task-specific training equally divided among balance; gait training; and strength, coordination, and range.

Main Outcome Measures

Pain and fatigue were recorded before and after each session to assess feasibility. Treatment outcomes were assessed before training (pre), after 10 sessions (interim), after 20 sessions (post), and at 3-months follow-up and included the Berg Balance Scale and gait speed.

Results

Participants averaged 150.1±2.7 minutes per session. Median presession and postsession pain scores were 0 (out of 10) for 20 sessions; median presession fatigue scores ranged from 0 to 2.5 (out of 10); and postsession scores ranged from 3 to 5.5 (out of 10). Four outcome measures demonstrated significant improvement from the pretest to interim, with 7 out of 10 participants exceeding the minimal detectable change (MDC) for fast walking speed. At the posttest, 2 additional measures were significant, with more participants exceeding the MDCs. Changes in fast walking speed and Timed Up and Go test were significant at follow-up.

Conclusions

Limited fluctuations in pain and fatigue scores indicate feasibility of IMT in this population. Participants demonstrated improvements in walking speed, mobility, and balance postintervention and maintained gains in fast walking speed and mobility at 3 months.     

No Effects of Whole-Body Vibration Training on Muscle Strength and Gait Performance in Persons With Late Effects of Polio: A Pilot Study

Brogårdh C, Flansbjer U-B, Lexell J. No effects of whole-body vibration training on muscle strength and gait performance in people with late effects of polio: a pilot study.

Objective

To evaluate the feasibility and possible effects of whole-body vibration (WBV) training on muscle strength and gait performance in people with late effects of polio.

Design

A case-controlled pilot study with assessments before and after training.

Setting

A university hospital rehabilitation department.

Participants

People (N=5; 3 men, 2 women; mean age, 64±6.7y; range, 55−71y) with clinically and electrophysiologically verified late effects of polio.

Interventions

All participants underwent 10 sessions of supervised WBV training (standing with knees flexed 40°−55° up to 60 seconds per repetition and 10 repetitions per session twice weekly for 5 weeks).

Main Outcome Measures

Isokinetic and isometric knee muscle strength (dynamometer), and gait performance (Timed Up & Go, Comfortable Gait Speed, Fast Gait Speed, and six-minute walk tests).

Results

All participants completed the 5 weeks of WBV training, with no discernible discomfort. No significant changes in knee muscle strength or gait performance were found after the WBV training period.

Conclusions

This pilot study did not show any significant improvements in knee muscle strength and gait performance following a standard protocol of WBV training. Thus, the results do not lend support to WBV training for people with late effects of polio.     

Efficacy of Partial Body Weight-Supported Treadmill Training Compared With Overground Walking Practice for Children With Cerebral Palsy: A Randomized Controlled Trial

Willoughby KL, Dodd KJ, Shields N, Foley S. Efficacy of partial body weight-supported treadmill training compared with overground walking practice for children with cerebral palsy: a randomized controlled trial.

Objective

To evaluate the efficacy of 9 weeks of twice-weekly partial body weight-supported treadmill training (PBWSTT) for children with cerebral palsy (CP) and moderate to severe walking difficulty compared with overground walking.

Design

Randomized controlled trial.

Setting

Metropolitan Specialist School for children with moderate to severe physical and/or intellectual disabilities.

Participants

Thirty-four children classified level III or IV by the Gross Motor Function Classification System were recruited and randomly allocated to experimental or control groups. Of these, 26 (15 girls, 11 boys; mean age 10y, 10mo ± 3y, 11mo [range, 5-18y]) completed training and testing.

Interventions

Both groups completed 9 weeks of twice-weekly walking training. The experimental group completed PBWSTT, and the control group completed overground walking practice.

Main Outcome Measures

Ten-meter walk test (self-selected walking speed), 10-minute walk (walking endurance), School Function Assessment.

Results

The overground walking group showed a trend for an increase in the distance walked over 10 minutes (F=3.004, P=.097). There was no statistically significant difference in self-selected walking speed over 10 meters or in walking function in the school environment as measured by the School Function Assessment.

Conclusions

PBWSTT is safe and feasible to implement in a special school setting; however, it may be no more effective than overground walking for improving walking speed and endurance for children with CP. Continued emphasis on progressive reduction of body weight support along with adding concurrent overground walking practice to a treadmill training protocol may increase the intensity of training and assist with carryover of improvements to overground walking. Treadmill training programs that include concurrent overground walking as an additional key feature of the training protocol need to be rigorously evaluated for children with CP.