Predictive discriminative accuracy of walking abilities at discharge for community ambulation levels at 6 months post-discharge among inpatients with subacute stroke

[Purpose] This study aimed to compare the predictive accuracy of walking ability at discharge among subacute stroke inpatients at 6 months post-discharge in terms of community ambulation level and establish optimal cut-off values. [Participants and Methods] This prospective observational study included 78 patients who completed follow-up assessments. Patients were classified into three groups based on the Modified Functional Walking Category (household/most limited community walkers, least limited community walkers, and unlimited community walkers) obtained by telephone survey at 6 months post-discharge. Predictive accuracy and cut-off values for discriminating among groups were calculated from 6-minute walking distance and comfortable walking speed measured at the time of discharge using receiver operating characteristic curves. [Results] Between household/most limited and least limited community walkers, 6-minute walking distance and comfortable walking speed offered similar predictive accuracy (area under the curve, 0.6–0.7), with cut-off values of 195 m and 0.56 m/s, respectively. Between least limited and unlimited community walkers, the areas under the curve were 0.896 for 6-minute walking distance and 0.844 for comfortable walking speed, with cut-off values of 299 m and 0.94 m/s, respectively. [Conclusion] Walking endurance and walking speed among inpatients with subacute stroke provided superior predictive accuracy for unlimited community walkers at 6 months post-discharge.     

Nordic walking for geriatric rehabilitation: a randomized pilot trial

Purpose: There is a need to identify effective interventions to promote walking capacity in seniors. This study compares nordic walking (NW) and usual overground walking (OW) and estimates the relative efficacy in improving walking capacity (endurance and gait speed) of the elderly. Method: Single blind, site-stratified, randomized, pilot trial designed to estimate the amount of change with NW and OW. Main outcomes were distance walked measured by 6-min walk test (6MWT) and comfortable gait speed measured by 5-meter walk test (5MWT). Explanatory variables were age, sex, number of comorbidities, walking aids, balance, pain, and leg function. Results: NW and OW participants improved, respectively, 45 and 41 m on 6MWT and increased their gait speed by 0.14 and 0.07 m/s, respectively. NW effect sizes were moderate for 6MWT (ES = 0.53) and large for gait speed (effect size (ES) = 0.68). OW demonstrated moderate effect size for 6MWT (ES = 0.53) but a small one for gait speed (ES = 0.33). Relative efficacy, which was obtained from the ratio of NW and OW effects’ sizes, was 1 for 6MWT and 2.06 for gait speed. Conclusions: NW is 106% more effective in improving gait speed among elderly than OW.

Implications for Rehabilitation

• Elderly are the fastest growing segment of the population. With advanced age, greater number of disabilities, and consequently mobility limitations, are observed among this group.

• Nordic walking is a more intensive form of walking, using muscles of upper and lower body. There’s evidence that nordic walking leads to greater cardiorespiratory workload without an increase in the level of exertion.

• In this study, nordic walking was 106% more efficient than regular walking in improving gait speed among the elderly.

• Clinicians specialized in geriatric rehabilitation may contribute to improve gait speed of seniors by adding nordic walking, a non-expensive and feasible option, to their physiotherapy sessions.

     

Effect of hybrid assistive limb treatment on maximal walking speed and six-minute walking distance during stroke rehabilitation: a pilot study

[Purpose] In stroke rehabilitation, gait assessment measures the maximal walking speed and six-minute walking distance, both of which have not been thoroughly investigated as determinants of walking ability. Here, we assessed the methods for evaluating these gait parameters using clinical data on hybrid assistive limb treatment compared with conventional training. [Participants and Methods] In total, 20 stroke patients (hybrid assistive limb group, n=9; conventional group, n=11) participated in this randomized controlled trial. For 12 sessions (three times per week in 4 weeks), the hybrid assistive limb and conventional groups performed gait treatment with hybrid assistive limb and conventional gait training, respectively. Short physical performance battery and walking ability (maximal walking speed and six-minute walking distance) were evaluated pre- and post-intervention. Subsequently, the patients were divided further into two groups: low- and high-balance score groups. [Results] Maximum walking speed and six-minute walking distance were significantly associated, with a positive relationship observed post-intervention. The high-balance score group showed a significant improvement in the six-minute walking distance compared to the low-balance score group. However, no significant improvement in maximum walking speed was observed between both groups. [Conclusion] Due to its sensitivity in detecting differences in balance, six-minute walking distance may be a useful assessment parameter for stroke rehabilitation, particularly in the recovery of physiological walking ability.Key words: Gait assessment, Stroke rehabilitation, Hybrid assistive limb     

偏瘫患者步态空间—时间参数对自由和最大步行速度的影响

目的分析脑卒中偏瘫患者步态周期中空间—时间参数对自由和最大步行速度的影响。方法采用 10m步行速度法测定 85例脑卒中偏瘫患者的自由和最大步行速度以及步态周期参数 ,线性回归分析步长和步频对自由和最大步行速度的影响程度。结果自由和最大步行速度与步长和步频之间呈高度正相关 (r =0 .849-0 .915 ,P <0 .0 0 1) ,步长可预测自由步行速度84%的变异量 (P <0 .0 0 1) ,步长和步频可共同预测自由步行速度 94%的变异量 ;步长可预测最大步行速度 83 %的变异量 ,步长和步频可共同预测最大步行速度 96%的变异量。结论影响脑卒中偏瘫患者自由或最大步行速度的最重要因素是步长。     

脑卒中偏瘫患者步行速度变化的研究

目的该文通过对脑卒中偏瘫患者步行速度的变化与病程关系的研究,探讨脑卒中偏瘫患者步行速度恢复的规律。方法35例发病后6周内进行步行功能训练的的脑卒中偏瘫患者,连续进行12周的步行速度评测。步行速度测量方法采用10m最大步行速度测定方法。结果脑卒中偏瘫患者最大步行速度的变化与病程呈近似双曲线函数关系Y=A-B/X(R2=0.971)。结论脑卒中偏瘫患者的步行速度恢复的变化是有规律的,而且是可以预测的。     

Tests of walking ability at different speeds in patients with knee osteoarthritis

Background and Purpose . Measurements of walking speeds are commonly used as an objective measure of functional performance in patients with knee osteoarthritis (OA) and are easily performed in a clinical setting. However, the choice in which the walking speed evaluation should be performed is controversial. The aim of this study was to identify the most discriminating walking speed after surgical interventions in patients with knee osteoarthritis, and to compare the responsiveness of the different gait speeds. Method . A prospective clinical one‐year follow‐up study involving 54 patients with knee osteoarthritis (63 (±5) years of age) who were operated with either a unicompartmental knee arthroplasty or a high tibial osteotomy was undertaken. Thirty‐nine patients had unilateral knee OA and 15 patients had bilateral knee OA or other symptoms from the lower extremities that could influence walking. The patients were examined at a gait laboratory before surgery, and one year after surgery. The patients were instructed to walk at slow, normal and fast walking speed. Results . All patients (n = 54) walked faster one year after the surgical intervention compared to before surgery (p = 0.001) at slow (+15%), normal (+8%) and fast (+7%) walking speed. This increase was similar for the three walking speeds (p = 0.171). Patients with unilateral knee OA (n = 39) reached an average change of +0.12 m/s, which was considered clinically important, while patients with bilateral knee OA (n = 15) did not increase their walking speed > 0.12 m/s. Effect size was moderate for slow walking speed and small for normal and fast walking speeds, respectively. Conclusions . The different walking speeds were equally good in detecting changes one year after surgical interventions. In this study, responsiveness favoured slow walking speed, however, the advantages of normal walking speed are discussed. Copyright © 2007 John Wiley & Sons, Ltd.     

Rate of isometric knee extension strength development and walking speed after stroke

The relationship between lower-limb weakness and walking speed after stroke is not clear. This may be related to the measurement used to quantify weakness, typically peak strength. This study examined the relationship between two measures of isometric knee extension strength, i.e., peak torque and the rate of torque development and walking speed in adults with stroke. This study had 83 stroke survivors who participated. For the affected lower limb, rate and peak torque explained 12% of the variance in gait speed. Removing rate from the model significantly reduced the explained variance; in contrast, removing peak torque did not reduce the variance. For the less affected lower limb, rate tended to be more predictive of gait speed than peak torque. Diminished ability to rapidly generate knee extension torque contributes more to decreased walking speed after stroke than does maximal strength. Of note, 88% of the variance in gait speed is not explained by rate and peak isometric knee extension strength. Further studies are needed to determine if rehabilitation poststroke can increase the rate of knee strength development and if it results in faster walking speeds.     

Limitations in Gait Speed Persist at Discharge from Subacute Rehabilitation

[Purpose] Walking speed is related to important outcomes such as mortality and is fundamental to independent and safe ambulation in the community. The objectives of this study were to determine if the discharge gait speed of patients completing subacute rehabilitation was slow relative to normative and street crossing reference values, and whether such speed was associated with age, gender, or diagnosis. [Subjects and Methods] Consecutive patients admitted to a subacute rehabilitation facility were screened based on inclusion and exclusion criteria. Participants were 109 patients (56 women) 60 to 98 (mean=78.2) years old who were divided into 10 diagnostic categories. Gait speed was measured over a distance of 5.2 meters as patients walked at their most comfortable speed beyond a designated finish line. Timing with a digital stopwatch began after an acceleration distance of 1 meter and ceased as patients crossed the finish line. [Results] The patients'' comfortable gait speed (mean=0.58; SD=0.19; range=0.09–1.10 m/s) was significantly less than 1.0m/s (normal reference value) (1.11±0.15 m/s) but significantly greater than that required for crossing the street (0.49 m/s). Nevertheless, 27.5% of patients did not achieve a walking speed of 0.49 m/s. Speed was inversely related to age and was lower among women, but it was not affected by diagnostic category. [Conclusion] Gait speed remains limited when patients are discharged home from subacute rehabilitation and was slowest among older women patients. Further therapy may be warranted for such patients after discharge.Key words: Gait speed, Rehabilitation, Older adults     

步态适应性训练在脑卒中康复中应用的研究进展

步态适应性是指为了满足任务目标和环境限制而调整步态.在脑卒中康复中,步态适应性训练根据训练环境可分为真实环境和模拟环境两大类,模拟环境又分为简单室内场景和多模态场景.虚拟现实和增强现实等技术的发展为多模态步行训练提供了更加安全高效的方式.步态适应性训练可改善偏瘫患者步行功能和信心,帮助其重新回归社区生活,提高社会参与.     

脑卒中患者功能恢复的测定:自由步行与最大步行速度的比较

目的比较脑卒中患者自由与最大步行速度在评定功能恢复结果中的价值。方法对 3 2例恢复步行能力的脑卒中偏瘫患者 ,测定自然舒适状态下的 10m步行速度和 10m最大步行速度 ,用Fugl Meyer评定法评定下肢运动功能 ,用Berg平衡量表评定平衡功能 ,用功能独立性测量中的移动类项目测量综合移动能力。对自由步行和最大步行速度与临床评定变量间进行Pearson相关分析。结果自由步行和最大步行速度之间呈高度正相关 (r =0 95 3 ,P <0 0 0 1) ;自由步行和最大步行速度与平衡功能、下肢运动功能和综合移动能力之间呈高度正相关 (r =0 742— 0 83 4,P <0 0 0 1) ;但自由步行速度与功能恢复的相关性更高 (r =0 787— 0 83 4,P <0 0 0 1)。结论自由步行和最大步行速度都能够反映功能恢复结果 ,但是自由步行速度测定方法更实用、更安全和更敏感。     

The impact of walking speed on the effects of functional electrical stimulation for foot drop in people with multiple sclerosis

Purpose: Functional electrical stimulation (FES) is effective in assisting people with multiple sclerosis (pwMS) with gait. Previous studies have investigated the effects of FES in pwMS with slow self-selected walking speeds (SSWS). This study reports on the effect of the Odstock Dropped Foot Stimulator (ODFS) on the speed and oxygen (O₂) cost of gait in pwMS walking at a range of SSWS. Methods: Twenty pwMS (mean age 50.4?±?7.3 years) currently using FES walked at their SSWS for 5?min with and without FES. O₂ cost of gait was measured using a gas analysis system, and gait speed was calculated. Data were analysed for all participants, and comparisons were made between those with a SSWS < and >0.8?m/s (walking speed required for community ambulation). Results: Significant improvements in the speed and O₂ cost of gait were seen using FES in the group with SSWS <0.8?m/s (n?=?11, p?=?0.005). When participants’ SSWS >0.8?m/s, no difference in gait speed was noted, and a significant increase in O₂ cost of gait using FES (n?=?9, p?=?0.004) was noted. Conclusion: FES has a different effect on the speed and O₂ cost of gait dependent on the SSWS of pwMS. This requires further investigation.

• Implications for Rehabilitation

• Functional electrical stimulation (FES) used for foot drop is effective in improving the speed and oxygen cost of walking in pwMS walking at SSWS <0.8?m/s.

• FES does not seem to have a beneficial effect on the speed and oxygen cost of walking in pwMS walking at SSWS >0.8?m/s.

• Further research is needed to understand the possible mechanisms involved so that FES for foot drop can be efficiently prescribed.

     

The effect of environment and task on gait parameters after stroke: A randomized comparison of measurement conditions

OBJECTIVES: To assess the effect of environment and a secondary task on gait parameters in community ambulant stroke survivors and to assess the contribution of clinical symptoms to gait performance. DESIGN: A 2x3 randomized factorial design with 2 main factors: task (no task, motor task, cognitive task) and environment (clinic, suburban street, shopping mall). SETTING: Subjects were assessed in 1 of 3 settings: 2 in the community (a suburban street and shopping mall) and 1 clinical environment. PARTICIPANTS: Twenty-seven people with stroke (mean age, 61+/-11.6y; mean time since stroke onset, 45.8+/-34.2mo), living at home, were recruited from community stroke groups and from a local rehabilitation unit. Selection criteria included the following: ability to give informed consent, unilateral first ever or recurrent stroke at least 6 months previously, walking independently in the community, a gait speed between 24 and 50 m/min, Mini-Mental State Examination score of 24 or higher, and no severe comorbidity. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Gait speed (in m/min), cadence, and step length were assessed by using an accelerometer with adjustable thresholds. Clinical measures hypothesized to influence gait parameters in community environments were also assessed including fatigue, anxiety and depression, and attentional deficit. RESULTS: Twenty-seven people with a mean baseline gait speed of 42.2+/-5.9 m/min were randomly allocated to 1 of 9 conditions in which the setting and distraction were manipulated. Analysis of variance showed a significant main effect for environment (P = .046) but not for task (P = .37). The interaction between task and environment was not significant (P = .73). Adjusting for baseline gait speed, people walked on average 8.8m/min faster in the clinic (95% confidence interval, 0.3-17.3m/min) than in the mall. Scores for fatigue, anxiety and depression, and attentional deficit were higher than normative values but did not influence gait performance. CONCLUSIONS: This study suggests that people with chronic stroke cope well with the challenges of varied environments and can maintain their gait speed while performing a secondary task. Despite moderate levels of gait impairment, gait automaticity may be restored over time to a functional level.     

Gait outcomes after additional backward walking training in patients with stroke: a randomized controlled trial

OBJECTIVE: To examine the effectiveness of additional backward walking training on gait outcome of patients post stroke. DESIGN: Randomized controlled trial. SETTING: Medical centre. SUBJECTS: Twenty-five subjects with stroke, who were lower extremity Brunnstrom motor recovery stage at 3 or 4 and were able to walk 11 m with or without a walking aid or orthosis, randomly allocated to two groups, control (n = 12) and experimental (n = 13). INTERVENTIONS: Subjects in both groups participated in 40 min of conventional training programme three times a week for three weeks. Subjects in experimental group received additional 30 min of backward walking training for three weeks at a frequency of three times per week. MAIN MEASURES: Gait was measured using the Stride Analyzer. Gait parameters of interest were walking speed, cadence, stride length, gait cycle and symmetry index. Measures were made at baseline before commencement of training (pre-training) and at the end of the three-week training period (post-training). RESULTS: After a three-week training period, subjects in experimental group showed more improvement than those in control group for walking speed (change score: 8.60 +/- 6.95 versus 3.65 +/- 2.92, p-value = 0.032), stride length (change score: 0.090 +/- 0.076 versus -0.0064 +/- 0.078, p-value = 0.006), and symmetry index (change score: 44.07 +/- 53.29 versus 5.30 +/- 13.91, p-value = 0.018). CONCLUSIONS: This study demonstrated that asymmetric gait pattern in patients post stroke could be improved from receiving additional backward walking therapy.     

功能性电刺激对偏瘫患者下肢功能及步态的影响

目的:观察功能性电刺激对脑卒中偏瘫患者下肢运动功能及步态的影响。方法:60例脑卒中偏瘫患者分成观察组和对照组,每组30例。对照组采用常规康复训练方法,观察组在此基础上增加佩戴步态诱发功能电刺激仪的步态训练,每次20min,每周5次,持续8周。于治疗前后采用下肢Fugl-Meyer运动功能评分(FMA)、功能性步行能力分级(FAC)及足印分析法对2组患者进行评定。结果:治疗8周后,2组患者下肢FMA评分、FAC分级及患侧的平均步长、步宽及步速均较治疗前显著提高(P<0.05),且观察组更高于对照组(P<0.05)。结论:使用功能性电刺激进行步态训练后可进一步改善脑卒中偏瘫患者的下肢运动功能,提高步行能力。     

Physiological cost index (PCI) and walking performance in individuals with transfemoral prostheses compared to healthy controls

Purpose.?Uncomplicated methods for evaluation of prosthetic walking performance for individuals with lower limb amputations are valuable. The Physiological Cost Index (PCI), the comfortable walking speed (CWS) and self-reported walking distances are three examples of such measures. The aim was to obtain values for these measures for individuals walking with transfemoral prostheses and to compare the results with healthy controls.

Method.?Individuals with an established transfemoral amputation for reasons other than vascular disease (TFA-group, n = 41, 30 male/11 female, mean age 49, SD 11.5) were compared to age-and gender matched healthy controls (Healthy group, n = 22). PCI was assessed walking in CWS for 5 min and self-reported distances accomplished outdoors was assessed with the Walking Habit Score (0 – 100).

Results.?Mean PCI was 0.55 (SD 0.19) in the TFA-group and 0.31 (SD 0.09) in the Healthy group (p < 0.001). The CWS was 62 (SD 12.6) and 90 (SD 12.8) m/min and the Walking Habit Score 48 (SD 19) and 74 (SD 16) score-points respectively (p < 0.001).

Conclusions.?By using uncomplicated and inexpensive methods, this study shows that walking with transfemoral prostheses is done with considerably increased energy cost, slower CWS and that limited walking distances outdoors are performed compared to healthy controls.     

Dual-task exercise improves walking ability in chronic stroke: a randomized controlled trial

Yang YR, Wang RY, Chen YC, Kao MJ. Dual-task exercise improves walking ability in chronic stroke: a randomized controlled trial.

Objective

To examine the effectiveness of a dual-task-based exercise program on walking ability in subjects with chronic stroke.

Design

Single-blind randomized controlled trial.

Setting

General community.

Participants

Twenty-five subjects with chronic stroke who were at least limited community ambulatory subjects (a minimum gait velocity, 58cm/s).

Interventions

Participants were randomized into a control group (n=12) or experimental group (n=13). Subjects in the control group did not receive any rehabilitation training. Subjects in the experimental group underwent a 4-week ball exercise program.

Main Outcome Measures

Gait performance was measured under single task (preferred walking) and tray-carrying task. Gait parameters of interest were walking speed, cadence, stride time, stride length, and temporal symmetry index.

Results

The experimental group showed significant improvement in all selected gait measures except for temporal symmetry index under both task conditions. In the control group, there were no significant changes over the 4-week period for all selected measures. There was a significant difference between groups for all selected gait variables except for temporal symmetry index under both task conditions.

Conclusions

The dual-task-based exercise program is feasible and beneficial for improving walking ability in subjects with chronic stroke.     

Matching walking speed of controls affects identification of gait deviations in patients with a total knee replacement

BackgroundThe assessment of functional recovery of patients after a total knee replacement includes the quantification of gait deviations. Comparisons to comfortable gait of healthy controls may incorrectly suggest biomechanical gait deviations, since the usually lower walking speed of patients already causes biomechanical differences. Moreover, taking peak values as parameter might not be sensitive to actual differences. Therefore, this study investigates the effect of matching walking speed and full-waveform versus discrete analyses.MethodsGait biomechanics of 25 knee replacement patients were compared to 22 controls in two ways: uncorrected and corrected for walking speed employing principal component analyses, to reconstruct control gait biomechanics at walking speeds matched to the patients. Ankle, knee and hip kinematics and kinetics were compared over the full gait cycle using statistical parametric mapping against using peak values.FindingsAll joint kinematics and kinetics gait data were impacted by applying walking speed correction, especially the kinetics of the knee. The lower control walking speeds used for reference generally reduced the magnitude of differences between patient and control gait, however some were enlarged. Full-waveform analysis identified greater deviating gait cycle regions beyond the peaks, but did not make peak value analyses redundant.InterpretationMatching walking speed of controls affects identification of gait deviations in patients with a total knee replacement, reducing deviations confounded by walking speed and revealing hidden gait deviations related to possible compensations. Full-waveform analysis should be used along peak values for a comprehensive quantification of differences in gait biomechanics.     

脑卒中偏瘫患者下肢痉挛与步行速度的关系

目的探讨脑卒中偏瘫患者下肢痉挛与步行速度之间的关系。方法对 3 5例脑卒中偏瘫痉挛患者用改良Ashworth法评定下肢膝伸肌和足跖屈肌的痉挛程度 ;测定步行速度、步距和步频 ;分析膝伸肌和足跖屈肌痉挛与步行速度、步长和步频之间的相关性 ,以及决定步行速度、步长和步频的下肢痉挛因素。结果患者在自由步行时的步行速度与膝伸肌和足跖屈肌痉挛呈中度负相关 (r =-0 .43 2 ,P <0 .0 5 ;r =-0 .44 8,P <0 .0 5 ) ,其中膝伸肌痉挛仅与步频呈中度负相关 (r =-0 .415 ,P <0 .0 5 ) ,而足跖屈肌痉挛与步距和步频呈中度负相关 (r =-0 .41,P <0 .0 5 ;r =-0 .3 3 5 ,P <0 .0 5 )。最大步行速度时的步长和步频与膝伸肌和足跖屈肌痉挛之间无相关性 (r =-0 .118— 0 .3 0 7,P >0 .0 5 )。决定自由步行速度、步长的下肢痉挛因素是足跖屈肌痉挛 (分别为R2 =0 .2 0 ,P <0 .0 1;R2 =0 .168,P <0 .0 5 ) ;决定步频的是膝伸肌痉挛 (R2 =0 .172 ,P <0 .0 5 )。结论脑卒中偏瘫患者下肢痉挛对步行速度的影响力较小 ,在以改善患者步行能力为目的的治疗中 ,应重点关注痉挛以外的其他更重要的临床因素。     

Gait impairments in persons with multiple sclerosis across preferred and fixed walking speeds

Remelius JG, Jones SL, House JD, Busa MA, Averill JL, Sugumaran K, Kent-Braun JA, Van Emmerik RE. Gait impairments in persons with multiple sclerosis across preferred and fixed walking speeds.ObjectivesTo investigate (1) whether previously observed changes in gait parameters in individuals with multiple sclerosis (MS) are the result of slower preferred walking speeds or reflect adaptations independent of gait speed; and (2) the changes in spatiotemporal features of the unstable swing phase of gait in people with MS.DesignCross-sectional study assessing changes in gait parameters during preferred, slow (0.6m/s), medium (1.0m/s), and fast (1.4m/s) walking speeds.SettingGait laboratory with instrumented walkway and motion capture system.ParticipantsMS group with mild to moderate impairment (n=19, 16 women) with a median Expanded Disability Status Scale score of 3.75 (range, 2.5–6), and a sex- and age-matched control group (n=19).InterventionsNot applicable.Main Outcome MeasuresGait speed, stride length, stride width, cadence, dual support time, swing time, and timing of swing foot and body/head center of mass during swing phase.ResultsIndividuals with MS walked at slower preferred speeds with longer dual support times compared with controls. In fixed-speed conditions, dual support times were longer and swing times were shorter in MS compared with controls. Stride width was wider for all speed conditions in the MS group. In fixed-speed conditions, the MS group positioned their head and body centers of mass closer to the anterior base of support boundary when entering the unstable equilibrium of the swing phase.ConclusionsLonger dual support time is part of a gait strategy in MS that is apparent even when controlling for the confounding effect of slower preferred speed. However, a gait strategy featuring longer dual support times may have limitations if potentially destabilizing swing dynamics exist, which especially occur at walking speeds other than preferred for people with MS.