Psychometric properties of dual-task balance and walking assessments for individuals with neurological conditions: A systematic review

BackgroundThe ability of performing a balance or walking task in conjunction with a secondary cognitive or motor task, referred to as dual-task (DT) ability, is essential in daily living. While there is some evidence that DT performance is impaired in individuals with neurological conditions, using reliable and valid tools to measure DT performance is essential. This systematic review aimed to evaluate the psychometric properties of DT balance and walking assessments in individuals with different neurological conditions.MethodsA systematic literature search was conducted using PubMed, CINAHL, MEDLINE, PsycINFO, SCOPUS, Web of Science, and Cochrane Library (last search done in April 2016). The methodological quality was rated using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist.ResultsTwenty-three articles involving individuals with stroke, Parkinson’s disease, mild cognitive impairment, dementia, Alzheimer’s disease, and multiple sclerosis were included. Outcomes derived from the walking tasks under DT condition generally demonstrated good reliability (correlation coefficient ≥0.75) across different neurological disorders, but their usefulness in distinguishing fallers from non-fallers was inconclusive. The reliability of outcomes derived from the cognitive/motor tasks and from the dual-task effect (DTE) (i.e., DT performance minus single-task performance) seemed to be lower but was understudied. The reliability of static or dynamic sitting/standing balance outcomes in DT condition was not assessed in any of the selected studies.ConclusionsThe reliability of the outcomes derived from walking tasks was good. The psychometric properties of other DT outcomes need to be further investigated.     

Comparable walking gait performance during executive and non-executive cognitive dual-tasks in chronic stroke: A pilot study

BackgroundFalls are a serious problem among stroke survivors due to subsequent injuries, recovery setbacks, dependence, and mortality. A growing body of dual-task (DT) studies suggests a role of executive functions in gait control and falls, particularly in subacute stroke. However, few studies have compared distinct executive and non-executive tasks, nor their effects on chronic stroke gait. Research question: The purpose of this cross-sectional study was to compare the effects of distinct working memory (2-back) and inhibition (Stroop) tasks on walking gait performance in chronic stroke survivors.MethodsA pilot sample of chronic stroke survivors (n = 11, 8 males, mean age = 70.91, 6-12months post-stroke event) and age-matched healthy controls (n = 13, 4 male; mean age = 68.46) were tested. Gait performance (speed, stride time, stride time variability, stride length and stride length variability) was measured using 2 wireless inertial measurement sensors under 4 walking conditions: 1) preferred walking (single-task: ST), 2) walking with a 2-back DT, 3) walking with a Stroop DT, and 4) walking with a non-executive motor response DT. The secondary tasks were also carried out in both ST (seated) and DT conditions, to examine bidirectional effects.ResultsWhile the stroke survivor sample had a slower gait speed across conditions and tasks, there were no significant differences between the groups [F(1, 22) = 1.13, p =.299, η²p = .049] on the spatial or temporal gait characteristics recorded: gait performance was maintained during executive and non-executive DTs. In addition, we did not find a significant effect of group on cognitive task performance (all p > .052). However, we observed a cost in accuracy on the 2-back DT for both groups, suggesting resource overlap and greater cognitive load (all t > 19.72, all p < .001).SignificanceOur gait data contradict previous studies evidencing impaired gait post-stroke, suggesting functional recovery in this chronic stroke sample.     

Effects of augmented somatosensory input using vibratory insoles to improve walking in individuals with chronic post-stroke hemiparesis

BackgroundStroke survivors suffer from hemiparesis and somatosensory impairments, which adversely impact walking performance, placing them at higher risks for trips and falls. Post-stroke, somatosensory deficits are commonly observed as impaired interpretation of afferent input and increased threshold. Diminishing or augmenting somatosensory inputs via various techniques have been demonstrated to be able to modify static and dynamic balance, postural and locomotor control in non-neurologically impaired as well as neurologically impaired individuals.Research question: We sought to investigate whether enhancing somatosensory input using vibratory insoles, can improve post-stroke gait. We hypothesized that with augmentation of somatosensory input at the soles via vibratory insoles would improve post-stroke gait via increased propulsive forces, decreased braking forces and increased ankle angle movements in the paretic legs of individuals with chronic post-stroke hemiparesis.MethodsFifteen individuals with chronic post-stroke hemiparesis and 15 age-similar non-neurologically impaired controls participated in this cross-sectional study. Enhanced somatosensory stimulation was delivered using a pair of tactor-embedded insoles, providing suprathreshold vibratory stimulation to the bottom of the feet. Participants walked over an instrumented treadmill with self-selected speeds, under 5 conditions: no insole in shoe (NT), insoles in shoe with no vibration (BOFF), vibration under both feet (BON), vibration under one foot only (ION, CON). Kinetics and kinematics during walking were recorded and analyzed offline.ResultsSuprathreshold vibratory stimulations did not alter gait kinetics under any stimulation conditions. We observed increased paretic ankle dorsiflexions in the paretic legs, when vibratory stimuli were applied unilaterally.SignificanceVibratory stimulations applied at suprathreshold intensity to the bottom of the feet to augment somatosensory feedback can potentially be used as a low-cost solution to address the inadequate toe clearance during walking in people post-stroke, which is an important goal in post-stroke rehabilitation.     

Comparison of underwater gait training and overground gait training for improving the walking and balancing ability of patients with severe hemiplegic stroke: A randomized controlled pilot trial

BackgroundWalking training is an essential intervention to improve the function in stroke patients. However, only a limited number of gait training strategies are available for stroke patients with relatively severe disabilities.Research questionIs underwater gait training or overground gait training more effective in severe stroke patients?MethodsA total of 21 patients with severe hemiplegic stroke were randomly assigned to the experimental and control groups. All participants (n = 21) received 60-minute sessions of general physical therapy, 5 times a week for a period of 12 weeks. Additionally, the experimental and control groups underwent underwater and overground walking training, respectively, for 30 min twice times a week for 12 weeks. Postural assessment for stroke score, center of pressure path length and velocity, step time and step length difference, and walking velocity were measured before and after the 12-week training.ResultsBoth groups showed a significant decrease in the center of pressure path length and velocity after the intervention compared to the values before the intervention (p < .05). However, there was no significant difference in the center of pressure path length and velocity changes after training between the two groups (p > .05). In the walking variables, the step length difference changes after training between the two groups showed a significant difference (p < .05). In the experimental group, the step length difference increased after the intervention compared to that before the intervention (+4.55 cm), whereas that of the control group decreased (-1.25 cm).SignificanceIn severe stroke patients, underwater gait training can be effective for improving balancing ability, but it may be less effective on the improvement of gait function than overground walking.Clinical trial registration number: KCT0002587 (https://cris.nih.go.kr)     

Attentional prioritization in dual-task walking: Effects of stroke,environment, and instructed focus

BackgroundThe impact of high distraction, real-world environments on dual-task interference and flexibility of attentional prioritization during dual-task walking in people with stroke is unknown.Research questionHow does a real-world environment affect dual-task performance and flexible task prioritization during dual-task walking in adults with and without stroke?MethodsAdults with stroke (n = 29) as well as age-, gender-, and education-matched adults without stroke (n = 23) participated. Single and dual-task walking were examined in two different environments (lab hallway, hospital lobby). Two different dual-task combinations were assessed (Stroop-gait, speech-gait). Each dual-task was performed first without explicit instruction about task prioritization (no-priority) and then with gait-priority instruction and Stroop/speech-priority instruction in randomized order.ResultsPeople with stroke had significantly slower dual-task gait speed (Stroop only) in the lobby than the lab, but the effect was not clinically meaningful. Stroop reaction time for all participants was also slower in the lobby than the lab. All participants slowed their walking speed while generating spontaneous speech, but this effect was not influenced by environment. The dual-task attention allocation strategy was generally inflexible to instructed prioritization in adults with and without stroke in both environments, however, the volitional attention allocation strategy differed for the two dual-task conditions such that speech was prioritized in the speech-gait dual-task and gait appeared to be prioritized in the Stroop-gait dual-task.SignificanceAlthough dual-tasking slows walking speed and verbal responses to auditory stimuli in people with stroke, the effects are not considerably impacted by a more complex, distracting environment. Adults with and without stroke may have difficulty overriding the preferred attention allocation strategy during dual-task walking, especially for habitual dual-tasks such as walking while speaking. It may also be that the cognitive control strategy governing task prioritization is influenced by degree of cognitive engagement.     

Utility of an obstacle-crossing test to classify future fallers and non-fallers at hospital discharge after stroke: A pilot study

BackgroundExisting clinical assessments of balance and functional mobility have poor predictive accuracy for prospectively identifying post-stroke fallers, which may be due to a lack of ecological complexity that is typical of community-based fall incidents.Research questionDoes an obstacle-crossing test at hospital discharge predict fall status of ambulatory stroke survivors 3 months after discharge?MethodsAmbulatory stroke survivors being discharged home completed an obstacle-crossing test at hospital discharge. Falls were tracked prospectively for 3 months after discharge. Logistic regression examined the relationship between obstacle-crossing at discharge (pass/fail) and fall status (faller/non-faller) at 3 months post discharge.Results45 participants had discharge obstacle test and 3-month fall data. 21 (47 %) participants experienced at least one fall during follow-up, with 52 % of the falls occurring within the first month after discharge. Of the 21 fallers, 14 failed the obstacle-crossing test (67 % sensitivity). Among the 24 non-fallers, 20 passed the obstacle-crossing test (83 % specificity). The area under the receiver operating characteristic curve was 0.75 (95 % CI 0.60–0.90). Individuals who failed the obstacle-crossing test were 10.00 (95 % CI: 2.45–40.78) times more likely to fall in the first 3 months after discharge. The unadjusted logistic regression model correctly classified 76 % of the subjects. After adjusting for age, sex, days post stroke, and post-stroke disability, the odds ratio remained significant at 6.93 (95 % CI: 1.01–47.52) and correctly classified 79.5% of the participants.SignificanceThe obstacle-crossing test may be a useful discharge assessment to identify ambulatory stroke survivors being discharged home who are likely to fall in the first 3 months post discharge. Modifications to improve the obstacle-crossing test sensitivity should be explored further.     

Single session of repetitive transcranial magnetic stimulation to left dorsolateral prefrontal cortex increased dual-task gait speed in chronic stroke: A pilot study

BackgroundIndividuals with stroke often experience difficulty in dual-task walking and are prone to falling when walking and talking. Previous studies in other populations have suggested that non-invasive brain stimulation could enhance dual-task gait performance by stimulating dorsolateral prefrontal cortex (DLPFC) or supplementary motor area (SMA). It was unclear if the benefits of brain stimulation would be observed in individuals with stroke.Research QuestionWould single-session 5 Hz rTMS applied to DLPFC or SMA improve dual-task gait performance in individuals with stroke?MethodsThis single group repeated measure study included fifteen individuals with left chronic stroke (mean age = 58 years). Participants received 5 Hz rTMS to either DLPFC, SMA, or M1 of the left lesioned hemisphere across three different sessions. Single- and dual-task gait speed was assessed before and after rTMS with the dualtask gait being walking and counting backward by 3 s.ResultsWe observed that rTMS to left DLPFC resulted in a greater increase in dual-task gait speed, but not single-task gait speed, compared to the other two stimulation sites (M1 and SMA) but the difference was not statistically significant (p = 0.06). Five out of fifteen participants demonstrated a clinically significant improvement in dual-task gait speed (> 0.1 m/s) after rTMS to DLPFC.SignificancesThe results suggest that DLPFC could be a potential treatment target to improve dual-task gait performance in persons with chronic stroke.     

Efficacy of lateral stair walking training in patients with chronic stroke: A pilot randomized controlled study

BackgroundPatients with chronic stroke have reduced capacity for performing activities of daily living (ADLs) and are at increased risk for falls during walking due to long-term changes to muscle tone and force, as well as movement control.Research questionTo investigate the efficacy of lateral stair walking training on muscle strength of affected lower extremities, balance, ADLs, and gait ability in patients with chronic stroke.MethodsThe experimental group received 15 min of lateral stair walking exercise along with 15 min of traditional physiotherapy, whereas the control group received only traditional physiotherapy for 30 min. Both groups received the intervention once a week for 12 weeks. Outcome measurements included muscle strength, postural assessment scale for stroke patients (PASS), Fugal–Meyer assessment for lower extremity (FMA-LE), Barthel index (BI), timed up and go test (TUG), and the gait parameters which were determined by the Reha-Watch system.ResultsA total of 24 participants completed the study. The experimental group showed significant improvements in hip extensor, flexor, and abductor strength of the affected limb, FMA-LE, BI, TUG, and gait parameters of stride length, velocity, and cadence. Significant differences in affected limb ankle plantar strength (p = 0.024), PASS (p = 0.017), BI (p = 0.039), TUG (p = 0.049), and gait velocity (p < 0.001) were observed between the 2 groups.SignificanceLateral stair walking training alongside physical therapy resulted in significant improvements in hip muscle strength and gait parameters in patients with chronic stroke. Our results support the incorporation of lateral stair walking training into clinical rehabilitation programs. Lateral stair walking training in patients with chronic stroke can be used as an effective treatment to improve gait, balance performance, and ADLs.     

Temporal and spatial gait parameters in patients dependent on walking assistance after stroke: Reliability and agreement between simple and advanced methods of assessment

The aim of this study was to investigate the reliability of temporal and spatial gait parameters in patients dependent on walking assistance after severe stroke, and to examine agreement between simple and advanced methods. Twenty-one patients, admitted for in-patient multidisciplinary rehabilitation, were assessed repeatedly for walking function, both in a test corridor and a gait laboratory (3D camera system) before and after 11 weeks of rehabilitation. The test–retest reliability was examined using intraclass correlation (ICC_1.1), and measurement error was reported by within-subject standard deviation (S_w). The agreement between different methods for assessing walking speed, cadence and step length was explored by Bland–Altman plots. High to excellent test–retest reliability was found between trials, both when assessed in the corridor (ICC: 0.93–0.99) and in the laboratory (ICC: 0.88–0.99). Agreement between methods was satisfactory at baseline and was higher after the rehabilitation period. Agreement was found to be slightly better at lower walking speeds and for shorter step lengths. The results implicate that temporal–spatial gait parameters may be measured reliably by both simple and advanced methods in dependent walkers after stroke. A high level of agreement was found between the two methods for walking speed, cadence and average step length at both test points.     

Inter- and intra-rater reliability of the GAITRite system among individuals with sub-acute stroke

Technology-based assessment tools with semi-automated processing, such as pressure-sensitive mats used for gait assessment, may be considered to be objective; therefore it may be assumed that rater reliability is not a concern. However, user input is often required and rater reliability must be determined. The purpose of this study was to assess the inter- and intra-rater reliability of spatial and temporal characteristics of gait in stroke patients using the GAITRite system. Forty-six individuals with stroke attending in-patient rehabilitation walked across the pressure-sensitive mat 2–4 times at preferred walking speeds, with or without a gait aid. Five raters independently processed gait data. Three raters re-processed the data after a delay of at least one month. The intraclass correlation coefficients (ICC) and 95% confidence intervals of the ICC were determined for velocity, step time, step length, and step width. Inter-rater reliability for velocity, step time, and step length were high (ICC > 0.90). Intra-rater reliability was generally greater than inter-rater reliability (from 0.81 to >0.99 for inter-rater versus 0.77 to >0.99 for intra-rater reliability). Overall, this study suggests that GAITRite is a reliable assessment tool; however, there still remains subjectivity in processing the data, resulting in no patients with perfect agreement between raters. Additional logic checking within the processing software or standardization of training could help to reduce potential errors in processing.     

Association between movement patterns and risk of musculoskeletal injuries in navy cadets: A cohort study

ObjectiveTo investigate the association of movement patterns evaluated by the Dynamic Movement Assessment (DMA) with the occurrence of musculoskeletal injuries in navy cadets.DesignCohort study.SettingParticipants were filmed performing the six functional tests of the DMA (deep squat, step up, single-leg squat, hop, plank and side-plank tests).Participants240 navy cadets.Main outcome measurementsDepending on the number of certain movement patterns on the Dynamic Movement Assessment (DMA), participants were classified as high, moderate, medium or low risk of developing injuries. Predictive associations between injuries and risk classification were examined using logistic regression analysis.ResultsConsidering sex, previous injuries and the type of secondary school as covariates, participants who were classified as high risk were not more likely to develop injuries. Non-military high school was an independent risk factor for any injuries (OR = 3.14, 95% CI [1.43,6.91]; OR = 4.57, 95% CI [1.92,10.83]), overuse injuries (OR = 2.58, 95% CI [1.05,6.30]; OR = 2.55, 95% CI [1.06, 6.14]) and acute injuries (OR = 4.88, 95% CI [1.19,19.99]), respectively. Previous musculoskeletal symptoms also increased the chance of AI (OR = 4.45, 95% CI [1.15,17.18]; OR = 5.91, 95% CI [1.13,30.88]).ConclusionsMovement patterns evaluated by DMA are not associated with an increased risk of injuries. However, attendance of a non-military high school and previous musculoskeletal symptoms are associated with musculoskeletal injuries.     

Anxiety-mediated gait adaptations reduce errors of obstacle negotiation among younger and older adults: implications for fall risk

The purpose of this study was to determine if anxiety-mediated gait adaptations can reduce the risk for falling among younger and older adults. Fourteen younger adults (23.14 ± 3.08 years) and 14 older adults (69.28 ± 5.41 years) participated in this study. Participants were asked to walk the length of a 7.20 m walkway and avoid contact with an obstacle that appeared suddenly underfoot at either 25% or 75% of the gait cycle duration. Testing was conducted in four conditions of postural threat. The obstacle was presented as a light beam and did not jeopardize balance when contacted. Fall risk was inferred from the frequency of obstacle contacts. Our findings indicated that obstacle contact frequency decreased when conservative gait patterns emerged. These findings imply that anxiety-mediated gait adaptations are beneficial in reducing the risk for falling among older adults and present the possibility that fear of falling may offer protective benefits for postural control. One possibility is that the beneficial effects of anxiety can only be realized among older adults who do not fear falling.     

Energetics of walking in individuals with cerebral palsy and typical development,across severity and age: A systematic review and meta-analysis

BackgroundIndividuals with cerebral palsy (CP) report physical fatigue as a main cause of limitation, deterioration and eventually cessation of their walking ability. A consequence of higher level of fatigue in individuals with CP leads to a less efficient and long-distance walking ability.Research questionThis systematic review investigates the difference in 1) walking energy expenditure between individuals with CP and age-matched typically developing (TD) individuals; and 2) energetics of walking across Gross Motor Function Classification System (GMFCS) levels and age.MethodsFive electronic databases (PubMed, Web of Science, CINAHL, ScienceDirect and Scopus) were searched using search terms related to CP and energetics of walking.ResultsForty-one studies met inclusion criteria. Thirty-one studies compared energy expenditure between CP and age-matched controls. Twelve studies correlated energy expenditure and oxygen cost across GMFCS levels. Three studies investigated the walking efficiency across different ages or over a time period. A significant increase of energy expenditure and oxygen cost was found in individuals with CP compared to TD age-matched individuals, with a strong relationship across GMFCS levels.SignificanceDespite significant differences between individuals with CP compared to TD peers, variability in methods and testing protocols may play a confounding role. Analysis suggests oxygen cost being the preferred/unbiased physiological parameter to assess walking efficacy in CP. To date, there is a knowledge gap on age-related changes of walking efficiency across GMFCS levels and wider span of age ranges. Further systematic research looking at longitudinal age-related changes of energetics of walking in this population is warranted.     

Association of carotid atherosclerotic plaque features with acute ischemic stroke: A magnetic resonance imaging study

Background and purpose

It remains unclear whether direct vessel wall imaging can identify carotid high-risk lesions in symptomatic subjects and whether carotid plaque characteristics are more effective indicators for cerebral infarct severity than stenosis. This study sought to determine the associations of carotid plaque characteristics by MR imaging with stenosis and acute cerebral infarct (ACI) sizes on diffusion weighted imaging (DWI).

Materials and methods

One hundred and fourteen symptomatic patients underwent carotid and brain MRI. ACI volume was determined from symptomatic internal carotid artery territory on DWI images. Ipsilateral carotid plaque morphological and compositional characteristics, and stenosis were also determined. The relationships between carotid plaque characteristics, stenosis and ACIs size were then evaluated.

Results

In carotid arteries with 30–49% stenosis, 86.7% and 26.7% were found to have lipid-rich necrotic core (LRNC) and intraplaque hemorrhage, respectively. Furthermore, 45.8% of carotid arteries with 0–29% stenosis developed LRNCs. Carotid morphological measurements, such as % wall volume, and the LRNC size were significantly associated with ipsilateral ACIs volume before and after adjustment for significant demographic factors (age and LDL) or stenosis in patients with carotid plaque (all p < 0.05).

Conclusions

A substantial number of high-risk plaques characterized by vessel wall imaging exist in carotid arteries with lower grade stenosis. In addition, carotid plaque characteristics, particularly the % wall volume and LRNC size, are independently associated with cerebral infarction as measured by DWI lesions. Our findings indicate that characterizing atherosclerotic plaque by MR vessel wall imaging might be useful for stratification of plaque risk and infarction severity.     

Gait characteristics under single-/dual-task walking conditions in elderly patients with cerebral small vessel disease: Analysis of gait variability,gait asymmetry and bilateral coordination of gait

BackgroundDual-task walking (DTW) is common in daily life and represents an ideal paradigm for elucidating gait irregularity. Under single-task walking (STW) and DTW conditions, the symmetric and bilaterally coordinated human gait pattern found in healthy individuals is absent in individuals with neurological ailments such as Parkinson’s disease, Alzheimer’s disease and post-stroke issues. Cerebral small vessel disease (CSVD) is a neuropathological and radiological issue that has been reported to be associated with cognitive and motor disorders. However, few gait analyses have focused on elderly individuals with CSVD under DTW conditions.Research questionAre parameters of gait analysis helpful in elucidating gait abnormalities in elderly patients with CSVD under DTW conditions?MethodsA total of 46 elderly patients with CSVD (CSVD group) and 22 healthy, age-matched individuals (HE group) were recruited. Gait data were collected from both groups under STW and DTW conditions. Direct parameters and metrics reflecting gait variability, gait asymmetry, and bilateral coordination of gait in the two groups were compared.ResultsUnder STW conditions, elderly individuals with CSVD showed markedly shorter stride length, were slower, and had higher gait asymmetry (GA) and phase coordination index (PCI) than healthy controls after adjusting for age, sex and level of education. Under DTW conditions, there were statistically significant differences between the two groups in stride time, stride length, cadence, stride time variability, GA and PCI after adjusting for age, sex, and level of education.SignificanceReanalysis-generated parameters, such as gait variability, GA, and PCI, are biomarkers for gait dysfunction in elderly patients with CSVD. In this study, elderly individuals with CVSD showed abnormal gait features under both STW and DTW conditions.     

Effects of orthopedic insoles on postural balance in patients with chronic stroke: A randomized crossover study

BackgroundOrthopedic insoles (OIs) with medial arch support and heel cushion are widely used to manage lower extremity injuries, but their effects on postural balance in patients with chronic stroke have not been adequately explored.MethodsDesign: Double-blinded, sham-controlled, randomized crossover trial. Participants: A total of 32 ambulatory patients (20 men and 12 women, aged between 30 and 76 years) with more than 6 months since stroke onset. Interventions: All participants received one assessment session wearing OIs and one session wearing sham insole (SI) in a random order with a 1-day interval. Outcomes: Our primary outcome was the Berg Balance Scale score. Secondary outcomes included the Functional Reach Test, Timed Up and Go test, and computerized posturography. All were performed in both sessions. Subgroup analyses regarding demographic and functional variables were conducted to identify potential responders.ResultsSignificant between-insole differences favoring OIs were seen in all clinical tests (P < 0.05), but were seen only in the static medial-lateral sway in computerized posturography assessment (P = 0.04). An approximate 2-point difference in the BBS score favoring OIs was observed in all subgroups, not reaching the minimal clinically important difference.ConclusionThe use of OIs generated small but significant positive effects on improving postural balance among patients with chronic stroke. Additional biomechanical and clinical studies are required to evaluate their potential for routine clinical use.Trial registrationNCT03194282     

Towards an objective assessment of motor function in sub-acute stroke patients: Relationship between clinical rating scales and instrumental gait stability indexes

The assessment of walking function alterations is a key issue to design effective rehabilitative interventions in sub-acute stroke patients. Nevertheless, the objective quantification of these alterations remains a challenge.Clinical rating scales are commonly used in clinical practice, but have been proven prone to errors associated to the evaluator subjective perception. On the other hand, instrumental measurement of trunk acceleration can be exploited for an objective quantitative characterization of gait function, but it is not applied in routine clinical practice, because the resulting quantitative indexes have not been related to the clinically information, conventionally provided by the rating scales. To overcome this limitation, the relationship between the indexes, in specific clinical conditions, and rating scale must be better investigated, to support their exploitability in the clinical practice as a fast and reliable screening tool.Thirty-one sub-acute stroke patients (17 with and 14 without cane) participated in the study. All were assessed with 6 rating scales (MI, TCT, MRI, FAC, WHS, CIRS) and 2 functional tests (2MWT and TUG). Sample Entropy (SEN) and Recurrence Quantification Analysis (RQA) in AP, ML and V directions were calculated over 2MWT and walking section of TUG. The influence of assessment task and cane was analysed, as well as correlation of SEN and RQA indexes with clinical rating scales.SEN and RQA on the medio-lateral plane resulted influenced by the use of the cane, while the correlations between indexes and clinical scales showed that SEN and RQA for antero-posterior direction correlate positively with WHS.     

Association of postural balance and falls in adult patients receiving haemodialysis: A prospective cohort study

BackgroundStatic postural balance performance is often impaired in people receiving haemodialysis (HD) for the treatment of stage-5 chronic kidney disease (CKD-5). However, the question as to whether lower postural balance is associated with adverse clinical outcomes such as falls has not been addressed yet.Research questionWe conducted a prospective cohort study to explore the association between static postural balance and falls in people receiving HD. We hypothesised that higher postural sway would be associated with increased odds of falling.MethodsSeventy-five prevalent CKD-5 patients receiving HD (age: 61.8 ± 13.4 years) from three Renal Units were enrolled in this prospective cohort study. At baseline, postural balance was assessed with a force platform in eyes open (EO) and eyes closed (EC) conditions. Centre of pressure (CoP) measures of range, velocity and area were taken for the analysis. Falls experienced by study participants were prospectively recorded during 12 months of follow-up. Secondary outcomes included timed-up and go, five-repetition sit-to-stand test and the Tinetti falls efficacy scale (FES).ResultsIn multivariable logistic regression analysis, higher CoP range in medial-lateral direction during EC was associated with increased odds of falling (OR: 1.04, 95 %CI: 1.00−1.07, p = 0.036). In ROC curve analysis, CoP velocity in EO exhibited the greatest prognostic accuracy (AUC: 0.69, 95 %CI: 0.55−0.82), however this was not statistically different from CoP measures of area and range. None of the postural balance measures exceeded the prognostic accuracy of the FES (AUC: 0.70, 95 %CI: 0.58−0.83, p = 0.005).SignificanceThis prospective cohort study showed that higher postural sway in medial-lateral direction was associated with increased odds of falling in people receiving HD. CoP measures of range, velocity and area displayed similar prognostic value in discriminating fallers from non-fallers. The overall utility of static posturography to detect future fall-risk may be limited in a clinical setting.     

Association of fluid balance trajectories with clinical outcomes in patients with septic shock:A prospective multicenter cohort study

Background:Septic shock has a high incidence and mortality rate in Intensive Care Units (ICUs).Earlier intravenous fluid resuscitation can significantly improve outcomes in septic patients but easily leads to fluid overload (FO),which is associated with poor clinical outcomes.A single point value of fluid cannot provide enough fluid information.The aim of this study was to investigate the impact of fluid balance (FB) latent trajectories on clinical outcomes in septic patients.Methods:Patients were diagnosed with septic shock during the first 48h,and sequential fluid data for the first 3 days of ICU admission were included.A group-based trajectory model (GBTM) which is designed to identify groups of individuals following similar developmental trajectories was used to identify latent subgroups of individuals following a similar progression of FB.The primary outcomes were hospital mortality,organ dysfunction,major adverse kidney events (MAKE) and severe respiratory adverse events (SRAE).We used multivariable Cox or logistic regression analysis to assess the association between FB traJectories and clinical outcomes.Results:Nine hundred eighty-six patients met the inclusion criteria and were assigned to GBTM analysis,and three latent FB trajectories were detected.64 (6.5％),841 (85.3％),and 81 (8.2％) patients were identified to have decreased,low,and high FB,respectively.Compared with low FB,high FB was associated with increased hospital mortality[hazard ratio (HR)=1.63,95％CI 1.22-2.:17],organ dysfunction[odds ratio (OR)=2.18,95％CI 1.22-3.42],MAKE (OR=1.80,95％CI 1.04-2.63) and SRAE (OR=2.33,95％CI 1.46-3.71),and decreasing FB was significantly associated with decreased MAKE(OR=0.46,95％CI 0.29-0.79) after adjustment for potential covariates.Conclusion:Latent subgroups of septic patients followed a similar FB progression.These latent fluid trajectories were associated with clinical outcomes.The decreasing FB trajectory was associated with a decreased risk of hospital mortality and MAKE.     

Validation of the stabilometer balance test: Bridging the gap between clinical and research based balance control assessments for stroke patients

BackgroundA pronounced discrepancy exists between balance assessments for stroke survivors that are used for clinical purposes and those used for research. Clinical assessments like the Berg Balance Scale generally have stronger ecological validity, whereas research-based assessments like posturography are generally more reliable and precise. We developed a stabilometer balance test (SBT) that aims to couple measurement reliability and precision to clinical meaningfulness by means of a personalized and adaptive test procedure.Research questionTo examine the validity, reliability, and measurement error of the stabilometer balance test in inpatient stroke patients.MethodsIn this cross-sectional study, inpatient stroke patients (FAC > 2) were tested on a stabilometer with adjustable resistance to mediolateral movement. A modified staircase procedure was used to adapt task difficulty (i.e., rotational stiffness) on a trial-by-trial basis. The main outcome was the threshold stiffness at which a patient could just stay balanced. Threshold stiffness was correlated with the Berg Balance Scale and posturography measurements to determine concurrent validity (N = 86). Test-retest reliability (N = 23) was analyzed with the Intraclass Correlation Coefficient (ICC). Floor and ceiling effects were assessed. The minimal detectable change was determined at individual and group level.ResultsThreshold rotational stiffness moderately correlated with the Berg Balance Scale (r=−0.559, p < 0.001), and the absolute path length of the center of pressure during posturography (r=0.348, p = 0.006). Test-retest reliability was good to excellent (ICC=0.869; 95%CI=0.696–0.944). There were no floor or ceiling effects. The minimal detectable change was sufficiently small to detect relevant changes in balance control both on individual and group level.RelevanceThe SBT is both a valid and reliable balance assessment in stroke patients. It is at least as precise as current clinically preferred measures and does not suffer from ceiling effects. Therefore, it is suitable for use in clinical practice as well as research.