Does increased prosthetic weight affect gait speed and patient preference in dysvascular transfemoral amputees?

OBJECTIVES: To determine if increased prosthetic weight affects gait speed in dysvascular transfemoral amputees and to see if there is any patient preference for lighter versus heavier prostheses. DESIGN: Randomized prospective double-blind crossover trial. SETTING: Outpatient, tertiary care, amputee clinic in Ontario, Canada. PARTICIPANTS: A convenience sample of 10 subjects with unilateral transfemoral amputations because of peripheral vascular disease. All subjects were independent community ambulators over 50 years old. INTERVENTION: Seemingly identical weights of 150g (placebo weight), 770g, and 1625g were added to the prosthesis 14cm below the knee joint. MAIN OUTCOME MEASURES: Two-minute walk test (2MWT) and subject preference. RESULTS: The 2MWT results were not significantly influenced by weight added (mean, 53.4+/-28.4m, 55.1+/-28.9m, and 52.8+/-26.7m for 150g, 770g, and 1625g of added weight, respectively). Subject preference revealed that more than half preferred a weighted prosthesis over the "placebo" weight (5 subjects preferred 770g added, 4 subjects preferred 150g added, 1 preferred 1625g added). CONCLUSIONS: Short-term intervention with increased prosthetic mass had no significant adverse affect on gait speed, and more than half of the subjects preferred an added mass condition.     

Hemiplegic gait after stroke: is measurement of maximum speed required?

OBJECTIVES: To study the relation between comfortable and maximum walking speed in stroke rehabilitation and to determine which parameters are predictive in this relation and increase the relations' precision. DESIGN: One-year prospective cohort study. Longitudinal information was obtained for 10-m comfortable and maximum walking speeds, hemiplegic limb muscle strength, and balance. In addition, subjects' ages and the type of rehabilitation they received were registered. SETTING: Stroke service facilities. PARTICIPANTS: Eighty-one acute stroke patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Ten-meter maximum walking speed. RESULTS: We found a progressive improvement in walking speed and a mean systematic difference between comfortable and maximum walking speeds. An overall mean intraclass correlation coefficient for consistency of rho equal to .96 and a within- and between-subject regression coefficient of 1.32 were demonstrated for the relation between comfortable and maximum walking speeds. None of the covariables included were statistically significant in the final linear regression prediction model. CONCLUSIONS: Independent of time after onset of stroke, maximum walking speed can be predicted by comfortable walking speed with considerable accuracy. The precision of this estimation is not increased by considering patients' age, hemiplegic muscle strength, balance, or therapeutic intervention.     

Differences in gait parameters between healthy subjects and persons with moderate and severe knee osteoarthritis: A result of altered walking speed?

Background

While knee osteoarthritis has been shown to affect a multitude of kinematic, kinetic and temporo-spatial gait parameters, few investigations have examined the effect of increasing levels of radiographic osteoarthritis severity on these gait parameters. Fewer still have investigated the effect of walking speed on gait variables in persons with knee osteoarthritis. The objective of this study was to investigate the influence of walking speed on biomechanical variables associated with joint loading in persons with varying severities of medial compartment knee osteoarthritis.

Methods

Twenty-one persons with moderate osteoarthritis (Kellgren–Lawrence score 2–3) and 13 persons with severe osteoarthritis (Kellgren–Lawrence score of 4) participated. Twenty-two persons without knee pain or radiographic evidence of arthritis comprised a healthy control group. Sagittal plane kinetics, knee adduction moment, sagittal plane knee excursion, ground reaction forces and knee joint reaction forces were calculated from three-dimensional motion analysis at 1.0 m/s, self-selected and fastest tolerable walking speeds. Differences were analyzed using multivariate analysis of variance and multivariate analysis of covariance with speed as a covariate.

Findings

Persons with knee osteoarthritis showed significantly lower knee and ankle joint moments, ground reaction forces, knee reaction force and knee excursion when walking at freely chosen speeds. When differences in walking speed were accounted for in the analysis, the only difference found at all conditions was decreased knee joint excursion.

Interpretation

Compared to a healthy control group, persons with knee OA demonstrate differences in joint kinetics and kinematics. Except for knee excursion, these differences in gait parameters appear to be a result of slower freely chosen walking speeds rather than a result of disease progression.     

Gait speed and related factors in Parkinson’s disease

[Purpose] The aim of this study was to investigate the relationship between gait speed and various factors in ambulatory patients with idiopathic Parkinson’s disease. [Subjects] Fifty ambulatory patients with idiopathic Parkinson’s disease who were admitted to an outpatient clinic were included in this cross-sectional study. [Methods] The Hoehn and Yahr Scale was used for measurement of the disease severity. Gait speed was measured by the 10-Meter Walk Test. Mobility status was assessed by Timed Up and Go Test. The Hospital Anxiety and Depression Scale was used for evaluation of emotional state. Cognitive status was examined with the Mini-Mental State Examination. The Downton Index was used for fall risk assessment. Balance was evaluated with the Berg Balance Scale. Comorbidity was measured with the Cumulative Illness Rating Scale. The 36-Item Short Form Health Survey was completed for measurement of quality of life. [Results] The mean age was 66.7 (47–83) years. Twenty-eight (56%) patients were men. Gait speed was correlated positively with height, male gender, Mini-Mental Examination score, Berg Balance Scale score and physical summary scores of the 36-Item Short Form Health Survey. On the other hand, there was a negative correlation between gait speed and age, disease severity, TUG time, Downton Index, fear of falling, previous falls and the anxiety and depression scores of the Hospital Anxiety and Depression Scale. There was no correlation between gait speed and comorbidity. [Conclusion] The factors related with the slower gait speed are, elder age, clinically advanced disease, poor mobility, fear of falling, falling history, higher falling risk, and mood disorder.Key words: Gait, Fear of falling, Parkinson’s disease     

Does knee alignment influence gait in patients with severe knee osteoarthritis?

Background

Patients with knee osteoarthritis present an altered gait pattern. Amongst many factors, the lower limb alignment (varus, valgus) has been identified as an important risk factor for the progression of knee osteoarthritis. Among the large number of studies on knee osteoarthritis gait, only a few have included patients with a valgus deformity. The aims of this study were to determine how knee alignment influences full-body gait in patients with knee osteoarthritis and if knee malalignment is associated with pain and functional capacity.

Methods

Sixty patients with severe knee osteoarthritis scheduled for a total knee arthroplasty were included in this study. Twenty-six subjects were recruited as the control group. The spatio-temporal parameters, three-dimensional full-body kinematics, and lower body kinetics were evaluated during a comfortable gait and compared between the groups. Pain and function were assessed with the WOMAC questionnaire.

Findings

The full-body gait analysis demonstrated substantially different gait patterns and compensation mechanisms between the three groups. Patients with varus knee alignment significantly augmented their trunk movements in sagittal and frontal planes compared to patients with a valgus knee. In addition, patients with a valgus knee reported lower pain and lower functional deficits compared to patients with a varus knee.

Interpretation

We found that gait compensations were significantly influenced by lower limb alignment. These new insights related to different knee osteoarthritis gait patterns might help in the understanding of gait compensation behaviours prior to total knee arthroplasty and better manage the strategies of rehabilitation following surgery.     

Do French medical schools provide appropriate training on gait and gait disorders?

AimEvaluate the need for integrated teaching on normal and pathological gait at medical school.MethodA questionnaire filled out by 91 French general practitioners (GPs, 130 of whom were contacted) with an average of 19 years of practice and 56 sixth-year medical students. Assessment of the students’ knowledge of normal and pathological gait.ResultsSeventy-two percent of the GPs and 82% of the students considered gait to be a frequent reason for consultation. Eighty-nine percent of the GPs and 98% of the students stated that they had difficulty analysing a gait disorder. Eighty percent of the GPs and 50% of the students considered that the teaching on gait and gait disorders at medical school was insufficient. The responses notably highlighted the poor coordination between teachers from the various disciplines involved. The students’ knowledge of gait was poor (only 20% of their answers were correct). This was especially true for semiological questions, which were correctly answered by less than one student in 10.ConclusionThe results of the present study demonstrate that French medical schools need to provide better teaching on gait. We, therefore, propose the implementation of an integrated teaching programme with a sufficient focus on functional and semiological approaches.     

Fast gait speed and self-perceived balance as valid predictors and discriminators of independent community walking at 6 months post-stroke – a preliminary study

Abstract

Purpose: To determine the validity of walking speed, muscle strength, function of the hemiparetic lower limb and self-perceived balance to predict and discriminate independent community walkers (ICW) within the first 6 months post-stroke. Methods: Inpatients with a first ischemic stroke (<3 months), able to walk, were evaluated (T₀) and re-evaluated after 6 months post-stroke (T₁). Comfortable, fast speed and the difference between fast and comfortable speed, muscle strength of knee flexors and extensors, sensory-motor function of the hemiparetic lower limb and self-perceived balance were assessed at T₀ and T₁. At T₁, a self-reported question was used to discriminate ICW versus Dependent Community Walkers (DCW). ROC curve analysis was used to determine valid predictive (T₀) and discriminative (T₁) cut-offs of ICW. Results: Only 25.7% of the 35 participants were ICW at T₁. Valid predictive cut-offs at T₀ were found for fast speed (≥0.42?m/s) and Falls Efficacy Scale (<57). Valid discriminators were found at T1 for fast speed (>0.84?m/s) and FES (<18.50). Conclusion: Fast speed and self-perceived balance appear to be important characteristics of ICW at 6 months and may be useful early predictors of the potential for patients to achieve this. Further research is needed to ensure the precision of these functional cut-offs.

• Implications for Rehabilitation

• Prognostic information is important for people with stroke and health services. The ability to walk faster than 0.42?m/s and a fear of falling on the Falls Efficacy Scale of less than 57 in the first 3 months after stroke predict who will be an independent community walker at 6 months.

• At 6 months after stroke, people who cannot walk faster than 0.84?m/s or who have a have Falls Efficacy Scale score <18.5 are unlikely to be walking independently in the community.

• Rehabilitation to promote independent walking should focus on walking speed, balance re-education and strategies to reduce fear of falling.

     

Influence of fear of falling on gait and balance in Parkinson’s disease

Abstract

Purpose: To study the relationship of fear of falling (FoF) with gait characteristics and balance in individuals with Parkinson's disease (PD). Method: Seventy-nine non-demented individuals (62 males) with PD were studied. Their mean age was 69.22?±?8.93 years. The average time since diagnosis was 8.27?±?5.31 years. FoF was assessed by the Activities-specific Balance Confidence (ABC) Scale in which high scores indicate less FoF. Gait was measured using a computerized walkway. Balance was measured by timed tests including the 5-step test, 360 degree turn, timed sideways walk, and timed up and go test. Participants were divided into two groups based on their ABC score (high FoF, ABC score <69; low FoF, ABC score ≥69). Gait characteristics and balance measures of the two groups were compared. Results: Gait speed and stride length for forward walking (p?<?0.0005 for both) and backward walking (p?=?0.001 and 0.002, respectively) were lower for those with a high level of FoF compared to those with a low level of FoF. The time to take five steps (p?=?0.025), time to turn (p?<?0.0005), time to walk sideways (p?=?0.001), and time to complete the up and go test (p?=?0.003) were longer in those with a high level of FoF than in those with a low level of FoF. Number of steps to complete the turn (p?=?0.001) and steps to walk sideways (p?=?0.002) were greater in those with a high level of FoF than in those with a low level FoF. Conclusions: Gait and balance of individuals with PD with a high level of FoF were poorer than those with a low level of FoF, regardless of previous fall history.

• Implications for Rehabilitation

• The results demonstrates that fear of falling (FoF) is related to gait and balance in individuals with PD.

• Clinicians should be aware that FoF has a negative impact on gait and balance in individuals with PD.

     

Differences in hip–knee joint coupling during gait after anterior cruciate ligament reconstruction

BackgroundAfter anterior cruciate ligament injury, patients have increased risk for developing degenerative osteoarthritis, potentially due to the kinematic changes that persist after surgical reconstruction. Current research only describes single joint kinematic differences rather than the way in which two joints behave concurrently, termed joint coupling. The purpose of this study was to compare knee motion relative to hip motion in anterior cruciate ligament reconstructed and healthy limbs during walking and jogging.MethodsThirty-seven recreationally active volunteers (22 reconstructed, 15 healthy) walked and jogged at 4.83 km/h and 9.66 km/h respectively. Vector coding methods were used to calculate stride-to-stride variability, magnitude, and vector angle of 6 joint couples during walking and jogging: hip frontal–knee frontal planes, hip frontal–knee sagittal, hip frontal–knee transverse, hip sagittal–knee frontal, hip sagittal–knee transverse, and hip transverse–knee frontal planes.FindingsThe hip sagittal–knee frontal and hip sagittal–knee transverse joint couples had decreased variability during mid-stance, and all other couples had increased variability during the stance phase in the reconstructed group. The reconstructed group had decreased magnitude of joint excursion in the hip frontal–knee sagittal couple during all phases of gait during walking. Vector angles of the hip frontal–knee transverse couple increased in the reconstructed group during the loading, middle, and terminal stance phases, and swing phase of gait during walking.InterpretationThe increased variability and decreased magnitude of joint excursion indicate that movement patterns were less consistent during walking gait despite employing a more constrained system during movement in the reconstructed limb compared to healthy controls.     

The influence of a rocker sole adaptation on gait parameters in spinal cord injury patients ambulating with the advanced reciprocating gait orthosis – a pilot study

Objective: When walking with an advanced reciprocating gait orthosis (ARGO), ankle and knee joint motion is restricted which causes an un-cosmetic gait compared to normal walking. The purpose of this study was to develop and evaluate a rocker modification for use with the ARGO in order to improve hip joint kinematics, walking speed, step length and cadence. Method: Spinal cord injury patients (n?=?4) with thoracic-level injury participated in this study, and walked with a standard ARGO and one which was also adapted with a rocker sole in a randomized order. Results: Mean walking speed and step length were both significantly increased by volunteer SCI subjects when ambulating using the ARGO adapted with a rocker sole compared to the standard ARGO. Cadence was not significantly affected, but swing time was significantly reduced and mean hip flexion and extension were both significantly increased when walking with the adapted ARGO. Conclusion: The rocker sole modification produced an increase in walking speed and step length, and improved sagittal plane hip joint kinematics when ambulating using an ARGO. Using this type of shoe modification has the potential to improve gait parameters in SCI patients compared to the standard unmodified version.

• Implications for Rehabilitation

• The ARGO adapted with a rocker sole could be used by spinal cord injury patients.

• A major advantage of the walking with the ARGO adapted with a rocker sole was increased of walking speed and step length, and improvement of the sagittal plane hip joint kinematics.

• The findings of this study would appear to provide useful data for rehabilitation teams who utilize orthoses to walk and rehabilitate SCI subjects. Using this type of shoe modification has the potential to improve gait parameters in SCI patients compared to the standard un-modified version.

     

Comparative biomechanical analysis of gait in patients with central cord and Brown-Séquard syndrome

Abstract

Purpose: This is a pilot study with the aim to highlight the use of kinematic and kinetic analyses as an adjunct to the assessment of individual patients with central cord syndrome (CCS) and hemisection or Brown-Séquard syndrome (BSS) and to discuss their possible consequences for clinical management. Methods: The sample studied consisted of 17 patients with CCS, 13 with BSS and 20 control subjects (control group (CG)). Data were obtained using a three-dimensional motion analysis system and two force plates. Gait differences were compared between CCS, BSS walking at a self-selected speed and CG at both a self-selected and a similar speed to that of the patient groups. Results: The most relevant findings involved the knee and ankle, especially in the sagittal plane. In patients with CCS, knee flexion at initial contact was increased with respect to those in the BSS group (p?<?0.01). The ankle in the BSS group made initial contact with a small degree of plantar flexion. Conclusion: The use of gait biomechanical analysis to detect underlying impairments can help the physician to set a specific rehabilitation program in each CCS and BSS walking patient. In this group of patients, rehabilitation treatment should aim to improve gait control and optimise ankle positioning at initial contact.

• Implications for Rehabilitation

• In this study, gait differences between patients with CSS and BSS were evaluated with biomechanical equipment.

• The most remarkable differences were found in the knee and ankle sagittal plane due to ankle position at initial contact.

• In this group of patients, rehabilitation treatment should aim to improve gait control and to get a better ankle positioning at initial contact.

     

Construct and criterion validity of the functional gait assessment—Brazil in community-dwelling older adults

BackgroundThe functional gait assessment (FGA) is a reliable instrument to evaluate walking balance in the Brazilian older population. However, other measurement properties need investigation.ObjectiveTo determine the construct and criterion validity of the FGA-Brazil and its ceiling and floor effects.MethodsSociodemographic, clinical, and anthropometric data were collected from 126 older adults. Participants completed the Mini-mental state examination followed by the FGA-Brazil, Berg balance scale (BBS), gait speed, and the Falls Efficacy Scale-International. Six months later, the participants were interviewed by telephone about their fall history. Exploratory factor analysis was used to determine the structural validity. We also determined the construct validity of the FGA-Brazil, using hypothesis testing, by investigating the differences between groups using the Mann–Whitney U test. Criterion validity was determined using the Spearman correlation between the FGA-Brazil and the other balance and gait measures, and using the Receiver Operator Characteristic curve.ResultsParticipants’ mean age was 69.3 ± 7.4 years, and 84 (69.4%) were female. Factor analysis resulted in two factors explaining 53.3% of the total variance. Moderate and high significant correlations were found between the FGA-Brazil and gait speed (r = 0.65) and BBS (r = 0.80). A significant difference in the FGA-Brazil median score between older adults with low and high concern about falls was observed. The cutoff score recommended for predicting falls was 22 or less. No ceiling and floor effects were observed.ConclusionWe recommend the FGA-Brazil to determine the risk of falls in community-dwelling older adults.     

Do gait adaptations during stair climbing result in changes in implant forces in subjects with total hip replacements compared to normal subjects?

BACKGROUND: The study objective was to identify gait abnormalities and their relationships to hip loading during stair climbing after total hip replacement. Hypotheses: (1) total hip replacement subjects would have significantly lower dynamic hip range of motion and peak external moments during stair climbing compared to normal subjects and (2) the peak twisting moment about the long axis of the implant and peak hip forces would be significantly reduced in subjects with total hip replacements compared to normal subjects. METHODS: Gait parameters during a stair climbing task were measured for 15 total hip replacement subjects and 15 matched normal subjects. Forces were predicted using an analytical model. FINDINGS: The peak external adduction moment for the total hip replacement subjects was 25% less than normal (P=0.001). The external rotation moment was 26% less than normal (P=0.029) but the extension moment was 77.5% higher in the total hip subjects than in normal subjects (P=0.004). The peak twisting moment and first peak contact force were 18% and 14% lower in the total hip group compared to normal (P=0.090 and P=0.055, respectively). The second peak force was nearly equal (P=0.424) between the two groups. INTERPRETATION: Stair climbing biomechanics differ from normal in subjects with total hip replacements, however these unconscious alterations do not abnormally increase the hip loads during this activity. More work is necessary to determine exactly what constitutes optimal stair climbing biomechanics for patients with total hip replacements.