Function In Ambulatory Patients Research Articles

Appendicular lean mass index and motor function in ambulatory patients with Duchenne muscular dystrophy.

Appendicular lean mass index (ALMI) has been linked to motor function in patients with Duchenne muscular dystrophy (DMD). However, quantification of the relationship between ALMI and disease-specific clinical outcome assessment trajectories is needed. The purpose of this study was to determine associations between dual-energy x-ray absorptiometry (DXA) derived estimates of ALMI and motor function in ambulatory patients with DMD. A retrospective analysis of longitudinal clinical visit data from 137 glucocorticoid-treated patients with DMD collected via structured motor assessment protocol evaluated associations between ALMI and motor function indexed by the North Star Ambulatory Assessment (NSAA) and 10 Meter Walk/run Test (10MWT). Body composition was assessed using DXA. ALMI was calculated by dividing arm and leg lean mass by height in m2; fat mass index (FMI) was calculated by dividing whole body fat mass by height in m2. Linear mixed-effects models were used to estimate associations between ALMI and motor function, controlling for age and FMI. The full prediction model (age, age,2 ALMI, and FMI) explained 57% of the variance in NSAA scores and 63% of the variance in 10MWT speed. A 1 kg/m2 higher ALMI value predicted a 5.4-point higher NSAA score (p < .001) and 0.45 m/s faster 10MWT speed (p < .001). A 1 kg/m2 higher FMI value predicted a 1.5-point lower NSAA score (p < .001) and 0.14 meters/second slower 10MWT speed (p < .001). DXA-derived estimates of ALMI and FMI are associated with motor function in DMD and may explain variation in DMD disease progression.

Exoskeletal wearable robot on ambulatory function in patients with stroke: a protocol for an international, multicentre, randomised controlled study

IntroductionThe purpose of this study is to determine the effect of overground gait training using an exoskeletal wearable robot (exoskeleton) on the recovery of ambulatory function in patients with subacute...

The impact of intrathecal baclofen on the ability to walk: A systematic review

Objective Intrathecal baclofen (ITB) is an effective treatment for lower limb spasticity. In ambulatory patients with spasticity, there is a justifiable concern that ITB treatment may compromise ambulatory function by reducing the heightened muscle tone, thereby unmasking underlying muscle weakness. ITB is hence offered with reservation in ambulant patients. In this article, we review the literature surrounding the effect of ITB therapy on ambulatory function in patients with concurrent spasticity and discuss the key findings. Data sources A literature search of ProQuest Medline and EBSCO CINAHL databases was performed. Review method Inclusion criteria included (a) studies reporting the effect of ITB in adult ambulatory patients; (b) studies with an intervention of screening test trial via either bolus injections or continuous infusion tests; and (c) studies with an intervention of ITB pump implantation. Seventeen eligible studies were identified and two authors independently assessed the study quality using the risk of bias in nonrandomised studies of interventions tool (ROBINS-I). Results Seventeen studies were included, with a total of 534 participants. Most of the patients remain ambulatory after ITB treatment, accompanied by improvements in gait speed and reduction in spasticity. Conclusion ITB therapy when administered in carefully selected ambulatory patients with spasticity is not associated with loss of ambulatory function.

Disease-Modifying Treatments and Time to Loss of Ambulatory Function in Patients With Primary Progressive Multiple Sclerosis

Except for ocrelizumab, treatment options in primary progressive multiple sclerosis (PPMS) are lacking. To investigate the effectiveness of DMTs on the risk of becoming wheelchair dependent in a real-world population of patients with PPMS. This was a multicenter, observational, retrospective, comparative effectiveness research study. Data were extracted on November 28, 2018, from the Italian multiple sclerosis register and analyzed from June to December 2021. Mean study follow-up was 11 years. Included in the study cohort were patients with a diagnosis of PPMS and at least 3 years of Expanded Disability Status Scale (EDSS) evaluations and 3 years of follow-up. The risk of reaching an EDSS score of 7.0 was assessed through multivariable Cox regression models. Patients who received DMT before the outcome were considered treated. DMT was assessed as a time-dependent variable and by class of DMT (moderately and highly effective). From a total of 3298 patients with PPMS, 2633 were excluded because they did not meet the entry criteria for the phase 3, multicenter, randomized, parallel-group, double-blind, placebo-controlled study to evaluate the efficacy and safety of ocrelizumab in adults with PPMS (ORATORIO) trial. Among the remaining 665 patients (mean [SD] age, 43.0 [10.7] years; 366 female patients [55.0%]), 409 were further selected for propensity score matching (288 treated and 121 untreated patients). In the matched cohort, during the study follow-up, 37% of patients (152 of 409) reached an EDSS score of 7.0 after a mean (SD) follow-up of 10.6 (5.6) years. A higher EDSS score at baseline (adjusted hazard ratio [aHR], 1.32; 95% CI, 1.13-1.55; P < .001), superimposed relapses (aHR, 2.37; 95% CI, 1.24-4.54; P = .009), and DMT exposure (aHR, 1.75; 95% CI, 1.04-2.94; P = .03) were associated with a higher risk of an EDSS score of 7.0, whereas the interaction term between DMT and superimposed relapses was associated with a reduced risk of EDSS score of 7.0 (aHR, 0.33; 95% CI, 0.16-0.71; P = .004). Similar findings were obtained when treatment according to DMT class was considered and when DMT was included as a time-dependent covariate. These results were confirmed in the subgroup of patients with available magnetic resonance imaging data. Results of this comparative effectiveness research study suggest that inflammation also occurs in patients with PPMS, may contribute to long-term disability, and may be associated with a reduced risk of becoming wheelchair dependent by current licensed DMTs.

Prospective comparison of one-year survival in patients treated operatively and nonoperatively for spinal metastatic disease: results of the prospective observational study of spinal metastasis treatment (POST)

A sea-change occurred in the field of spine surgery in 2005 following the landmark publication of Patchell et al [1]. regarding the efficacy of spine surgery for restoration of ambulatory function in patients with spinal metastatic disease. In the succeeding 15 years, enthusiasm grew for surgical interventions as a standard treatment option for patients with spinal metastases [2]. Several investigations touted that surgery not only preserved ambulatory ability but also improved survival [3–6]. There was a concern that many of these investigations were confounded by selection bias and controversy remains regarding the utility of spine surgery in subsets of patients with spinal metastases based on baseline neurologic status [7].

Hereditary Spastic Paraplegia in Koreans: Clinical Characteristics and Factors Influencing the Disease Severity.

Hereditary spastic paraplegia (HSP) progresses over time and is associated with locomotive dysfunction. Understanding the factors affecting disease severity and locomotive function is important in HSP. This study investigated the factors influencing disease severity and ambulation status of HSP.We consecutively enrolled 109 Korean patients (64 males, and 45 females)from 84 families with a clinical diagnosis of HSP. HSP was primarily diagnosed based on clinical criteria including clinical findings, family history, and supported by genetic studies. Epidemiological and clinical features of the patients were analyzed, and the Spastic Paraplegia Rating Scale (SPRS) score and ambulatory status were used to evaluate disease severity.Ninety-two (84.4%) patients had pure HSP, and 55 (50.4%) had a dominant family history. Thirty-one (28.4%) patients required a mobility aid for locomotion. A Kaplan-Meier analysis showed that HSP patients lost their independent gait ability after a median disease duration of 34 years. Those with an age at onset of ≤18 years had a longer median independent walking time. Pure HSP is characterized by predominant bilateral lower extremity weakness and spasticity, whereas complicated HSP presents more complex neurological findings such as ocular and bulbar symptoms, ataxia, and cognitive impairment. Complicated HSP was significantly correlated with the SPRS mobility score (β=3.70, 95% confidence interval=0.45-6.94). The age at onset and disease duration were significantly correlated with disease severity, and they were significant predictors of the use of a mobility aid (p<0.05).These findings suggest that a later age at onset and longer disease duration are significant factors affecting the disease severity and ambulatory function in patients with HSP. These findings can help clinicians to identify subjects at risk of locomotive impairment.

Hereditary Spastic Paraplegia in Koreans: Clinical Characteristics and Factors Influencing the Disease Severity.

Background and PurposeHereditary spastic paraplegia (HSP) progresses over time and is associated with locomotive dysfunction. Understanding the factors affecting disease severity and locomotive function is important in HSP. This study investigated the factors influencing disease severity and ambulation status of HSP.MethodsWe consecutively enrolled 109 Korean patients (64 males, and 45 females)from 84 families with a clinical diagnosis of HSP. HSP was primarily diagnosed based on clinical criteria including clinical findings, family history, and supported by genetic studies. Epidemiological and clinical features of the patients were analyzed, and the Spastic Paraplegia Rating Scale (SPRS) score and ambulatory status were used to evaluate disease severity.ResultsNinety-two (84.4%) patients had pure HSP, and 55 (50.4%) had a dominant family history. Thirty-one (28.4%) patients required a mobility aid for locomotion. A Kaplan-Meier analysis showed that HSP patients lost their independent gait ability after a median disease duration of 34 years. Those with an age at onset of ≤18 years had a longer median independent walking time. Pure HSP is characterized by predominant bilateral lower extremity weakness and spasticity, whereas complicated HSP presents more complex neurological findings such as ocular and bulbar symptoms, ataxia, and cognitive impairment. Complicated HSP was significantly correlated with the SPRS mobility score (β=3.70, 95% confidence interval=0.45–6.94). The age at onset and disease duration were significantly correlated with disease severity, and they were significant predictors of the use of a mobility aid (p<0.05).ConclusionsThese findings suggest that a later age at onset and longer disease duration are significant factors affecting the disease severity and ambulatory function in patients with HSP. These findings can help clinicians to identify subjects at risk of locomotive impairment.

Gait Evaluation with Bioelectrical Signal Patterns during Cybernic Treatment.

Cybernic treatment with a wearable cyborg Hybrid Assistive Limb for medical use (Medical HAL) improves ambulatory function in patients with progressive neuromuscular diseases. The progress of cybernic treatment is evaluated based on the change in the patient's walking distance and walking speed over a certain treatment period. However, evaluation methods to capture temporal changes in gait functions during each therapy are required for more effective evaluation in clinical practice. Because the patients' muscular activities are measured with each trial of cybernic treatment, bioelectrical signals (BES) of lower limb muscles measured by Medical HAL may aid in evaluating the wearers' gait functions. Thus, this study proposed a method to quantify the BES patterns of patients during cybernic treatment and compared them with the BES patterns of healthy personnel for evaluation, which confirmed the correlation between the BES pattern and the patients' gait abilities. First, we obtained a reference BES pattern from the BES of three healthy personnel during walking using Medical HAL. Second, we calculated the similarity between the reference BES pattern of the healthy personnel and the patient's BES pattern using derivative dynamic time warping (DDTW), which quantified the patients' BES patterns based on their shape. Third, we investigated the correlation between patients' DDTW of BES patterns during cybernic treatment and 2-minute walking distances. The correlation coefficient between the patients was -0.83 (p < 0.01) and that within patients was -0.38 (p < 0.05), indicating a significant BES pattern relationship between walking with Medical HAL and gait abilities. Conclusively, the similarity between the BES patterns of healthy personnel and patients calculated using DDTW might be applied to the evaluation of patients' gait functions. The ability to assess the gait function with data measured during cybernic treatment would provide understandings of the patient's functional changes over time.

Cybernic treatment with wearable cyborg Hybrid Assistive Limb (HAL) improves ambulatory function in patients with slowly progressive rare neuromuscular diseases: a multicentre, randomised, controlled crossover trial for efficacy and safety (NCY-3001)

BackgroundRare neuromuscular diseases such as spinal muscular atrophy, spinal bulbar muscular atrophy, muscular dystrophy, Charcot-Marie-Tooth disease, distal myopathy, sporadic inclusion body myositis, congenital myopathy, and amyotrophic lateral sclerosis lead to incurable amyotrophy and consequent loss of ambulation. Thus far, no therapeutic approaches have been successful in recovering the ambulatory ability. Thus, the aim of this trial was to evaluate the efficacy and safety of cybernic treatment with a wearable cyborg Hybrid Assistive Limb (HAL, Lower Limb Type) in improving the ambulatory function in those patients.ResultsWe conducted an open-label, randomised, controlled crossover trial to test HAL at nine hospitals between March 6, 2013 and August 8, 2014. Eligible patients were older than 18 years and had a diagnosis of neuromuscular disease as specified above. They were unable to walk for 10 m independently and had neither respiratory failure nor rapid deterioration in gait. The primary endpoint was the distance passed during a two-minute walk test (2MWT). The secondary endpoints were walking speed, cadence, and step length during the 10-m walk test (10MWT), muscle strength by manual muscle testing (MMT), and a series of functional measures. Adverse events and failures/problems/errors with HAL were also evaluated. Thirty patients were randomly assigned to groups A or B, with each group of 15 receiving both treatments in a crossover design. The efficacy of a 40-min walking program performed nine times was compared between HAL plus a hoist and a hoist only. The final analysis included 13 and 11 patients in groups A and B, respectively. Cybernic treatment with HAL resulted in a 10.066% significantly improved distance in 2MWT (95% confidence interval, 0.667–19.464; p = 0.0369) compared with the hoist only treatment. Among the secondary endpoints, the total scores of MMT and cadence at 10MWT were the only ones that showed significant improvement. The only adverse effects were slight to mild myalgia, back pain, and contact skin troubles, which were easily remedied.ConclusionsHAL is a new treatment device for walking exercise, proven to be more effective than the conventional method in patients with incurable neuromuscular diseases.Trial registration: JMACTR, JMA-IIA00156

Simple and Reliable Magnetic Resonance Imaging Parameter to Predict Postoperative Ambulatory Function in Patients With Metastatic Epidural Spinal Cord Compression.

Retrospective case-control study. The aim of this study was to develop a simple and reliable imaging parameter to predict postoperative ambulatory status in patients with metastatic epidural spinal cord compression (MESCC). Sixty-three patients with MESCC underwent spine surgery because of neurologic deficits were included. On preoperative axial MRI, the cord compression ratio was analyzed for postoperative ambulatory status. The relationship between other imaging features, such as fracture of the affected vertebra and increased T2 signal intensity of the spinal cord at the compression level, and the postoperative ambulatory status were also analyzed. Cord compression ratio and increased T2 signal change of the spinal cord were significantly different between the postoperative ambulatory group and the non-ambulatory group. Receiver operating characteristic analysis showed that the optimal cut-off value was 0.84. In the multivariate regression analysis, only a cord compression ratio of more than 0.84 was significantly associated with postoperative ambulatory status (odds ratio = 10.80; 95% confidence interval = 2.79-41.86; P = .001). Interobserver/intraobserver agreements were strong for the cord compression ratio, however those agreements were weak for increased T2 signal intensity. On preoperative MRI, the cord compression ratio may predict postoperative ambulatory status in patients with MESCC. The measurement of this imaging parameter was simple and reliable. This imaging predictor may be helpful for both clinicians and patients.

Comparison of Long-term Ambulatory Function in Patients with Duchenne Muscular Dystrophy Treated with Eteplirsen and Matched Natural History Controls.

Background:Duchenne muscular dystrophy (DMD) is a rare, X-linked, fatal, degenerative neuromuscular disease caused by DMD gene mutations. A relationship between exon skipping and dystrophin production in exon 51-amenable patients treated with eteplirsen (EXONDYS 51®) is established. Once-weekly eteplirsen significantly increased dystrophin, with slower decline in ambulatory function compared to baseline. Long-term treatment with eteplirsen leads to accumulation of dystrophin over time and observed functional benefits in patients with DMD.Objective:Compare long-term ambulatory function in eteplirsen-treated patients versus controls.Methods:Study 201/202 included 12 eteplirsen-treated patients assessed twice/year for ambulatory function over 4 years. Ambulatory evaluations (6-minute walk test [6MWT], loss of ambulation, and North Star Ambulatory Assessment [NSAA]) were compared with matched controls from Italian Telethon and Leuven registries.Results:At Years 3 and 4, eteplirsen-treated patients demonstrated markedly greater mean 6MWT than controls (difference in change from baseline of 132 m [95%CI (29, 235), p = 0.015] at Year 3 and 159 m [95%CI (66, 253), p = 0.002] at Year 4). At Year 4, a significantly greater proportion of eteplirsen-treated patients were still ambulant versus controls (10/12 vs 3/11; p = 0.020). At Year 3, eteplirsen-treated patients demonstrated milder NSAA decline versus controls (difference in change from baseline of 2.6, 95%CI [-6, 11]), however, the difference was not statistically significant; Year 4 control NSAA data were not available.Conclusion:In this retrospective matched control study, eteplirsen treatment resulted in attenuation of ambulatory decline over a 4-year observation period, supporting long-term benefit in patients with DMD.

Physical activity is associated with neuromuscular and physical function in patients with multiple sclerosis independent of disease severity

Purpose Examine the association between physical activity and neuromuscular and physical function in patients with multiple sclerosis when also considering disease severity. Methods 91 patients with multiple sclerosis were enrolled. Assessments included physical activity by 7-day thigh-worn accelerometry, knee extensor neuromuscular function by dynamometry (maximal isometric muscle strength, rate of force development (0–50 ms)), and physical function by 5× sit-to-stand, 2-min walk test, and timed 25 ft walk test. Physical activity tertile comparisons along with simple and multiple regressions (adjusting for age, gender, EDSS, time since diagnosis) were performed. Results Physical activity tertiles revealed differences (p < 0.05) in maximal muscle strength (1.77 ≈ 1.97 < 2.28 Nm/kg), rate of force development (4.66 < 8.03 ≈ 10.55 Nm/kg/s), 5× sit-to-stand (11.4 ≈ 9.7 > 8.5 s), 2-min walk test (153 < 183 < 207 m), and timed 25 ft walk test (6.3 > 4.4 > 4.3 s). Moreover, physical activity was associated (p < 0.05) with maximal muscle strength and rate of force development (r 2 = 0.13–0.15) along with 5× sit-to-stand, 2-min walk test, and timed 25 ft walk test (r 2 = 0.18–0.24), also after adjusting for age + gender + EDSS + time since diagnosis (r 2 = 0.25–0.37 and 0.24–0.52), with physical activity consistently being a strong predictor. Conclusions Higher levels of physical activity are associated with greater neuromuscular and physical function in ambulatory patients with multiple sclerosis independent of disease severity. These findings emphasize the importance of performing regular physical activity at all stages of multiple sclerosis. IMPLICATIONS FOR REHABILITATION Physical activity is associated with neuromuscular and physical function, independent of disease severity. Physical activity may be important in improving or preserving neuromuscular and physical function at all stages of ambulatory multiple sclerosis patients, yet longitudinal studies are warranted. Clinicians and rehabilitation professionals should encourage ambulatory patients at all stages of their disease to be as physically active as possible.

Prognostic Effect of Renal Function in Ambulatory Patients With Heart Failure and Reduced Ejection Fraction: The Kidney Is a Marker of Cardiac Function

BackgroundChronic kidney disease is a frequent comorbidity in heart failure (HF), associated with increased mortality. The impact of temporal evolution of kidney function in HF prognosis is largely unknown. We evaluated the effect of renal function over time in all-cause mortality among ambulatory patients with HF. MethodsWe retrospectively analyzed data from 560 patients with HF with left ventricular systolic dysfunction followed for a median of 25.1 months at an outpatient clinic. Demographics and comorbidities were collected at baseline. Creatinine values were abstracted from records at each clinical visit. Kidney function was assessed by estimated glomerular filtration rate (eGFR) and was categorized into 3 classes. Extended Cox models were performed to study the association between time-varying eGFR and death. ResultsPatients’ mean age was 67.5 ± 13.9 years, 67.0% were men, 46.1% had ischemic etiology, the majority had moderate-to-severe left ventricular systolic dysfunction, and 45.9% had chronic kidney disease at baseline. The eGFR declined approximately 9.0 mL/min/1.73 m2 over 5 years. In crude analysis, time-varying eGFR had a significant dose-dependent association with death (hazard ratio [HR] = 1.34, 95% confidence interval [CI]: 1.03-1.75 for eGFR between 30 and 60 mL/min/1.73 m2; HR = 1.55, 95% CI: 1.11-2.17 for <30 mL/min/1.73 m2). The prognostic value of time-varying eGFR was totally explained by baseline comorbidities, indicators of HF severity and drugs (adjusted HR = 1.11, 95% CI: 0.83-1.48; HR = 1.19, 95% CI: 0.79-1.80, for eGFR 30-60 and <30 mL/min/m2, respectively). ConclusionsTime-varying kidney function is not independently related to poor prognosis in HF. Rather than directly affecting survival, renal impairment is probably a surrogate marker of HF severity.

Sit to Stand (STS) Vs. Stair Climbing (SC) as a Measure of Lower Extremity (LE) Function In Ambulatory Patients with Amyotrophic Sclerosis (ambALS). (S25.007)

Sit to Stand (STS) Vs. Stair Climbing (SC) as a Measure of Lower Extremity (LE) Function In Ambulatory Patients with Amyotrophic Sclerosis (ambALS). (S25.007)

Editors' Note

Editors' Note: In “Monitoring long-term efficacy of fampridine in gait-impaired patients with multiple sclerosis,” authors Filli et al. showed that prolonged-release fampridine improved walking speed, endurance, and self-perceived ambulatory function in patients with multiple sclerosis (MS). Furthermore, patients showed additional drug responsiveness with long-term treatment. Commenting on the article, Dr. Davis asks whether there is a correlation between increased fampridine responsiveness over time and cotreatment with natalizumab. He notes that 32% of the patients studied were also treated with natalizumab. Since the latter decreases disability in MS, it might increase the conduction safety factor sufficiently to restore impulse conduction in blocked axons and increase the efficacy of fampridine. To address Dr. Davis' comments, authors Filli et al. quantify the long-term responsiveness to fampridine of 6 patients with MS cotreated with natalizumab over a period of 2 years. They did not find an increased benefit with respect to walking function in patients treated with natalizumab vs other study participants. However, the number was small and studies with larger cohorts are needed. The editorial “A model for predicting the growth of unruptured intracranial aneurysms: Beyond fortune telling” addressed the article by Backes et al., “ELAPSS score for prediction of risk of growth of unruptured intracranial aneurysms.” ELAPSS (earlier subarachnoid hemorrhage, location of the aneurysm, age >60 years, population, size of the aneurysm, and shape of the aneurysm) is a tool developed to predict the growth of unruptured aneurysms using a weighted composite of patient- and aneurysm-specific characteristics. Editorialists Ding and Etminan believe that ELAPSS is a useful tool to predict risk of growth of unruptured intracranial aneurysms but that the management strategy for these lesions must be supplemented by numerous patient- and aneurysm-specific characteristics not included in the scoring system. Commenting on the editorial, Dr. Munakomi suggests evaluating the role of computational flow dynamics (CFD) to assess further the aneurysm-specific rupture risk. Dr. Ding agrees that CFD may, in the future, provide valuable insight into the rupture risk of unruptured aneurysms, but warns that CFD models require rigorous and prospective validation before they can be applied to clinical decision-making for unruptured aneurysms. —Chafic Karam, MD, and Robert C. Griggs, MD Editors' Note: In “Monitoring long-term efficacy of fampridine in gait-impaired patients with multiple sclerosis,” authors Filli et al. showed that prolonged-release fampridine improved walking speed, endurance, and self-perceived ambulatory function in patients with multiple sclerosis (MS). Furthermore, patients showed additional drug responsiveness with long-term treatment.

Outcomes of primary total knee arthroplasty in patients with Parkinson’s disease: A Case Control Comparison Study

Introduction and Aims:There is considerable debate and a paucity of evidence regarding whether Total Knee Replacement (TKR) is of benefit in patients with Parkinson’s disease (PD) and knee osteoarthritis, and whether PD would compromise the outcome of TKR. Therefore, we aimed to compare the effect of TKR on range of motion and Oxford Knee Scores (OKS) between PD patients and age-matched controls at 1 year follow-up.Methods:A cohort of 45 knees from 35 patients was identified as having a confirmed diagnosis of Parkinson’s disease and received a primary TKR between January 2004 and December 2015, which was extracted from a clinical database (Socrates, v3.5, Orthosoft, AUS) maintained by two orthopaedic surgeons in two hospitals. An age-matched control group (mean age: 73 years) of 45 knees from 41 patients without Parkinson’s disease was randomly computer-generated from the same database. The indication for TKR in both groups was osteoarthritis, an independent assessment of each knee to meet appropriate selection criteria for TKR, as well as preoperative physician review for medical comorbidities. Outcome measures analysed in the study were the difference in pre-operative range of motion (RoM) and 12-point Oxford Knee Scores and at 1-year follow-up respectively. Postoperative complications and revisions were also recorded during the follow-up period.Results:In the PD group, RoM improved from a mean of 100 degrees preoperatively to 114 degrees at 12 months, compared to the control group which improved from a mean of 102 degrees to 114 degrees respectively. OKS in the Parkinson’s group improved from a mean of 23 preoperatively to 38 at 12 months compared to 23 preoperatively and 40 at 12 months in the control group. After adjusting for sex, we found that the difference in the ROM and OKS between the Parkinson’s and control groups was not significantly different (p = 0.9725; 0.6450 respectively). Furthermore, in all Parkinson’s patients the minimal clinically important difference for OKS (≥6) was achieved at 1-year follow-up (4). There were no mortalities during the study follow-up period, with 4 complications in the PD group (DVT, superficial infection) and two in the control group (DVT, bowel pseudo-obstruction).Conclusions:This study demonstrates that TKR provides comparable outcomes with regard to range of movement and ambulatory function in patients with Parkinson’s disease who are also suffering from severe osteoarthritis. We also feel that TKR has an acceptable complication profile in this subgroup of patients. The presence of PD does not appear to compromise the outcome of TKR in these patients, and the same indications for TKR should therefore apply as for the general OA population.

Long-term ambulatory change after lower extremity orthopaedic surgery in children with cerebral palsy: a retrospective review.

Long-term studies of lower extremity orthopaedic surgery in children with cerebral palsy (CP) tend to focus on gait kinematics and kinetics, with little to no emphasis on gross motor ambulatory function. The current study was undertaken to examine the long-term impact of surgery on ambulatory function in patients with CP enrolled in a government-funded, outpatient therapy program. Retrospective medical record review was conducted of 127 children with CP, Gross Motor Function Classification System (GMFCS) levels I to IV, followed up to 14 years after lower extremity orthopaedic surgery. Data were extracted from medical/operative records and routine physical therapy evaluations performed over the course of follow-up. Functional Mobility Scale (FMS) scores were assigned based on gross motor function information contained in each 6- to 12-month physical therapy evaluation. Data were compared statistically among GMFCS levels. Average length of follow up was 11.8±4 years. Subjects underwent 0.61±0.43 surgical procedures per person-year in 0.16±0.09 operative sessions per person-year with no differences between GMFCS levels. Subjects at GMFCS level I improved significantly in community (P=0.02) but not household ambulation, reflecting the ceiling effect of the FMS. Subjects at GMFCS levels II to IV showed statistically significant improvements at all distances. Subjects at level III gained more in household than long-distance ambulation (P=0.002). Subjects functioning at GMFCS level II improved by 1 FMS level for household and school distances, and 2 FMS levels for community distances (P<0.02). Subjects at level IV exhibited small ambulatory gains at all distances (P<0.04). Significant long-term improvement in functional ambulation is seen after surgery for children at all GMFCS levels. Children with more independence tend to make gains in long-distance ambulation, whereas those who use assistive devices tend to improve more in short-distance ambulation. This information may be useful to clinicians when counseling patients and their families regarding potential for ambulatory improvement after lower extremity orthopaedic surgery. Level IV: case series.

Cognitive function in ambulatory patients with systolic heart failure: insights from the warfarin versus aspirin in reduced cardiac ejection fraction (WARCEF) trial.

We sought to determine whether cognitive function in stable outpatients with heart failure (HF) is affected by HF severity. A retrospective, cross-sectional analysis was performed using data from 2, 043 outpatients with systolic HF and without prior stroke enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) Trial. Multivariable regression analysis was used to assess the relationship between cognitive function measured using the Mini-Mental Status Exam (MMSE) and markers of HF severity (left ventricular ejection fraction [LVEF], New York Heart Association [NYHA] functional class, and 6-minute walk distance). The mean (SD) for the MMSE was 28.6 (2.0), with 64 (3.1%) of the 2,043 patients meeting the cut-off of MMSE <24 that indicates need for further evaluation of cognitive impairment. After adjustment for demographic and clinical covariates, 6-minute walk distance (β-coefficient 0.002, p<0.0001), but not LVEF or NYHA functional class, was independently associated with the MMSE as a continuous measure. Age, education, smoking status, body mass index, and hemoglobin level were also independently associated with the MMSE. In conclusion, six-minute walk distance, but not LVEF or NYHA functional class, was an important predictor of cognitive function in ambulatory patients with systolic heart failure.

Clot strength is negatively associated with ambulatory function in patients with peripheral artery disease and intermittent claudication.

Peripheral artery disease (PAD) is associated with exercise impairment and greater thrombotic risk. We investigated whether clot formation and platelet aggregation assessed by thromboelastography and light-transmission aggregometry correlate with the severity of symptomatic PAD assessed by ambulatory function measures. We studied 40 symptomatic patients with PAD in whom severity of disease was assessed using ankle-brachial index, peak walking time (PWT), claudication onset time, peak oxygen uptake, daily ambulatory activity, and walking impairment questionnaire (WIQ) scores. Clot strength correlated negatively with peak oxygen uptake, PWT, WIQ distance, and stair-climbing scores. Time to clot formation did not correlate with exercise parameters. Platelet aggregation was negatively correlated with WIQ distance score and was positively correlated with PWT and peak oxygen uptake. In conclusion, clot strength and platelet aggregation correlated with objective and self-perceived ambulatory measures. Patients with PAD having more severe walking impairment may be likely to form stronger clots.

Motion of the Multisegmental Foot in Hallux Valgus

Hallux valgus is a common condition characterized by lateral deviation of the large toe and medial deviation of the first metatarsal. While some gait analyses of patients with hallux valgus have been performed using plantar pressures, very little is known about the kinematics of gait in this population. The purpose of this study was to evaluate triplanar kinematics in patients with hallux valgus using a multisegmental foot model. A 15-camera Vicon Motion Analysis System was used to evaluate the gait of 38 feet in 33 patients with mild to severe hallux valgus. The Milwaukee foot model was used to characterize dynamic foot and ankle kinematics and temporal-spatial parameters. Values were compared with normal subjects. Outcomes were evaluated using the SF-36 assessment tool. Patients with hallux valgus showed significantly decreased velocity and stride length and prolonged stance. Significant alterations in gait kinematics were observed in various planes in all segments (hallux, forefoot, hindfoot, and tibia) of the foot and ankle, particularly in the ranges of motion of the hallux and the forefoot. The results demonstrate significantly altered kinematic and temporal-spatial parameters reflective of reduced ambulatory function in patients with hallux valgus. As reports describing multisegmental foot and ankle kinematics in this population are limited, this study is valuable in characterizing gait in patients with hallux valgus. A better understanding of altered gait dynamics of the multisegmental foot in patients with hallux valgus provides valuable insight on how distal pathology affects proximal segments.