Functional Ambulation Category Research Articles

Accuracy of Physiotherapist Predictions for Independent Walking After Stroke

Background The use of prediction tools in stroke rehabilitation research and clinical practice is increasing, but it is not clear whether these prediction tools out-perform clinician predictions. Objective This study aimed to compare physiotherapist predictions for independent walking with the Time to Walking Independently after STroke (TWIST) prediction tool. Methods Adults with new lower limb weakness and unable to walk independently (Functional Ambulation Category [FAC] < 4) were recruited. At 1 week post-stroke, the treating physiotherapist was asked to predict whether their patient would achieve independent walking by 4, 6, 9, 12, 16, or 26 weeks, or remain dependent. Predictions were also made using the TWIST prediction tool, but not shared. Binary logistic regressions were conducted with the time independent walking was achieved as the dependent variable and independent variables were the physiotherapist and TWIST predictions. Results Ninety-one participants were included (median age 71 years, 36 [40%] female). Most participants (67 [74%]) were non-ambulatory (FAC = 0) at 1-week post-stroke. Thirty-seven physiotherapists were recruited. Physiotherapists made accurate predictions for time taken to achieve independent walking for 39 participants (43%). Prediction accuracy was not related to physiotherapist confidence or years of stroke-specific experience. TWIST out-performed physiotherapist predictions (Physiotherapists 76%-77%, TWIST 86%-88% accurate) for participants who achieved independent walking by 4, 6, and 9 weeks post-stroke. Accuracy of physiotherapist and TWIST predictions was similar for 16 and 26 weeks post-stroke. Conclusions The TWIST prediction tool is more accurate than physiotherapists at predicting whether a patient will achieve independent walking by 4, 6, or 9 weeks post-stroke, but not for 16 or 26 weeks post-stroke. TWIST may be useful to inform early rehabilitation and discharge planning. Clinical Trial Registration-URL: www.anzctr.org.au Unique Identifier: ACTRN12617001434381.

Gait Performance and Brain Activity Are Improved by Gait Automatization during Robot-Assisted Gait Training in Patients with Burns: A Prospective, Randomized, Single-Blinded Study.

Background: Patients with lower extremity burn injuries have decreased gait function. Gait dysfunctions are compensated by activation of executive areas such as the prefrontal cortex (PFC). Although robot-assisted gait training (RAGT) can improve gait function, the training mechanisms of RAGT are unknown. We aimed to determine the clinical effects of RAGT in patients with burns and investigate their underlying mechanisms. Methods: This single-blind, randomized controlled trial involved 54 patients with lower extremity burns. The RAGT group underwent RAGT using SUBAR® and conventional training. The control (CON) group underwent only conventional training. The primary outcome was cortical activity measured using a functional near-infrared spectroscopy device before and after 8 weeks of training to confirm the compensatory effect of gait dysfunction. The secondary outcomes were the functional ambulation category (FAC) to evaluate gait performance, 6-min walking test (6 MWT) distance to measure gait speed, isometric force and range of motion (ROM) of lower extremities to evaluate physical function, and the visual analog scale (VAS) score to evaluate subjective pain during gait. Results: PFC activation during the gait phase in the RAGT group decreased significantly compared with that of the CON. The VAS score decreased and FAC score improved after 8 weeks of training in both groups. The 6 MWT scores, isometric strengths (the left knee flexor and bilateral ankle plantar flexors), and the ROMs (the extensions of bilateral hip and bilateral knee) of the RAGT group were significantly improved compared with those of the CON. RAGT improved gait speed, lower extremity ROMs, and lower extremity muscles strengths in patients with burns. Conclusions: The improvement in gait speed and cerebral blood flow evaluation results suggests that the automatization of gait is related to the treatment mechanism during RAGT.

Effect of short-term 10 Hz repeated transcranial magnetic stimulation on postural control ability in patients with mild hemiparesis in acute ischemic stroke: a single-blinded randomized controlled trial.

Previous studies have demonstrated that repetitive transcranial magnetic stimulation (rTMS) can improve postural control in subacute and chronic ischemic stroke, but further research is needed to investigate the effect of rTMS on acute ischemic stroke. We compared the therapeutic effects of rTMS plus conventional rehabilitation and conventional rehabilitation on postural control in patients with mild hemiparesis in acute ischemic stroke. Eighty-six patients with acute ischemic stroke were randomly assigned to either the experimental group or the control group within 1-7 days of onset. Patients in both groups received conventional rehabilitation for 2 weeks. Patients in the experimental group received rTMS treatments lasting for 2 weeks. Before and after the 2-week treatment, patients were assessed based on the Timed up and Go (TUG) test, Dual-Task Walking (DTW) test, Functional Ambulation Category (FAC), Tinetti Performance Oriented Mobility Assessment (POMA), gait kinematic parameters, Barthel Index (BI), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and National Institutes of Health Stroke Scale (NIHSS). Additionally, TUG and single-task gait velocity were assessed at 2 months after the start of treatment, and independent walking recovery was also followed up. After 2 weeks of treatment, compared to conventional rehabilitation, participants who underwent rTMS treatment plus conventional rehabilitation exhibited notable enhancements in TUG, FAC, POMA, and some gait parameters [single-task gait velocity, gait stride length, gait cadence, gait cycle]. Changes in cognitive function partially mediated the improvement in single-task gait velocity and gait stride length by rTMS plus conventional rehabilitation. Generalized Estimating Equation (GEE) analysis showed that the trend of improvement in single-task gait velocity over time was more pronounced in the experimental group than in the control group. The results of the Kaplan-Meier curve indicated a median gait recovery time of 90 days for patients in the experimental group and 100 days for the control group. Multifactorial Cox regression analyses showed that rTMS plus conventional rehabilitation promoted faster recovery of independent walking compared with conventional rehabilitation. rTMS plus conventional rehabilitation outperformed conventional rehabilitation in improving postural control in patients with acute ischemic stroke. Improvements in cognitive function may serve as a mediating factor in the favorable treatment outcome of rTMS plus conventional rehabilitation for improving postural control. https://www.chictr.org.cn, identifier ChiCTR1900026225.

2226 Assessing quantitative sonographic changes in the muscle mass of geriatric patients hospitalised using point of care ultrasound

Abstract Introduction One of the most important consequences of hospitalisation in older patients is sarcopenia. This study aims to determine the impact of hospitalisation on the muscle mass, functional status, nutritional status, and short-term clinical outcomes. Methods A prospective study of patients admitted to an Acute Geriatric Ward between 1st November and 30th December 2022. Muscle ultrasound, utilising Point of Care Ultrasound (POCUS) at bedside, was employed to estimate rectus femoris muscle thickness (MT), area (Ar), pennation angle (PA), and fascicle length (FL) at the time of hospital admission, 3 days post-admission, and at hospital discharge. Results 30 patients included, with a median age of 84 years (SD 72–93), 63.3% male, and 70% Clinical Frailty Scale score ≥ 4. Barthel Index and Functional Ambulation Category revealed median values of 72.33 and 3.87 respectively. Global Deterioration Scale median was 2.47. Mini Nutritional Assessment Short-Form (MNA) and total serum protein showed median values of 7.40 and 6.35 respectively. The median length of hospital stay was 5.79 days, with inpatient mortality rate of 10% and 53.3% incidence of delirium. Ultrasound showed a decrease in PA by 36.31%, Ar by 34.30%, and MT by 24.50%, and increase in FL by 10.47%. Sarcopenia classification at admission and discharge revealed an increase in mean index from 5.04 to 7.74. Conclusions In our cohort of patients admitted to an acute geriatric unit, POCUS identified real-time decreases in MT, Ar, and PA at the muscular level before these manifested as functional changes. It demonstrated an inverse relationship between frailty and muscle morphology as living with frailty associated further decreases in muscle mass at discharge. The study also established a direct relationship between MNA, muscle thickness, PA, and fascicles length at discharge. POCUS assessment of muscle mass could indirectly predict outcomes and guide decisions to address muscle mass abnormalities.

Rehabilitation of Frail Older Adults after Hip Fracture Surgery: Predictors for the Length of Geriatric Rehabilitation Stay at a Skilled Nursing Home.

Background: Approximately 50% of older patients hospitalized for hip fractures are admitted to a geriatric rehabilitation department at a skilled nursing home. Given the wide variation in rehabilitation stay lengths, predicting the length of stay upon hospital discharge would help manage patients' recovery expectations and create appropriate therapy schedules. Existing literature on length of stay predictors included both acute hospital and in-hospital rehabilitation phases or involved small sample sizes. The present study aims to identify predictors for the length of geriatric rehabilitation stay in skilled nursing homes for older patients after hip fracture surgery upon hospital discharge. Methods: This retrospective cohort study was conducted from 1 October 2017 to 1 July 2023, including 561 patients. Potential predictors of the length of geriatric rehabilitation stay were first tested univariately, with variables showing p < 0.15 entered into a multivariate forward linear regression model. Results: This model identified the following independent predictors of a longer length of geriatric rehabilitation stay: Functional Ambulation Categories (FACs) 0 (B = 29.9, 95% CI 24.1-35.7), 1 (B = 18.0, 95% CI 11.8-24.2), 2 (B = 12.0, 95% CI 7.1-17.0), or 3 (B = 3.6, 95% CI -1.2-9.4) at hospital discharge vs. FAC 4, living independently with home care services (B = 5.9, 95% CI 2.5-9.3) or in a residential home prior to the hip fracture (B = 0.2, 95% CI -7.4-7.8) vs. living independently without home care services, non- or partial weight-bearing mobilization vs. full weight-bearing mobilization (B = 15.4, 95% CI 8.5-22.2), internal fixation vs. hemiarthroplasty (B = 4.7, 95% CI 1.4-7.9), in-hospital delirium (B = 7.0, 95% CI 2.2-11.7), and in-hospital heart failure (B = 7.9, 95% CI 0.5-15.3). The explained variance was 32.0%. Conclusions: This study identified FAC at hospital discharge, premorbid living situation, postoperative weight-bearing protocol, surgery type, in-hospital delirium, and in-hospital heart failure as independent predictors of the length of geriatric rehabilitation stay. Future investigations are needed to identify additional predictors, such as cognitive functioning, to better predict the length of geriatric rehabilitation stay upon hospital discharge.

Effects of the intermittent theta burst stimulation on gait, balance and lower limbs motor function in stroke: study protocol for a double-blind randomised controlled trial with multimodal neuroimaging assessments

IntroductionApproximately, 50% of stroke survivors experience impaired walking ability 6 months after conventional rehabilitation and standard care. However, compared with upper limb motor function, research on lower limbs rehabilitation through...

Availability of Observational Pain Assessment Tools in Hospitalized Patients with Osteoporotic Vertebral Fractures.

Background and Objectives: Osteoporotic vertebral fractures in older patients cause lower back pain and abnormal posture, resulting in impaired activities of daily living (ADLs). Assessing pain using self-reported assessment tools is difficult, especially in patients with moderate-to-severe cognitive impairment. Recently, observational assessment tools have been used when self-reported ones were difficult to administer. No studies have reported the usefulness of observational assessment tools in patients with acute-phase orthopedic disorders without complication. This study aimed to examine the availability of observational tools for pain assessment in patients with lumbar vertebral fractures. Materials and Methods: Patients admitted to our hospital with acute-phase vertebral fractures were enrolled in this prospective observational study. Pain was assessed using Japanese versions of the Abbey pain scale and Doloplus-2 observational assessment tools, and the Numerical Rating Scale, a self-reported assessment tool. To compare the pain assessment tool, we examined whether each tool correlated with ADLs and ambulatory status. ADLs were assessed using the Barthel Index. Ambulatory status was assessed using the Functional Ambulation Categories and the 10-m walking test. Results: Similar to the Numerical Rating Scale scores, assessments with the Abbey pain scale and Doloplus-2 showed significant decreases in scores over time. A significant positive correlation was observed between the self-reported and observational assessment tools. Each pain assessment tool was significantly negatively correlated with ADLs and ambulatory status. Conclusions: When self-reported assessment with the Numerical Rating Scale is difficult for patients with cognitive impairment, pain can be estimated using the Abbey pain scale and Doloplus-2 observational assessment tools.

Factors affecting decreased walking ability in patients with conservatively treated fragility fracture of the pelvic ring

Background: The clinical results of conservative treatment in correctly selected patients with fragility fracture of the pelvis are acceptable. However, there is a loss of social and physical independence and autonomy. This study aimed to evaluate factors associated with decreased walking ability in patients with conservatively treated fragility fractures of the pelvis. Methods: Overall, 124 patients aged &gt;70 years were included. Fragility fracture of the pelvis was classified according to the Rommens classification. Walking ability before and 1 year after injury was assessed using the Functional Ambulation Category. Results: The overall recovery rate of walking ability of conservatively treated patients to the preinjury state was 73%, one year after injury. The presence of cancer and &gt; four-week bed rest were determinants of decreased walking ability one year after injury. Conclusions: The presence of cancer and more than four-week bed rest were risk factors for a significant decrease in walking ability.

Effects of acupuncture combined with trunk strengthening training on balance and gait abilities in stroke hemiplegic patients.

This study aimed to observe the effects of acupuncture combined with trunk strengthening training on balance and gait abilities in stroke hemiplegic patients. Sixty stroke hemiplegic patients were selected and randomly divided into a treatment group and a control group, with 30 patients in each group. The control group received conventional rehabilitation training and trunk strengthening exercises, while the treatment group received acupuncture in addition to the same interventions. Before and after 8 weeks of treatment, patients were assessed using the Holden Functional Ambulation Categories and Berg Balance Scale, and measurements were taken for step length, step width, and gait speed. Prior to treatment, there were no significant differences in Holden scores, Berg scores, step length, step width, or gait speed between the 2 groups (P > .05). After 8 weeks of treatment, significant improvements were observed in the aforementioned parameters in both groups (P < .05), with the acupuncture group showing significantly greater improvement compared to the control group (P < .05). Acupuncture combined with trunk strengthening training can significantly improve balance and gait impairments in stroke hemiplegic patients.

Efficacy of personalized rTMS to enhance upper limb function in subacute stroke patients: a protocol for a multi-center, randomized controlled study.

Repetitive transcranial magnetic stimulation (rTMS) is widely used therapy to enhance motor deficit in stroke patients. To date, rTMS protocols used in stroke patients are relatively unified. However, as the pathophysiology of stroke is diverse and individual functional deficits are distinctive, more precise application of rTMS is warranted. Therefore, the objective of this study was to determine the effects of personalized protocols of rTMS therapy based on the functional reserve of each stroke patient in subacute phase. This study will recruit 120 patients with stroke in subacute phase suffering from the upper extremity motor impairment, from five different hospitals in Korea. The participants will be allocated into three different study conditions based on the functional reserve of each participant, measured by the results of TMS-induced motor evoked potentials (MEPs), and brain MRI with diffusion tensor imaging (DTI) evaluations. The participants of the intervention-group in the three study conditions will receive different protocols of rTMS intervention, a total of 10 sessions for 2 weeks: high-frequency rTMS on ipsilesional primary motor cortex (M1), high-frequency rTMS on ipsilesional ventral premotor cortex, and high-frequency rTMS on contralesional M1. The participants of the control-group in all three study conditions will receive the same rTMS protocol: low-frequency rTMS on contralesional M1. For outcome measures, the following assessments will be performed at baseline (T0), during-intervention (T1), post-intervention (T2), and follow-up (T3) periods: Fugl-Meyer Assessment (FMA), Box-and-block test, Action Research Arm Test, Jebsen-Taylor hand function test, hand grip strength, Functional Ambulatory Category, fractional anisotropy measured by the DTI, and brain network connectivity obtained from MRI. The primary outcome will be the difference of upper limb function, as measured by FMA from T0 to T2. The secondary outcomes will be the differences of other assessments. This study will determine the effects of applying different protocols of rTMS therapy based on the functional reserve of each patient. In addition, this methodology may prove to be more efficient than conventional rTMS protocols. Therefore, effective personalized application of rTMS to stroke patients can be achieved based on their severity, predicted mechanism of motor recovery, or functional reserves. https://clinicaltrials.gov/, identifier NCT06270238.

Which Acute Stroke Patients can Walk while Returning Home? Factors Predicting Ambulation.

Regaining gait is the primary goal in stroke rehabilitation. In this study, we aimed to investigate the effect of premorbid features of acute stroke patients on the ambulatory level. The study included 174 patients who applied to our rehabilitation clinic within the first month after the onset of stroke. Demographic characteristics of patients, pre-stroke symptoms, and stroke characteristics were questioned from patient files and historical data. The ambulation levels of patients before and after rehabilitation were evaluated with the functional ambulation category. The relationship between demographic characteristics, pre-stroke symptoms, stroke characteristics, and ambulation levels of patients before and after rehabilitation was examined. The presence of coronary heart diseases, atrial fibrillation, and nausea/vomiting before stroke were independent negative risk factors on both pre- and post-rehabilitation ambulation levels (P < 0.05). Additionally, advanced age, oxygen, and mechanical ventilation requirement were other negative independent risk factors on post-rehabilitation ambulation levels (P < 0.05). Knowing some of the pre-stroke characteristics of patients while applying rehabilitation programs may be useful in estimating the ambulatory levels on returning home.

Association between Height and Functional Outcomes of Patients 6 Months after a Stroke: A Multicenter Prospective Observational Cohort Study.

Many physical factors influence post-stroke functional outcomes. However, few studies have examined the influence of height on these outcomes. Here, data from the Korean Stroke Cohort for Functioning and Rehabilitation were used and patients' height was categorized into three groups: short (lower 25%), middle (middle 50%), and tall (upper 25%). Differences in the modified Rankin scale (mRS), functional ambulatory category (FAC), and Korean-translated version of the Modified Barthel Index (K-MBI) scores were analyzed for each group at 6 months post-stroke. A subgroup analysis was conducted based on the initial Fugl-Meyer Assessment (FMA) score. We analyzed functional outcomes in 5296 patients at 6 months post-stroke, adjusting for age and body mass index. The short-height group exhibited higher mRS scores (1.88 ± 0.043), lower FAC scores (3.74 ± 0.045), and lower K-MBI scores (82.83 ± 0.748) than the other height groups (p < 0.05). In the subgroup analysis, except for the very severe FMA group, the short-height group also exhibited worse outcomes in terms of mRS, FAC, and K-MBI scores (p < 0.05). Taken together, the short-height group exhibited worse outcomes related to disability, gait function, and ADLs at 6 months post-stroke.

AI in evaluating ambulation of stroke patients: severity classification with video and functional ambulation category scale

ABSTRACT Background The evaluation of gait function and severity classification of stroke patients are important to determine the rehabilitation goal and the level of exercise. Physicians often qualitatively evaluate patients’ walking ability through visual gait analysis using naked eye, video images, or standardized assessment tools. Gait evaluation through observation relies on the doctor’s empirical judgment, potentially introducing subjective opinions. Therefore, conducting research to establish a basis for more objective judgment is crucial. Objective To verify a deep learning model that classifies gait image data of stroke patients according to Functional Ambulation Category (FAC) scale. Methods Gait vision data from 203 stroke patients and 182 healthy individuals recruited from six medical institutions were collected to train a deep learning model for classifying gait severity in stroke patients. The recorded videos were processed using OpenPose. The dataset was randomly split into 80% for training and 20% for testing. Results The deep learning model attained a training accuracy of 0.981 and test accuracy of 0.903. Area Under the Curve(AUC) values of 0.93, 0.95, and 0.96 for discriminating among the mild, moderate, and severe stroke groups, respectively. Conclusion This confirms the potential of utilizing human posture estimation based on vision data not only to develop gait parameter models but also to develop models to classify severity according to the FAC criteria used by physicians. To develop an AI-based severity classification model, a large amount and variety of data is necessary and data collected in non-standardized real environments, not in laboratories, can also be used meaningfully.

Post-stroke spasticity: follow-up and functional implications of chronic long-term treatment with botulinum toxin.

Around 40% of stroke survivor develop spasticity. Plantar flexors (PF) muscles are often affected, with severe functional impairment. The treatment of choice is botulinum toxin type A (BoNT-A) combined with adjuvant treatments. The temporary pharmacological effect implies periodic reassessment and reinjection. These long-term chronic programs require monitoring the functional impact of each cycle and the clinical evolution in relation to aging and repeated interventions. Evaluating changes of functional level in patients with post-stroke spasticity treated with BoNT-A by assessing the long-term maintenance of the therapeutic efficacy. Retrospective longitudinal observational study. Outpatients. Chronic stroke survivors undergoing BoNT-A treatment and subsequent intensive rehabilitation (10 sessions in a day-hospital regime). Medical records of the enrolled patients were consulted. The primary endpoint was the change in PF spasticity by at least 1 point on the Modified Ashworth Scale (MAS) at each cycle. Secondary endpoints were the assessment of possible trends in gait parameters (Six Minute Walking Test [6MWT]; Timed Up and Go [TUG], and 10 Meters Walking Test [10mWT]) pre- and post-injection and at each cycle. Thirty-six patients were enrolled. A reduction of at least one MAS point for PF was recorded after each cycle in all subjects. A time-dependent reduction in the proportion of patients reporting an improvement higher than the minimal clinically important difference (MCID) in 6MWT and 10mWT was observed. In the case of TUG, this data kept stable at all cycles. A one-point increase in the basal functional ambulation classification (FAC) score resulted in a reduction in the probability of having a TUG improvement greater than the MCID. The opposite correlation was found for 6MWT and 10mWT. With the proposed treatment, the clinical significance TUG improvement remains constant throughout repeated cycles and the proportion of patients with improvement in 6MWT and 10mWT tends to decline over time. The predictive value of basal FAC on the functional variables expected improvement may provide a potential treatment targeting tool. These results may deliver prognostic indication allowing an optimized integration of different post-BoNT-A rehabilitation approaches, agreeing with current evidence. Adequate monitoring and treatment protocols are crucial for the stability of functional level and may prevent excessive fluctuations.

Association of Characteristics between Acute Stroke Patients and Sarcopenia: A Cross-Sectional Study

PURPOSE: This study aimed to identify the prevalence of sarcopenia among acute stroke patients, differences in characteristics based on the presence of sarcopenia, the association between functional and sarcopenia factors, and the association between characteristics and the presence of sarcopenia.METHODS: This study was conducted using a cross-sectional design. Sixty-two stroke patients volunteered to participate and were assigned to the sarcopenia group (n = 32) and the non-sarcopenia group (n = 30). All data collection, including assessment of general characteristics, sarcopenia factors and functional factors, was completed within one day.RESULTS: A sarcopenia prevalence rate of 51% was observed. As skeletal muscle mass index (SMI) and grip strength increased, the berg balance scale (BBS) also increased. Additionally, as grip strength increased, the modified Barthel index (MBI) increased. Significant differences between groups were observed in the characteristics of age, weight, mini-mental state examination, SMI, grip strength, manual muscle testing, BBS, functional ambulation category, and MBI. Furthermore, with each increase of 1 in SMI, the probability of belonging to the sarcopenia group decreased by 0.204 times.CONCLUSIONS: A high prevalence of sarcopenia was observed in acute stroke patients, with differences in characteristics between stroke patients without sarcopenia and those with sarcopenia. As sarcopenia factors increased, BBS and MBI also increased. Increasing SMI in acute stroke patients can reduce the risk of sarcopenia diagnosis; therefore, exercise interventions aimed at increasing SMI should be considered.

Factors Associated with Discharge Destination in Patients with Bone Metastases.

Background and Objectives: The discharge destination of patients with advanced cancer correlates with their quality of life. Patients with bone metastases often undergo lifestyle changes owing to pain and activity limitations. However, there are few reports on factors related to the discharge destination of patients with bone metastases. This study aimed to elucidate the factors associated with the discharge destination of patients with bone metastases. Methods: This study included 278 patients diagnosed with bone metastases who were admitted to the University of Tsukuba Hospital between April 2015 and March 2020. This study examined discharge destination, occurrence of skeletal-related events (SREs), primary lesions, locations of bone metastases, functional ambulation categories (FAC), age, and length of hospital stay. A binomial logistic regression analysis was conducted to compare the home and non-home discharge groups. Results: Of the 278 patients, 142 were discharged to home, 89 were discharged to somewhere other than home (non-home), and 47 died. The discharge destination was associated with spinal cord compression (SCC) (odds ratio [OR] 3.37, 95% confidence interval [CI] 1.35-8.43), hypercalcemia (OR 6.84, 95% CI 1.09-42.76), and FAC at admission (OR 0.45, 95% CI 0.35-0.58). The admission FAC cut-off value for discharge to home was determined to be 1.5 (area under the curve [AUC] 0.79, sensitivity 77.5%, specificity 68.5%). Conclusions: Factors associated with discharge destination were identified. The walking ability required for discharge to home was FAC 1.5, meaning that the patient needed one person to assist in preventing falls when walking on level ground. A cut-off value for FAC on admission for predicting outcomes was identified, suggesting the importance of gait ability assessment on admission.

Exoskeleton-assisted training to enhance lower limb motor recovery in subacute stroke: does timing matter? A pilot randomized trial

BackgroundLower limb motor recovery, including abnormal muscle synergies, occurs mainly within the first 5–8 weeks after a stroke. This suggests the importance of delivering impairment-focused therapies, such as therapeutic robots that promote symmetric gait, during this time-sensitive period, following the principle of “the earlier, the better.”ObjectiveFirst, to compare early robotic training (ERT) with usual care (UC) against UC alone on restoring intralimb muscle synergies and interlimb symmetry during functional tasks; Second, to investigate whether ERT is superior to delayed robotic training (DRT) starting after the proposed time-sensitive period.MethodsThis observer-blinded, randomized pilot trial with crossover design involved 19 nonambulatory adults included within 14 days poststroke. Those allocated to ERT (N = 10) received immediately 4 weeks of training (16 sessions, 4× /week) with the Ekso GT® above UC and were compared with the DRT group (N = 9) who received UC alone at this point. Thereafter a 3-week UC period followed to investigate sustainability of ERT and the interventional roles were exchanged; at about week 8 poststroke DRT subjects started the same experimental robotic protocol and ERT subjects continued UC as controls. Outcomes included changes in Fugl-Meyer lower extremity scores (FM-LE) reflecting muscle synergies, weight-bearing asymmetry (WBA), and dynamic control asymmetry (DCA) during quiet standing. Functional ambulation category (FAC) was used to classify walking independence (cut-off ≥4).ResultsA trend toward earlier reacquisition of walking independence favoring ERT with UC over UC was not accompanied by differences in FM-LE, WBA, or DCA (first objective). Thereafter, DRT with UC did not yield any significant changes relative to UC, such that no between-group differences were found favoring restorative effects of ERT over DRT (second objective).ConclusionThis pilot trial shows the feasibility of investigating a wearable exoskeleton as an adjunct therapy in subacute stroke. Nevertheless, our preliminary findings suggest that motor recovery of lower limb muscle synergies was not enhanced by 4 weeks of robotic training to reduce compensations with the less-affected side, irrespective of the timing of application.Trial registrationClinicalTrials.gov, identifier: NCT03727919.

Prevalence and Clinical Implications of Osteosarcopenia in Patients with Acute Stroke: A Cross-sectional Study.

To investigate the prevalence and risk factors of osteosarcopenia in patients with acute stroke. Overall, 224 patients within 2 weeks of having a stroke were enrolled. Demographic characteristics, National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), modified Barthel Index (MBI), Functional Ambulation Category (FAC), Berg Balance Scale (BBS), and handgrip strength were recorded. Body composition was evaluated using dual-energy X-ray absorptiometry. Patients who met the diagnostic criteria for osteoporosis and sarcopenia were defined as having osteosarcopenia. The overall prevalence of osteoporosis and sarcopenia was 46.9% and 50.9%, respectively. The prevalence of osteoporosis without sarcopenia, sarcopenia without osteoporosis, and osteosarcopenia was 18.3%, 22.3%, and 28.6%, respectively. The proportion of female sex (71.9%), median age, and NIHSS score were significantly higher, and mRS, BBS, MBI, FAC, and grip strength were significantly lower in patients with osteosarcopenia. Older age (≥65-years) (OR, 15.4), female sex (OR, 6.23), and lower BMI (<25 kg/m 2 ) (OR, 43.13) were independently associated with the likelihood of osteosarcopenia. Osteosarcopenia may occur in acute stroke survivors. Patients with osteosarcopenia have a significantly higher stroke severity and disability. A comprehensive diagnostic approach is imperative for osteosarcopenia, thereby facilitating implementation of optimal rehabilitative strategies.

Longitudinal changes in vertical stride regularity, hip flexion, and knee flexion contribute to the alteration in gait speed during hospitalization for stroke

Changes in stride regularity and joint motion during gait appear to be related to improved gait speed in hospitalized patients with stroke. We aimed to clarify the changes in stride regularity and joint motion during gait through longitudinal observations. Furthermore, we aimed to clarify the relationship between changes in gait speed, stride regularity, and joint motion during gait. Seventeen inpatients with stroke were assessed for physical and gait functions at baseline, when they reached functional ambulation category 3, and before discharge. Physical function was assessed using the Fugl-Meyer assessment for the lower extremities and the Berg Balance Scale. Gait function was assessed on the basis of gait speed, joint motion, stride regularity, and step symmetry using inertial sensors. The correlations between the ratio of change in gait speed and each indicator from baseline to discharge were analyzed. Both physical and gait functions improved significantly during the hospital stay. The ratio of change in gait speed was significantly and positively correlated with the ratio of change in vertical stride regularity (r = 0.662), vertical step symmetry (rs = 0.627), hip flexion (rs = 0.652), knee flexion (affected side) (r = 0.611), and ankle plantarflexion (unaffected side) (rs = 0.547). Vertical stride regularity, hip flexion, and knee flexion (affected side) were significant factors in determining the ratio of changes in gait speed. Our results suggest that stride regularity, hip flexion, and knee flexion could explain the entire gait cycle and that of the affected side. These parameters can be used as indices to improve gait speed.

Construct validity, responsiveness and minimal important difference of the cumulated ambulation score in older adults with hip fracture in sub-acute rehabilitation facility

Objective To assess the construct validity, responsiveness and minimal important difference of the cumulated ambulation score in patients with hip fracture in sub-acute rehabilitation facility. Design Observational, prospective, monocenter, cohort study. Setting Rehabilitation Institute. Participants 456 older adults with hip fracture (≥65 years) admitted for inpatient rehabilitation. Main outcome measures Cumulated ambulation score, functional independence measure and functional ambulation category were collected at admission and discharge. Construct validity and responsiveness were assessed through hypothesis testing and minimal important difference was determined using the anchor-based method; floor and ceiling effects were also assessed. Results The cumulated ambulation score showed strong correlations with the functional independence measure and functional ambulation category scores at both admission and discharge, satisfying all the hypotheses for construct validity. The effect size of cumulated ambulation score was 1.63. Changes in cumulated ambulation score had a moderate-to-strong correlation with changes of other instruments and were able to discriminate patients improved from those not-improved, and patients classified as independent ambulators from those dependent. A ceiling effect was found only at discharge. The estimated minimal important difference was 2 points. Conclusions The cumulated ambulation score showed high levels of construct validity and responsiveness according to the hypothesis testing. A two points improvement at the end of rehabilitation was found to be clinically important in people with hip fracture in the sub-acute phase. The ceiling effect found at discharge suggested the limitation of the scale in assessing people with a partially recovered autonomy in performing postural changes and gait.