Gait Aid Research Articles

Motor and Sensory Impairments of the Lower Extremities After L2 Nerve Root Transection During Total en Bloc Spondylectomy.

Retrospective study. The purpose of this study was to examine motor and sensory impairments of the lower extremities after L2 nerve root transection during total en bloc spondylectomy (TES) for spinal tumors. At our institute, for TES at L3 to L5 lumbar levels, the nerve roots are preserved. However, at the level of L1 and L2, the vertebral resection and spinal reconstruction via a posterior approach is employed with transection of the nerve roots during dissection and resection of the vertebra. This study included 13 patients who had undergone TES for spinal tumors involving L2 between 2007 and 2016. Postoperative motor function of the lower extremities was quantified using the Manual Muscle Testing grade for the iliopsoas (IP) and quadriceps femoris (QF) muscles, and a grade of the modified Frankel Classification. Postoperative sensory impairment was quantified by the sites of lower extremity pain and numbness. An initial decrease in strength of the IP and QF muscles in more than 60% of the patients, with a decline in the modified Frankel grade in 76.9%, was observed at 1-week after surgery. All patients recovered by the final follow-up, with 12 of the 13 patients walking without a gait aid. The other patient, who had undergone a bilateral dissection of L3 nerve root during TES of L2 and L3, had a mild QF muscle weakness, requiring a cane for walking. Eleven of 13 patients developed pain or numbness in the groin or thigh area after surgery, with the most common area being the anterior aspect of the thigh. Although IP and QF weakness was observed in the majority of patients who underwent bilateral transection of L2 nerve roots during TES, these deficits recovered over time and did not finally affect activities of daily living. 4.

Predicting Mobility Limitations in Patients With Total Knee Arthroplasty in the Inpatient Setting

ObjectiveTo develop a prediction model for postoperative day 3 mobility limitations in patients undergoing total knee arthroplasty (TKA). DesignProspective cohort study. SettingInpatients in a tertiary care hospital. ParticipantsA sample of patients (N=2300) who underwent primary TKA in 2016-2017. InterventionsNot applicable. Main Outcome MeasureCandidate predictors included demographic variables and preoperative clinical and psychosocial measures. The outcome of interest was mobility limitations on post-TKA day 3, and this was determined a priori by an ordinal mobility outcome hierarchy based on the type of the gait aids prescribed and the level of physiotherapist assistance provided. To develop the model, we fitted a multivariable proportional odds regression model with bootstrap internal validation. We used a model approximation approach to create a simplified model that approximated predictions from the full model with 95% accuracy. ResultsOn post-TKA day 3, 11% of patients required both walkers and therapist assistance to ambulate safely. Our prediction model had a concordance index of 0.72 (95% confidence interval, 0.68-0.75) when evaluating these patients. In the simplified model, predictors of greater mobility limitations included older age, greater walking aid support required preoperatively, less preoperative knee flexion range of movement, low-volume surgeon, contralateral knee pain, higher body mass index, non-Chinese race, and greater self-reported walking limitations preoperatively. ConclusionWe have developed a prediction model to identify patients who are at risk for mobility limitations in the inpatient setting. When used preoperatively as part of a shared-decision making process, it can potentially influence rehabilitation strategies and facilitate discharge planning.

Effect of cane use on bone marrow lesion volume in people with medial tibiofemoral knee osteoarthritis: randomized clinical trial

To evaluate effects of daily cane use for 3 months on medial tibiofemoral bone marrow lesion (BML) volumes in people with medial tibiofemoral osteoarthritis (OA). In this randomized controlled trial (RCT), 79 participants with medial tibiofemoral OA were randomized to either a cane group (using a cane whenever walking) or control group (not using any gait aid) for 3 months. The cane group received a single training session by a physiotherapist, using a biofeedback cane to teach optimal technique and body weight support and motor learning principles to facilitate retention of learning. The primary outcome was change in total medial tibiofemoral BML volume (per unit bone volume) measured from magnetic resonance imaging (MRI) at 3 months. Secondary outcomes were BML volumes (per unit bone volume) of the medial tibia and femur, and patient-reported outcomes of overall knee pain, knee pain on walking, physical function, perceived global symptom changes and health-related quality of life. MRI analyses were performed by a blinded assessor. Seventy-eight participants (99%) completed the primary outcome. Mean (standard deviation) daily cane use was 2.3 (1.7) hours over 3 months. No evidence of between-group differences was found for change in total medial tibiofemoral BML volume (mean difference:-0.0010 (95% confidence intervals:-0.0022, 0.0003)). Most secondary outcomes showed minimal differences between groups. Daily use of a cane during walking for 3 months aiming to reduce knee joint loading did not change medial tibiofemoral BML volumes compared to no use of gait aids. Australian New Zealand Clinical Trial Registry (ACTRN12614000909628).

The Pediatric Toronto Extremity Salvage Score (pTESS): Validation of a Self-reported Functional Outcomes Tool for Children with Extremity Tumors.

The physical function of children with sarcoma after surgery has not been studied explicitly. This paucity of research is partly because of the lack of a sufficiently sensitive pediatric functional measure. The goal of this study was to establish and validate a standardized measure of physical function in pediatric patients with extremity tumors. (1) What is the best format and content for new upper- and lower-extremity measures of physical function in the pediatric population? (2) Do the new measures exhibit floor and/or ceiling effects, internal consistency, and test-retest reliability? (3) Are the new measures valid? In Phase 1, interviews with 17 consecutive children and adolescents with bone tumors were conducted to modify the format and content of draft versions of the pediatric Toronto Extremity Salvage Score (pTESS). In Phase 2, the pTESS was formally translated into French. In Phase 3, 122 participants between 7 and 17.9 years old with malignant or benign-aggressive bone tumors completed the limb-specific measure on two occasions. Older adolescents also completed the adult TESS. Floor and ceiling effects, internal consistency, test-retest reliability, and validity were evaluated. Feedback from interviews resulted in the removal, addition, and modification of draft items, and the pTESS-Leg and pTESS-Arm questionnaires were finalized. Both versions exhibited no floor or ceiling effects and high internal consistency (α > 0.92). The test-retest reliability was excellent for the pTESS-Leg (intraclass correlation coefficient [ICC] = 0.94; 95% CI, 0.90-0.97) and good for the pTESS-Arm (ICC = 0.86; 95% CI, 0.61-0.96). Known-group validity (ability to discriminate between groups) was demonstrated by lower mean pTESS-Leg scores for participants using gait aids or braces (mean = 68; SD = 21) than for those who did not (mean = 87; SD = 11; p < 0.001). There was no significant difference between pTESS arm scores among respondents using a brace (n = 5; mean = 73; SD = 11) and those without (n = 22; mean = 83; SD = 19; p = 0.13). To evaluate construct validity, we tested a priori hypotheses. The duration since chemotherapy correlated moderately with higher pTESS-Leg scores (r = 0.4; p < 0.001) but not with pTESS-Arm scores (r = 0.1; p = 0.80), and the duration since tumor resection correlated moderately with higher pTESS-Leg scores (r = 0.4; p < 0.001) but not pTESS-Arm scores (r = 0.2; p = 0.4). Higher VAS scores (that is, it was harder to do things) antecorrelated with both pTESS versions (pTESS-Leg: r = -0.7; p < 0.001; pTESS-Arm: r = -0.8; p < 0.001). To assess criterion validity, we compared the pTESS with the current "gold standard" (adult TESS). Among adolescents, strong correlations were observed between the TESS and pTESS-Leg (r = 0.97, p < 0.001) and pTESS-Arm (r = 0.9, p = 0.007). Both pTESS versions exhibited no floor or ceiling effects and had high internal consistency. The pTESS-Leg demonstrated excellent reliability and validity, and the pTESS-Arm demonstrated good reliability and reasonable validity. The pTESS is recommended for cross-sectional evaluation of self-reported physical function in pediatric patients with bone tumors. Level II, outcome measurement development.

Distal Junctional Failure Following Pediatric Spinal Fusion.

Adjacent segment pathology is a known complication after spinal fusion, but little has been reported on junctional failure. A series of adolescent patients presented with acute distal junctional failure (DJF). We sought to determine any common features of these patients to develop a prevention strategy. A retrospective review was conducted of pediatric patients who developed DJF after instrumented spinal fusion performed at 2 institutions from 1999 to 2013. Patients with proximal junctional failure or junctional kyphosis without failure were excluded. Fifteen subjects were identified with mean follow-up of 38 months. Distal failure occurred a mean of 60 days after index surgery, with history of minor trauma in 4 patients. Failures included 3-column Chance fracture (11) or instrumentation failure (4). Thirteen patients presented with back pain and/or acute kyphosis, whereas 2 asymptomatic patients presented with healed fractures. Two patients also developed new onset of severe lower extremity neurological deficit after fracture, which improved but never resolved after revision. A total of 13/15 subjects required revision surgery, typically within 1 week. Complications associated with revision surgery were encountered in 8 patients (62%). Major complications that required return to the operating room included 2 deep infections, 2 instrumentation failures, and dense lower extremity paralysis that improved after medial screw revision and decompression. At final follow-up, 10 patients are asymptomatic, 2 have persistent neurological deficit, 2 have chronic pain, and 1 has altered gait with gait aid requirement. This study analyzes a heterogenous cohort of spinal fusion patients who developed DJF from 3-column Chance fracture or instrumentation failure. Revision surgery is typically required, but has a high complication rate and can result in severe neurological deficit, highlighting the morbidity of this complication. It is unclear whether level of the lowest instrumented vertebra contributes to DJF. Increased awareness of junctional failure in children may prompt additional studies to further characterize risk factors and preventative strategies. Level IV-study-type case series.

Outcomes Following Treatment of the Infected Achilles Tendon.

Background:Infection following Achilles tendon surgery is a devastating complication and can be difficult to treat and often leads to poor outcomes. A number of treatments have been described, but there is little information concerning outcomes of these treatments. Our purpose was to evaluate the clinical and functional outcomes of patients who have undergone treatment for an infected Achilles tendon after acute and chronic midsubstance repair.Methods:We retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range, 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture-specific intravenous (IV) antibiotics for 3 to 6 weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale.Results:All wounds had healed at the time of last follow-up. Three patients (15%) required an unplanned return to the operating room for repeat debridement. All patients were able to walk without the use of a gait aid. Five patients (25%) required continued use of a boot or brace during ambulation. Fourteen patients participated in the FAAM ADL survey. There were 6 patients lost to follow-up. The average FAAM score was 87 (range, 71.4-100). At last follow-up, most patients reported their overall function as “normal” or “nearly normal.” Eradication of infection and satisfactory functional results can be attained after radical debridement, wound closure, and administration of culture-specific IV antibiotics.Level of Evidence:Level IV, retrospective case series.

Predicting individual knee range of motion, knee pain, and walking limitation outcomes following total knee arthroplasty

Background and purpose — Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA), mainly because of pain and restricted physical function. We developed a prediction model for 6-month knee range of motion, knee pain, and walking limitations in patients undergoing TKA surgery.Patients and methods — We performed a prospective cohort study of 4,026 patients who underwent elective, primary TKA between July 2013 and July 2017. Candidate predictors included demographic, clinical, psychosocial, and preoperative outcome measures. The outcomes of interest were (i) knee extension and flexion range of motion, (ii) knee pain rated on a 5-point ordinal scale, and (iii) self-reported maximum walk time at 6 months post TKA. For each outcome, we fitted a multivariable proportional odds regression model with bootstrap internal validation.Results — At 6 months post TKA, around 5% to 20% of patients had a flexion contracture ³ 10°, range of motion < 90°, moderate to severe knee pain, or a maximum walk time £ 15 minutes. The model c-indices (the probabilities to correctly discriminate between 2 patients with different levels of follow-up TKA outcomes) when evaluating these patients were 0.71, 0.79, 0.65, and 0.76, respectively. Each postoperative outcome was strongly influenced by the same outcome measure obtained preoperatively (all p-values < 0.001). Additional statistically significant predictors were age, sex, race, education level, diabetes mellitus, preoperative use of gait aids, contralateral knee pain, and psychological distress (all p-values < 0.001).Interpretation — We have developed models to predict, for individual patients, their likely post-TKA levels of knee extension and flexion range of motion, knee pain, and walking limitations. After external validation, they can potentially be used preoperatively to identify at-risk patients and to help patients set more realistic expectations about surgical outcomes.

Dynamic balance and instrumented gait variables are independent predictors of falls following stroke

BackgroundFalls are common following stroke and are frequently related to deficits in balance and mobility. This study aimed to investigate the predictive strength of gait and balance variables for evaluating post-stroke falls risk over 12 months following rehabilitation discharge.MethodsA prospective cohort study was undertaken in inpatient rehabilitation centres based in Australia and Singapore. A consecutive sample of 81 individuals (mean age 63 years; median 24 days post stroke) were assessed within one week prior to discharge. In addition to comfortable gait speed over six metres (6mWT), a depth-sensing camera (Kinect) was used to obtain fast-paced gait speed, stride length, cadence, step width, step length asymmetry, gait speed variability, and mediolateral and vertical pelvic displacement. Balance variables were the step test, timed up and go (TUG), dual-task TUG, and Wii Balance Board-derived centre of pressure velocity during static standing. Falls data were collected using monthly calendars.ResultsOver 12 months, 28% of individuals fell at least once. The faller group had increased TUG time and reduced stride length, gait speed variability, mediolateral and vertical pelvic displacement, and step test scores (P < 0.001–0.048). Significant predictors, when adjusted for country, prior falls and assistance (i.e., physical assistance and/or gait aid use) were stride length, step length asymmetry, mediolateral pelvic displacement, step test and TUG scores (P < 0.040; IQR-odds ratio(OR) = 1.37–7.85). With comfortable gait speed as an additional covariate, to determine the additive benefit over standard clinical assessment, only mediolateral pelvic displacement, TUG and step test scores remained significant (P = 0.001–0.018; IQR-OR = 5.28–10.29).ConclusionsReduced displacement of the pelvis in the mediolateral direction during walking was the strongest predictor of post-stroke falls compared with other gait variables. Dynamic balance measures, such as the TUG and step test, may better predict falls than gait speed or static balance measures.

The de Morton mobility index is a feasible and valid mobility assessment tool in hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease.

There is no accepted standard for measuring mobility in hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The objective of this study was to assess convergent, discriminant, and known-group validity and floor/ceiling effects of the de Morton Mobility Index (DEMMI) in hospitalized patients with AECOPD. Individuals with AECOPD (n = 22) admitted to an acute care hospital medical ward were recruited. Data on the DEMMI, gait speed, daytime energy expenditure, step counts, 6-minute walk distance (6MWD), dyspnea, respiratory and heart rates, quality of life, and oxygen supplementation were collected on day 3 of admission. The DEMMI demonstrated convergent validity with the 6MWD and gait velocity measures (Spearman’s ρ 0.69 and 0.61, respectively; p < 0.003) but not with measures of physical activity or respiratory impairment. Discriminant validity was present, with no correlation between the DEMMI and quality of life and resting heart rate. Known-group validity (gait aids vs. no gait aids) was demonstrated (p = 0.009). There was no floor effect but there was evidence of a possible ceiling effect (14% of participants received a perfect score). The DEMMI is feasible and showed moderate to strong validity with measures of observed physical function in hospitalized patients with AECOPD.

Clinical, Radiologic, and Prognostic Features of Myelitis Associated With Myelin Oligodendrocyte Glycoprotein Autoantibody

Recognizing the characteristics of myelin oligodendrocyte glycoprotein autoantibody (MOG-IgG) myelitis is essential for early accurate diagnosis and treatment. To evaluate the clinical, radiologic, and prognostic features of MOG-IgG myelitis and compare with myelitis with aquaporin-4-IgG (AQP4-IgG) and multiple sclerosis (MS). We retrospectively identified 199 MOG-IgG-positive Mayo Clinic patients from January 1, 2000, through December 31, 2017, through our neuroimmunology laboratory. Fifty-four patients met inclusion criteria of (1) clinical myelitis; (2) MOG-IgG positivity; and (3) medical records available. We excluded 145 patients without documented myelitis. Myelitis of AQP4-IgG (n = 46) and MS (n = 26) were used for comparison. Outcome variables included modified Rankin score and need for gait aid. A neuroradiologist analyzed spine magnetic resonance imaging of patients with MOG-IgG and control patients blinded to diagnosis. Of 54 included patients with MOG-IgG myelitis, the median age was 25 years (range, 3-73 years) and 24 were women (44%). Isolated transverse myelitis was the initial manifestation in 29 patients (54%), and 10 (19%) were initially diagnosed as having viral/postviral acute flaccid myelitis. Cerebrospinal fluid-elevated oligoclonal bands occurred in 1 of 38 (3%). At final follow-up (median, 24 months; range, 2-120 months), 32 patients (59%) had developed 1 or more relapses of optic neuritis (n = 31); transverse myelitis (n = 7); or acute disseminated encephalomyelitis (n = 1). Clinical features favoring MOG-IgG myelitis vs AQP4-IgG or MS myelitis included prodromal symptoms and concurrent acute disseminated encephalomyelitis. Magnetic resonance imaging features favoring MOG-IgG over AQP4-IgG or MS myelitis were T2-signal abnormality confined to gray matter (sagittal line and axial H sign) and lack of enhancement. Longitudinally extensive T2 lesions were of similar frequency in MOG-IgG and AQP4-IgG myelitis (37 of 47 [79%] vs 28 of 34 [82%]; P = .52) but not found in MS. Multiple spinal cord lesions and conus involvement were more frequent with MOG-IgG than AQP4-IgG but not different from MS. Wheelchair dependence at myelitis nadir occurred in one-third of patients with MOG-IgG and AQP4-IgG but never with MS, although patients with MOG-IgG myelitis recovered better than those with AQP4-IgG. Myelitis is an early manifestation of MOG-IgG-related disease and may have a clinical phenotype of acute flaccid myelitis. We identified a variety of clinical and magnetic resonance imaging features that may help clinicians identify those at risk in whom MOG-IgG should be tested.

Overground walking with a robotic exoskeleton elicits trunk muscle activity in people with high-thoracic motor-complete spinal cord injury

BackgroundThe trunk muscles are critical for postural control. Recent neurophysiological studies have revealed sparing of trunk muscle function in individuals with spinal cord injury (SCI) classified with thoracic or cervical motor-complete injuries. These findings raise the possibility for recruiting and retraining this spared trunk function through rehabilitation. Robotic gait training devices may provide a means to promote trunk muscle activation. Thus, the objective of this study was to characterize and compare the activation of the trunk muscles during walking with two robotic gait training devices (Ekso and Lokomat) in people with high thoracic motor-complete SCI.MethodsParticipants with chronic motor-complete paraplegia performed 3 speed-matched walking conditions: Lokomat-assisted walking, Ekso-assisted walking overground, and Ekso-assisted walking on a treadmill. Surface electromyography (EMG) signals were recorded bilaterally from the rectus abdominis (RA), external oblique (EO), and erector spinae (ES) muscles.ResultsGreater recruitment of trunk muscle EMG was elicited with Ekso-assisted walking compared to the Lokomat. Similar levels of trunk EMG activation were observed between Ekso overground and Ekso on the treadmill, indicating that differences between Ekso and Lokomat could not be attributed to the use of a hand-held gait aid. The level of trunk EMG activation during Lokomat walking was not different than that recorded during quiescent supine lying.ConclusionsEkso-assisted walking elicits greater activation of trunk muscles compared to Lokomat-assisted walking, even after controlling for the use of hand-held assistive devices. The requirement of the Ekso for lateral weight-shifting in order to activate each step could lead to better postural muscle activation.

Total Hip Arthroplasty Reduces Pain and Improves Function in Patients With Spondyloepiphyseal Dysplasia: A Long-Term Outcome Study of 50 Cases

BackgroundSpondyloepiphyseal dysplasia (SED) is rare genetic condition which leads to skeletal and joint deformities that can predispose patients to degenerative joint disease. There are limited reports on the results of total hip arthroplasty (THA) in this patient population. The purpose of this study is to review clinical and radiographic outcomes of THA performed in patients with SED at one institution. MethodsAmong 43,917 patients undergoing primary THA from 1970 to 2015, we identified 50 THAs performed in 29 patients with SED; 21 patients underwent bilateral THA (none simultaneous). There were 16 females and 13 males; mean age, body mass index, and height were 39 years, 28.7 kg/m2, and 145 cm, respectively. All patients were able to ambulate prior to the THA. Mean follow-up was 11 years (range 2-38). ResultsMean implant survival for primary THA in SED patients at the 5, 10, and 20-year time points was 96%, 85%, and 55%, respectively. Thirteen patients required revision THA, most commonly for polyethylene wear (n = 6) and aseptic loosening (n = 5), and 4 additional patients underwent nonrevision reoperations. Prior to surgery, 90% of patients had severe or moderate pain, which was reduced to 8% of patients postoperatively (P < .001). Mean Harris Hip Score improved from 47 to 87 (P < .001). Prior to surgery, 64% of patients required gait aids, which reduced to 34% postoperatively (P < .001). ConclusionTHA provided significant pain reduction and improvement in function, with a majority of patients ambulating independently following the procedure. There was a high incidence of complications following THA in patients with SED, most commonly secondary to polyethylene wear and osteolysis from conventional polyethylene and historical implants. Level of EvidenceLevel IV, Therapy.

The validity of using activity monitors to detect step count after lumbar fusion surgery

Purpose: Measuring step count using activity monitors is an increasingly popular method of quantifying physical activity, however it is unknown whether gait irregularities or the use of gait aids affect the accuracy of these devices. This study evaluates the validity of the ActivPAL3, Fitbit Flex, and Jawbone UP Move activity monitors for measuring step count in hospital inpatients after lumbar fusion.Methods: The ActivPAL3 was tested on the thigh, the Fitbit, and the Jawbone were tested on the wrist and thigh, each monitor was tested 20 times. Validity was examined by calculating the percentage of steps detected by each monitor compared to the criterion measure of observed step count, the Standard Error of Measurement, and the Intraclass Correlation Coefficient.Results: The ActivPAL3 detected 85% (SD 27%) of observed steps. On the wrist, the Fitbit detected 24% (SD 34%) and the Jawbone detected 17% (SD 40%) of observed steps. On the thigh, the Fitbit detected 66% (SD 42%) and the Jawbone detected 22% (SD 35%) of observed steps.Conclusion: The ActivPAL3 activity monitor is a sufficiently valid tool to detect step count immediately after lumbar fusion. Wrist worn monitors are not recommended in this population, particularly with patients using gait aids.Implications for RehabilitationWalking may be quantified using activity monitoring, as both an assessment tool and as an adjunct to treatmentThe ActivPAL3 is sufficiently valid for use after lumbar fusion surgeryThe Fitbit Flex and Jawbone UP Move had low accuracy, particularly when a gait aid was used

Anterior-posterior displacement of center of pressure measured by insole foot pressure measurement system in subacute recovery stage of post-stroke hemiplegia.

Anterior-posterior displacement of center of pressure (AP_CoP) reflects stance limb function. However, AP_CoP's clinical applicability in post-stroke hemiplegia is unclear. To investigate the clinical usefulness of parameters from AP_CoP in subacute stage post-stroke hemiplegia, their relationships with usage of gait aid, functional ambulatory category, and spatial-temporal parameters were tested. Nineteen participants with post-stroke hemiplegia were included in gait with aid group. Twenty one participants were included in gait with independence group. Twenty one participants were included in control group. Insole foot pressure measurement system was used to measure AP_CoP and spatial-temporal parameters. Effects of gait aid usage and functional ambulatory category on AP_CoP were tested with ANOVA. Relationships between AP_CoP and temporo-spatial parameters were investigated with correlation and linear regression analysis. AP_CoP parameters were shorter in gait with aid group than gait with independence group. With better functional ambulatory category, AP_CoP were longer. AP_CoP showed positive relationship with walking speed. AP_CoP in more affected side showed positive relationship with symmetry of single support phase proportion. AP_CoP showed positive relationship with stride length. AP_CoP reflects overall gait function, impairments in more affected side and adaptation in less affected side in subacute recovery stage of post-stroke hemiplegia. It can be used as a clinically significant parameter for gait rehabilitation.

Outcomes following treatment of the infected Achilles tendon

Category: Sports Introduction/Purpose: Infection following Achilles tendon surgery is a devastating complication and can be difficult to treat. Our purpose was to evaluate clinical and functional outcomes of patients who have undergone treatment for an infected Achilles tendon. Methods: We retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture specific intravenous antibiotics for three to six weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale. Results: All wounds had healed at the time of last follow-up. Three patients (15%) required an unplanned return to the operating room for repeat debridement. All patients were able to walk without the use of a gait aid. Five patients (25%) required continued use of a boot or brace during ambulation. The average FAAM score was 87 (range, 71.4-100). At last follow-up, most patients reported their overall function as “normal” or “nearly normal”. Conclusion: Eradication of infection and satisfactory functional results can be attained after radical debridement, wound closure, and administration of culture specific IV antibiotics.

Measuring disease progression and disability in orthostatic tremor

ObjectiveTo develop a questionnaire quantifying the impact of orthostatic tremor (OT) on patients' function and quality of life to enable longitudinal measurement of disease severity. MethodsPatients with OT were interviewed in order to identify domains for a new disease-specific impact profile. The OT impact profile (OTIP) included forty-seven items across activities of daily living (9), mobility (9), social participation (2), assistance (8) and emotional effects (19) scored from 0 to 4 (total range 0–188). The same patients were invited to complete this at baseline and six-years later. An exploratory univariate linear regression analysis was performed to identify factors contributing to OTIP scores. ResultsThirty-three patients were initially interviewed. Twenty-one completed the OTIP at baseline and 16 at follow-up. Over time there was an increase in falls and requirement for gait aids. The mean total OTIP score at baseline was 96(SD 52). There was no significant difference in the mean total (84, p = 0.4) or sub-domain scores at follow up. Regression analysis found the utility of gait aids and disease duration to predict a worse score. ConclusionOT has a broad range of impacts on patients' quality of life and the OTIP appears to have some utility in measuring the functional impact. We found no change in overall disease impact on multiple domains over six years follow-up. This apparent lack of change may be due to the significant early impact that fear of falling has on patients.

Immediate Effects of Mental Singing While Walking on Gait Disturbance in Hemiplegic Stroke Patients: A Feasibility Study.

ObjectiveTo investigate the immediate therapeutic effects of mental singing while walking intervention on gait disturbances in hemiplegic stroke patients.MethodsEligible, post-stroke, hemiplegic patients were prospectively enrolled in this study. The inclusion criteria were a diagnosis of hemiplegia due to stroke, and ability to walk more than 10 m with or without gait aids. Each patient underwent structured music therapy sessions comprising 7 consecutive tasks, and were trained to sing in their mind (mental singing) while walking. Before, and after training sessions, gait ability was assessed using the 10-Meter Walk Test (10MWT), the Timed Up and Go test (TUG), gait velocity, cadence and stride length.ResultsTwenty patients were enrolled in the interventions. Following the mental singing while walking intervention, significant improvement was observed in the 10MWT (13.16±7.61 to 12.27±7.58; p=0.002) and the TUG test (19.36±15.37 to 18.42±16.43; p=0.006). Significant improvement was also seen in gait cadence (90.36±29.11 to 95.36±30.2; p<0.001), stride length (90.99±33.4 to 98.17±35.33; p<0.001) and velocity (0.66±0.45 to 0.71±0.47; p<0.002).ConclusionThese results indicate the possible effects of mental singing while walking on gait in patients diagnosed with hemiplegic stroke.

Assessment of Mobility in Older People Hospitalized for Medical Illness Using the de Morton Mobility Index and Cumulated Ambulation Score-Validity and Minimal Clinical Important Difference.

Background and Purpose:Older adults acutely hospitalized for medical illness typically have comorbidity and disability, and in-hospital physical inactivity greatly increases the likelihood of developing new disability. Thus, assessment of the patients' mobility status is crucial for planning and carrying out targeted interventions that ensure mobilization during hospital admission. The aim of this study was to determine convergent validity, known group validity, floor and ceiling effects, and anchor-based minimal clinically important difference (MCID) of the more time-consuming de Morton Mobility Index (DEMMI) and the less time-consuming Cumulated Ambulation Score (CAS) in older adults acutely hospitalized for medical illness.Methods:In this multicenter cohort study, 235 older hospitalized adults, with a mean (standard deviation) age of 84.8 (7.1) years, were consecutively included. Assessments of mobility using the DEMMI (score range 0-100), the CAS (score range 0-6), and the Barthel Index (BI, score range 0-100) were performed by physical or occupational therapists at hospital admission and discharge. In addition, at discharge patients and therapists were independently asked to assess the patients' current mobility status compared with their mobility status at hospital admission using the Global Rating of Change scale.Results and Discussion:Complete data sets were obtained for 155 patients. Baseline characteristics of those with complete data sets did not differ from those with incomplete data sets, except for the number of secondary diagnoses, which was lower in the latter. Significant and moderate relationships existed both at admission and at discharge between scores in the DEMMI and the BI (rs = 0.68, P < .0001, and rs = 0.71, P < .0001), and between scores in the CAS and the BI (rs = 0.60, P < .0001, and rs = 0.57, P < .0001). Use of a gait aid and discharge to inpatient rehabilitation or nursing home were associated with significantly lower DEMMI and CAS scores. No floor or ceiling effects were present in the DEMMI, while a ceiling effect was present in the CAS. The MCID scores based on patients' assessments were 10.7 points for the DEMMI and 0.67 for the CAS.Conclusions:These data show that the DEMMI is valid and responsive to changes in mobility and can be considered to have the required properties for measuring mobility in older adults who are hospitalized in medical and geriatric wards. In contrast, the CAS appears to be appropriate to identify whether a patient is independently mobile or needs assistance, while the measure is less suitable for measuring improvements in mobility.

Association of Long-term Opioid Therapy With Functional Status, Adverse Outcomes, and Mortality Among Patients With Polyneuropathy

ImportancePolyneuropathy is one of the most common painful conditions managed within general and specialty clinics. Neuropathic pain frequently leads to decisions about using long-term opioid therapy. Understanding the association of long-term opioid use with functional status, adverse outcomes, and mortality among patients with polyneuropathy could influence disease-specific decisions about opioid treatment.ObjectivesTo quantify the prevalence of long-term opioid use among patients with polyneuropathy and to assess the association of long-term opioid use with functional status, adverse outcomes, and mortality.Design, Setting, and ParticipantsA retrospective population-based cohort study was conducted of prescriptions given to patients with polyneuropathy and to controls in ambulatory practice between January 1, 2006, and December 31, 2010, to determine exposure to long-term opioid use as well as other outcomes. The latest follow-up was conducted through November 25, 2016.ExposuresLong-term opioid therapy, defined by 1 or multiple consecutive opioid prescriptions resulting in 90 continuous days or more of opioid use.Main Outcomes and MeasuresPrevalence of long-term opioid therapy among patients with polyneuropathy and controls. Patient-reported functional status, documented adverse outcomes, and mortality were compared between patients with polyneuropathy receiving long-term opioid therapy (≥90 days) and patients with polyneuropathy receiving shorter durations of opioid therapy.ResultsAmong the 2892 patients with polyneuropathy (1364 women and 1528 men; mean [SD] age, 67.5 [16.6] years) and the 14 435 controls (6827 women and 7608 men; mean [SD] age, 67.5 [16.5] years), patients with polyneuropathy received long-term opioids more often than did controls (545 [18.8%] vs 780 [5.4%]). Patients with polyneuropathy who were receiving long-term opioids had multiple functional status markers that were modestly poorer even after adjusting for medical comorbidity, including increased reliance on gait aids (adjusted odds ratio, 1.9; 95% CI, 1.4-2.6); no functional status markers were improved by long-term use of opioids. Adverse outcomes were more common among patients with polyneuropathy receiving long-term opioids, including depression (adjusted hazard ratio, 1.53; 95% CI, 1.29-1.82), opioid dependence (adjusted hazard ratio, 2.85; 95% CI, 1.54-5.47), and opioid overdose (adjusted hazard ratio, 5.12; 95% CI, 1.63-19.62).Conclusions and RelevancePolyneuropathy increased the likelihood of long-term opioid therapy. Chronic pain itself cannot be ruled out as a source of worsened functional status among patients receiving long-term opioid therapy. However, long-term opioid therapy did not improve functional status but rather was associated with a higher risk of subsequent opioid dependency and overdose.

Feasibility Of Square-stepping Exercise To Improve Mobility And Cognition In Long-term Care And Retirement Living.

Square-stepping exercise (SSE) is a visuospatial working memory task with a cued stepping response; it has demonstrated mobility and cognitive benefits in older adults. PURPOSE: To explore whether a SSE program is feasible in long-term care (LTC) and retirement living (RL) facilities in populations with diverse mobility and cognitive abilities. METHODS: A cluster-randomized trial was conducted; 4 sites (2 LTC and 2 RL) were randomized to SSE [2x/wk for 12-wks by trained kinesiologists (kins)] or control (CON). Recruitment, attendance, program fidelity, and feedback were monitored throughout the program. RESULTS: All residents were invited to participate; in the intervention sites, there were 192 and 144 beds for the LTC and RL, respectively. Recruitment was via information sessions. Intervention participants (n=30) were 80.5 ± 13.2 yrs old, 77% female, and had 12.2 ± 3.2 years of education. In LTC (n=15) there was an average of 5.5 residents in attendance at each session ranging from 3-9 over 19 sessions. LTC residents attended an average of 45.6% sessions (range: 10.5-79.0%); 6 attended >50% of sessions. In RL (n=15) there was an average of 7.8 residents in attendance at each session ranging from 3-12 over 24 sessions. RL residents attended an average of 21% of sessions (range: 8.3-75%); 8 attended >50% of sessions. To maintain a pragmatic approach, SSE was modified following feedback: sessions were reduced from 60 to 45 min; residents who used gait aids were assisted by kins; and in LTC program, progression was limited. Residents in RL became peer-coaches to assist kins and act as moderators. Anecdotal feedback from kins and residents was positive, with comments about SSE being fun but also a ‘good’ challenge; both sites have continued the program. CONCLUSIONS: Recruitment for this study was considered a success from the perspective of the LTC and RL facilities. Attendance was variable; it is understandable with a variety of mobility and cognitive abilities that achieving perfect attendance is unlikely. It is reasonable, with program modifications and flexibility in program progression, for this to be a feasible program for adults living in LTC and RL facilities to engage physically, cognitively and socially. FUNDING: Western Centre for Studies in Family Medicine, Schlegel Villages and Ontario Graduate Scholarship.