Limited Community Ambulators Research Articles

Single-belt vs. split-belt treadmill symmetry training: is there a perfect choice for gait rehabilitation post-stroke?

Post-stroke gait asymmetry leads to inefficient gait and a higher fall risk, often causing limited home and community ambulation. Two types of treadmills are typically used for training focused on symmetry: split-belt and single belt treadmills, but there is no consensus on which treadmill is superior to improve gait symmetry in individuals with stroke. To comprehensively determine which intervention is superior, we considered multiple spatial and temporal gait parameters (step length, stride time, swing time, and stance time) and their symmetries. Ten individuals with stroke underwent a single session of split-belt treadmill training and single belt treadmill training on separate days. The changes in step length, stride time, swing time, stance time and their respective symmetries were compared to investigate which training improves both spatiotemporal gait parameters and symmetries immediately after the intervention and after 5min of rest. Both types of treadmill training immediately increased gait velocity (0.08m/s faster) and shorter step length (4.15cm longer). However, split-belt treadmill training was more effective at improving step length symmetry (improved by 27.3%) without sacrificing gait velocity or step length. However, this step length symmetry effect diminished after a 5-min rest period. Split-belt treadmill training may have some advantages over single belt treadmill training, when targeting step length symmetry. Future research should focus on comparing the long-term effects of these two types of training and examining the duration of the observed effects to provide clinically applicable information.

Physical Therapy and Aminopyridine for Downbeat Nystagmus Syndrome: A Case Report.

Individuals with downbeat nystagmus (DBN) syndrome present with DBN, dizziness, blurred vision, and unsteady gait. Pharmacological intervention with 4-aminopyridine (4-AP) may be effective in improving oculomotor function, but there is minimal evidence to date that it improves gait. This suggests the possible benefit of combining pharmacotherapy with physical therapy to maximize outcomes. This case report documents improvements in gait and balance after physical therapy and aminopyridine (AP) in an individual with DBN syndrome. The patient was a 70-year-old man with a 4-year history of worsening dizziness and imbalance, diagnosed with DBN syndrome. He demonstrated impaired oculomotor function, dizziness, and imbalance, which resulted in falls and limited community ambulation. The patient completed a customized, tapered course of physical therapy over 6months. Outcome measures included the 10-meter walk test, the Timed Up and Go (TUG), the Dynamic Gait Index (DGI), and the modified clinical test of sensory integration and balance. Improvements exceeding minimal detectable change were demonstrated on the TUG and the DGI. Gait speed on the 10-meter walk test did not change significantly, but the patient was able to use a cane to ambulate in the community and reported no further falls. Controlled studies are needed to explore the potential for AP to augment physical therapy in people with DBN syndrome. Physical therapists are encouraged to communicate with referring medical providers about the use of AP as pharmacotherapy along with physical therapy for individuals with DBN syndrome.

Validity of an android device for assessing mobility in people with chronic stroke and hemiparesis: a cross-sectional study

BackgroundIncorporating instrument measurements into clinical assessments can improve the accuracy of results when assessing mobility related to activities of daily living. This can assist clinicians in making evidence-based decisions. In this context, kinematic measures are considered essential for the assessment of sensorimotor recovery after stroke. The aim of this study was to assess the validity of using an Android device to evaluate kinematic data during the performance of a standardized mobility test in people with chronic stroke and hemiparesis.MethodsThis is a cross-sectional study including 36 individuals with chronic stroke and hemiparesis and 33 age-matched healthy subjects. A simple smartphone attached to the lumbar spine with an elastic band was used to measure participants’ kinematics during a standardized mobility test by using the inertial sensor embedded in it. This test includes postural control, walking, turning and sitting down, and standing up. Differences between stroke and non-stroke participants in the kinematic parameters obtained after data sensor processing were studied, as well as in the total execution and reaction times. Also, the relationship between the kinematic parameters and the community ambulation ability, degree of disability and functional mobility of individuals with stroke was studied.ResultsCompared to controls, participants with chronic stroke showed a larger medial-lateral displacement (p = 0.022) in bipedal stance, a higher medial-lateral range (p < 0.001) and a lower cranio-caudal range (p = 0.024) when walking, and lower turn-to-sit power (p = 0.001), turn-to-sit jerk (p = 0.026) and sit-to-stand jerk (p = 0.001) when assessing turn-to-sit-to-stand. Medial-lateral range and total execution time significantly correlated with all the clinical tests (p < 0.005), and resulted significantly different between independent and limited community ambulation patients (p = 0.042 and p = 0.006, respectively) as well as stroke participants with significant disability or slight/moderate disability (p = 0.024 and p = 0.041, respectively).ConclusionThis study reports a valid, single, quick and easy-to-use test for assessing kinematic parameters in chronic stroke survivors by using a standardized mobility test with a smartphone. This measurement could provide valid clinical information on reaction time and kinematic parameters of postural control and gait, which can help in planning better intervention approaches.

Design and testing of a simple quick connect for a prosthetic liner tether.

A limitation of tether lanyards is that fastening and unfastening the tether from the liner, which needs to be performed to clean or replace the liner, is difficult for some users. The purpose of this research was to create a quick connect that allows users to easily attach and detach the tether from the liner. Mechanical testing and pilot study. A slide-and-lock mechanism was used. To operate the quick connect, the prosthesis user turns open the lock, slides it onto a short pin extending from the liner, and releases the mechanism, causing it to spring back to the locked position. Mechanical tests demonstrated that the system well-tolerated tensile loads of 25,000 cycles at 100 N and single cycles at 350 N. Five transtibial users trialed the system and took between 2 and 30 s to fasten and unfasten the quick connect. They found the quick connect intuitive to use, secure, relatively quiet, and stable. However, they preferred their traditional pin lock over the quick connect system, mainly because the quick connect required a multistep procedure (twist-align-slide) that they considered more complex than operating the locking pin to which they were accustomed. In its current form, the quick connect is likely to be used by limited community ambulators who struggle with the pin lock donning procedure. It also has potential use with powered tethers that use a motor to adjust tether length.

Deficits in dynamic balance were the motor impairments that best explained limitations in community ambulation after stroke.

Improving walking capacity, in order to achieve community ambulation, is an important goal for both patients and rehabilitation professionals. However, only about 7 to 27% of the stroke survivors will be able to walk in the community. The aim of this study was to determine which measures of motor impairments would impair community ambulation in 90 individuals with chronic stroke. Cross-sectional study. Research laboratory at Federal University of Minas Gerais. Chronic stroke patients. For this exploratory study, the dependent variable, community ambulation, was determined by the distance covered during the 6-Minute Walking Test (6MWT). Participants, who covered ≥288 meters during the 6MWT, were classified as unlimited-community ambulators, whereas those who covered <288 meters were considered limited-community ambulators. Logistic regression analysis was carried-out to investigate which measures of motor impairments (deficits in strength of the knee extensor muscles, dynamic balance, and lower-limb motor coordination, as well as increased tonus of the ankle plantarflexor muscles) would explain the variance in community ambulation, i.e., the distance covered during the 6MWT. Out of the 90 participants, 51 were unlimited and 39 were limited-community ambulators. Only the measure of dynamic balance (OR=0.81, 95% CI: 0.72-0.91) reached significance and was kept in the logistic regression model. Deficits in dynamic balance best explained limitations in community ambulation in individuals with chronic stroke. Future studies are needed to determine whether rehabilitation interventions aiming at improving dynamic balance would lead to unlimited-community ambulation. Amongst common motor impairments observed after stroke, such as increased tonus of the ankle plantarflexor muscles and deficits in strength of the knee extensor muscles and lower-limb motor coordination, dynamic balance, was the only variable that explained limitations in community ambulation after stroke. Future studies aiming at investigating community ambulation after stroke could take into account measures of dynamic balance.

Outdoor Community Ambulation Interventions to Improve Physical and Mental Health in Older Adults: A Systematic Review and Meta-Analysis.

Limited community ambulation, defined as independent mobility outside the home, predicts adverse outcomes in older adults. We performed a systematic review and meta-analysis to examine outdoor community ambulation intervention effectiveness in older adults. We searched six databases until October 2021. Studies with an evaluative research objective, older adult population, and outdoor community ambulation interventions were eligible. After reviewing 23,172 records, five studies were included. The meta-analysis found no significant difference in walking endurance and depression outcomes between outdoor community ambulation and comparison interventions. For outcomes not suitable for meta-analysis, studies showed no significant difference in walking activity, anxiety, and general and health-related quality of life, and possible improvements in gait speed and lower extremity function and strength. Most evidence was of low to very low certainty. Considering the limited evidence base, the design, implementation, and evaluation of outdoor community ambulation interventions in older adults should be prioritized in primary research.

Two Balance Measures as Poststroke Predictors of Ambulation Status at Discharge From Inpatient Rehabilitation

Purpose: Early predictors of the degree of walking ability poststroke are vital considering the decreased length of stay in most inpatient rehabilitation facilities (IRFs). Prediction of functional walking capability upon discharge from IRFs requires more investigation. This study aimed to (1) determine whether the Postural Assessment Scale for Stroke (PASS) and the Berg Balance Scale (BBS) can predict an individual's IRF discharge poststroke gait category and (2) establish cut-off scores for these assessments to better forecast gait category upon discharge. Methods: A total of 180 individuals with an admitting stroke diagnosis were assessed with both balance measures and the 10-m walking test at admission and discharge from inpatient rehabilitation. Participants were stratified by gait speed into 4 groups (nonambulators: 0 m/s; household ambulators: &lt;0.4 m/s; limited community ambulators: 0.4-0.8 m/s; and community ambulators: &gt;0.8 m/s). Results: Both the admission PASS and the BBS scores may predict patients who will be ambulatory and performed similarly in differentiating between gait classifications upon discharge from inpatient rehabilitation (P &lt; .01). Cut-off scores of 6 or less on the BBS (sensitivity 96%; specificity 83%) and 17 on the PASS (sensitivity 92%; specificity 90%) were established to predict nonambulators, and cut-off scores of 29 or more on the BBS (sensitivity 92%; specificity 86%) and 30 on the PASS (sensitivity 80%; specificity 87%) were established to predict community ambulators. Conclusions: These results can inform clinicians of poststroke patients' walking prognosis and advise discharge needs early in a patient's IRF stay.

Effect of Walking Adaptability on an Uneven Surface by a Stepping Pattern on Walking Activity After Stroke.

Real-world walking activity is important for poststroke patients because it leads to their participation in the community and physical activity. Walking activity may be related to adaptability to different surface conditions of the ground. The purpose of this study was to clarify whether walking adaptability on an uneven surface by step is related to daily walking activity in patients after stroke. We involved 14 patients who had hemiparesis after stroke (age: 59.4 ± 8.9 years; post-onset duration: 70.7 ± 53.5 months) and 12 healthy controls (age: 59.5 ± 14.2 years). The poststroke patients were categorized as least limited community ambulators or unlimited ambulators. For the uneven surface, the study used an artificial grass surface (7 m long, 2-cm leaf length). The subjects repeated even surface walking and the uneven surface walking trials at least two times at a comfortable speed. We collected spatiotemporal and kinematic gait parameters on both the even and uneven surfaces using a three-dimensional motion analysis system. After we measured gait, the subjects wore an accelerometer around the waist for at least 4 days. We measured the number of steps per day using the accelerometer to evaluate walking activity. Differences in gait parameters between the even and uneven surfaces were calculated to determine how the subjects adapted to an uneven surface while walking. We examined the association between the difference in parameter measurements between the two surface properties and walking activity (number of steps per day). Walking activity significantly and positively correlated with the difference in paretic step length under the conditions of different surface properties in the poststroke patients (r = 0.65, p = 0.012) and step width in the healthy controls (r = 0.68, p = 0.015). The strategy of increasing the paretic step length, but not step width, on an uneven surface may lead to a larger base of support, which maintains stability during gait on an uneven surface in poststroke patients, resulting in an increased walking activity. Therefore, in poststroke patients, an increase in paretic step length during gait on an uneven surface might be more essential for improving walking activity.

The effect of microprocessor controlled exo-prosthetic knees on limited community ambulators: systematic review and meta-analysis

Purpose The clinical benefits of microprocessor-controlled prosthetic knees (MPKs) in community ambulators have been well-established. A systematic review in limited community ambulators published in 2014 found benefits in safety, performance-based, and patient-reported outcomes. This work updates the previous analysis to the current state of the published evidence. Methods Systematic review and meta-analysis of the effect of MPKs in limited community ambulators. Results Thirteen research projects presented in 15 publications were identified. Overall validity was “high” in nine studies, “moderate” in three, and “low” in one. The literature described a total of 2366 patients, with 704 classified as limited community ambulators. The use of MPKs in limited community ambulators led to a reduction in falls (SMD g: –0.59; 95% confidence interval (CI) [–0.85, –0.32; I 2=0%]), fear of falling (SMD g: 1.2; 95%CI [0.55, 1.85; I 2=80%]), risk of falling as indicated by the TUG (SMD g: –0.45, 95%CI [–0.87, –0.02; I 2=0%]), an improvement in mobility grade (0.51; 95%CI [0.47,0.55]), self-selected walking speed (SMD g: 0.47; 95%CI [0.14,0.81; I 2=0%]), and patient-reported ambulation (MD 9.32; 95%CI [3.61, 15.02; I 2=7%]), and utility (MD 7.76; 95%CI [2.05–13.47; I 2=0%]). Other outcomes exhibited trends in favor of MPK use or remained insensitive. No outcome was identified favoring non-MPKs. Conclusions These results suggest that MPKs may be considered a valuable therapeutic option in limited community ambulators with a transfemoral amputation. Implications for rehabilitation Above knee amputees may be treated with a large variety of artificial exo-prosthetic knee components. Microprocessor-controlled prosthetic knees have proven to be advantageous and cost effective for community ambulators. The current analysis shows similar effects in safety, mobility, and patient perception also for limited community ambulators. Microprocessor-controlled prosthetic knees are a viable therapeutic option for limited community ambulators.

Prognostic value of balance performance for improvements of community ambulation among stroke patients: a cohort study.

Despite the positive impact of improving the level of community ambulation among stroke patients, little prognostic research has focused on this indicator. To investigate the prognostic value of the side-by-side, semi-tandem, and tandem standing balance positions and the five-sit-stand (5STS) test for discriminating patients undergoing physical rehabilitation who improve level of functional ambulation and predicting transition time. A cohort study with assessments repeated monthly until discharge for classifying patients in a community ambulation class. A neurological rehabilitation unit of a hospital in Spain. A consecutive sample of 109 stroke patients (68.5±12.0 years) was screened and included within four months post stroke. Of them no one refused, 3 died, and 5 were lost earlier to transition or discharge. Balance tests, the 5STS and gait speed were measured at the center at baseline and monthly until discharge. Transition from household or limited community ambulation to a higher ambulatory capacity or class. Area under the curve (AUC) were used to compare discriminative abilities of the tests and Cox regression analysis to evaluate the association between the tests and time of transition. For household non-ambulators, the semi-tandem was the best discriminative test (AUC=0.850) and the three balance tests showed an association with time to transition. Among the limited community ambulators, the 5STS test also revealed discriminative ability (AUC: 0.822 [0.63-1.00]), with a good prognostic cut-off (14.8 seconds) and association with time to transition (Hazard Ratio: 1.22; 95%CI: 1.05-1.43). Semi-tandem and the 5STS tests can discriminate patients who improve level of functional ambulation and predict transition times within three months in non-ambulators and limited community ambulation patients, respectively. The semi-tandem and the 5STS tests can be performed easily in clinical settings to predict improvement of functional ambulation level in patients following stroke.

Using a microprocessor knee (C-Leg) with appropriate foot transitioned individuals with dysvascular transfemoral amputations to higher performance levels: a longitudinal randomized clinical trial

BackgroundIndividuals with transfemoral amputations who are considered to be limited community ambulators are classified as Medicare functional classification (MFCL) level K2. These individuals are usually prescribed a non-microprocessor controlled knee (NMPK) with an appropriate foot for simple walking functions. However, existing research suggests that these individuals can benefit from using a microprocessor controlled knee (MPK) and appropriate foot for their ambulation, but cannot obtain one due to insurance policy restrictions. With a steady increase in older adults with amputations due to vascular conditions, it is critical to evaluate whether advanced prostheses can provide better safety and performance capabilities to maintain and improve quality of life in individuals who are predominantly designated MFCL level K2. To decipher this we conducted a 13 month longitudinal clinical trial to determine the benefits of using a C-Leg and 1M10 foot in individuals at K2 level with transfemoral amputation due to vascular disease. This longitudinal clinical trial incorporated recommendations prescribed by the lower limb prosthesis workgroup to design a study that can add evidence to improve reimbursement policy through clinical outcomes using an MPK in K2 level individuals with transfemoral amputation who were using an NMPK for everyday use.MethodsTen individuals (mean age: 63 ± 9 years) with unilateral transfemoral amputation due to vascular conditions designated as MFCL K2 participated in this longitudinal crossover randomized clinical trial. Baseline outcomes were collected with their current prosthesis. Participants were then randomized to one of two groups, either an intervention with the MPK with a standardized 1M10 foot or their predicate NMPK with a standardized 1M10 foot. On completion of the first intervention, participants crossed over to the next group to complete the study. Each intervention lasted for 6 months (3 months of acclimation and 3 months of take-home trial to monitor home use). At the end of each intervention, clinical outcomes and self-reported outcomes were collected to compare with their baseline performance. A generalized linear model ANOVA was used to compare the performance of each intervention with respect to their own baseline.ResultsStatistically significant and clinically meaningful improvements were observed in gait performance, safety, and participant-reported measures when using the MPK C-Leg + 1M10 foot. Most participants were able to achieve higher clinical scores in gait speed, balance, self-reported mobility, and fall safety, while using the MPK + 1M10 combination. The improvement in scores were within range of scores achieved by individuals with K3 functional level as reported in previous studies.ConclusionsIndividuals with transfemoral amputation from dysvascular conditions designated MFCL level K2 benefited from using an MPK + appropriate foot. The inference and evidence from this longitudinal clinical trial will add to the knowledgebase related to reimbursement policy-making.Trial registration This study is registered on clinical trials.gov with the study title “Functional outcomes in dysvascular transfemoral amputees” and the associated ClinicalTrials.gov Identifier: NCT01537211. The trial was retroactively registered on February 7, 2012 after the first participant was enrolled.

Hydraulic- and Microprocessor-Controlled Ankle-Foot Prostheses for Limited Community Ambulators with Unilateral Transtibial Amputation: Pilot Study

ABSTRACT Introduction In the United States, access to microprocessor-controlled prosthetic ankles is limited to patients with lower-limb loss classified as unlimited community ambulators or greater. However, the potential benefits of these devices have not been evaluated among patients classified as household or limited community ambulators. This study examined the benefit of hydraulic- and microprocessor-controlled prosthetic ankles for patients classified as limited community ambulators. Materials and Methods Four different treatment configurations were evaluated using a randomized crossover study design. These four configurations included the participant's current flexible keel (FK) prosthetic foot, an energy-storage-and-return foot (ESAR), a hydraulic ankle (HA), and a microprocessor ankle (MPA). After a 2-week accommodation period, both patient-reported and performance-based outcome measures were recorded for each ankle foot system. A StepWatch activity monitor and two-dimensional video motion analysis were also used to evaluate each system. Results A single participant meeting the inclusion criteria was recruited. The patient-reported mobility and socket fit instruments were greatest with the HA system. When assessed on slopes and stairs, the MPA demonstrated benefits on hill ascent and stair descent. In considering the walking speed and perceived exertion jointly, the HA system allowed similar walking speed but lower exertion compared with fixed-ankle systems. The patient-reported low back pain and balance confidence instruments did not provide useful data for interpretation. Two-dimensional video motion analysis showed that the HA and MPA contributed to improved ankle and knee postures when ascending and descending a slope. The step activity data showed the greatest activity with the HA. Discussion The results from the outcome measures showed a varying level of benefit across all four of the treatment configurations. Both the HA and MPA had favorable scores in varying performance-based outcome measures, but the HA scored the most favorable in a majority of the patient-reported outcome measures. Conclusion The results show varying benefits of the microprocessor- and hydraulic-controlled prosthetic components over fixed-ankle ESAR and FK feet, based on both performance-based and patient-reported outcome measures. Further studies are needed to fully evaluate these benefits in larger sample sizes.

Responsiveness and Minimal Clinically Important Difference of the Five Times Sit-to-Stand Test in Patients with Stroke.

This study aimed to analyze the responsiveness of the 5STS test among stroke patients and to estimate the MCIDs (minimal clinically important differences) for different severity levels of community ambulation and stages of recovery. The 5STS and comparator instruments (gait speed and Functional Ambulatory Category (FAC)) were evaluated at baseline. These measures were repeated at 4 (Stage 1) and 8 weeks (Stage 2), together with the Global Rating of Change (GROC). The MCIDs were calculated with two anchor-based methods using the GROC as the external criterion. Responsiveness to change for the 5STS was estimated analyzing the correlation with changes in the two comparator instruments and their capacity to discriminate improvement. For the 5STS test, while the MCIDs of the limited community ambulators were similar in the two stages (around 3 s), those of the household ambulators decreased from 1.9 s to 0.72 s. Spearman’s rho coefficients showed an acceptable correlation between changes in 5STS and changes for both the FAC and gait speed changes in both stages of recovery. Our study revealed that the 5STS is responsive to functional changes in patients with stroke and that their degree of severity and stage of recovery influence the MCID values of the 5STS.

Which Balance Evaluation Systems Test sections best distinguish levels of post-stroke functional walking status?

ObjectiveTo determine which sections of the Balance Evaluation Systems Test (BESTest) distinguish levels of post-stroke functional walking status and to establish their cut-off scores.DesignA retrospective cross-sectional study.Subjects and methodsThe BESTest was administered to 87 stroke patients who were able to walk without physical assistance upon discharge from the hospital. Subjects were divided into 3 functional walking status groups: namely, household ambulators, limited community ambulators, and unlimited community ambulators. The receiver operating characteristic curve was determined and the cut-off score and area under the receiver operating characteristic curve (AUROC) of each section calculated.ResultsIn the comparison of household and limited community ambulators, the accuracies of all BESTest sections were moderate (AUROC>0.7), and the cut-off scores were 36.1–78.6%. In the comparison of limited and unlimited community ambulators, one section (stability in gait) had high accuracy (AUROC=0.908, cut-off scores=73.8%) and 3 sections (biomechanical constraints, anticipatory postural adjustments, and postural response) had moderate accuracy (AUROC=0.812–0.834, cut-off scores=75.0–83.4%).ConclusionThis study demonstrated that different sections of the BESTest had different abilities to discriminate levels of post-stroke functional walking status, and identified cut-off values for targeted improvement.LAY ABSTRACTThe Balance Evaluation Systems Test (BESTest), a clinical postural control measure, categorizes postural control systems in 6 different sections. This study investigated which sections of the BESTest distinguish levels of post-stroke functional walking status, which, in turn, is based on walking speed. Among the slower walkers, all sections of the BESTest showed moderate relationships to categories of walking status. Among the faster walkers, 4 sections showed moderate to strong relationships and 2 sections showed weak relationships. This study may have clinical implications for rehabilitation aimed at improving functional walking status in individuals with stroke. These findings will help rehabilitation professionals assess postural control in relation to stroke patients’ ability to walk in different settings (e.g. their household or the community) and determine which postural control systems should be prioritized in therapeutic interventions.

Walking Characteristics In Individuals With Stroke Differ Based On Walking Speed, Endurance And Daily Steps

PURPOSE: Walking is an ideal means of obtaining physical activity, yet people with stroke take few daily steps. The purpose of this study was to examine how the walking characteristics of bouts per day, maximum steps per bout and time spent walking differ between individuals with various walking speeds, walking endurance and daily steps. Additionally, we aimed to identify cutoff values for differentiating active and inactive ambulators (i.e. those who do and do not achieve physical activity guidelines through walking). METHODS: Stepping data from 252 individuals with chronic stroke (>6 months) with mean age of 63 (13) years and step count of 4,277 (3,064) steps per day were analyzed. Individuals were placed into previously established levels of ambulation (i.e. household ambulators, limited community and unlimited community ambulators), based on walking speed, walking endurance and daily steps (via two days of StepWatch activity monitoring). Differences in walking characteristics were assessed between ambulation levels (e.g. household vs. community ambulators). Linear regression determined which characteristics best predicted daily step counts. Receiver Operating Characteristic (ROC) curves and area under the curve (AUC) determined which variable was most accurate in classifying active (>5,500 steps) and inactive (<5,500 steps) individuals. RESULTS: Regardless of categorization by walking speed, walking endurance or daily steps, household ambulators had significantly fewer bouts per day, maximum steps per bout and time spent walking compared to both limited and unlimited community ambulators (p = <0.001). Only 81 (32%) participants obtained >5,500 steps per day. The two highest AUC values were 0.91 (95% CI 0.88, 0.95) for maximum steps per bout and 0.83 (95% CI 0.78, 0.88) for bouts per day. Cutoff values of 648 maximum steps per bout or 53 bouts were used to differentiate active and inactive ambulators. CONCLUSIONS: Walking characteristics differed based on an individual’s walking speed, walking endurance and daily steps. Differences in daily steps between household and community ambulators are largely due to shorter and fewer walking bouts. Interventions aimed at improving walking after stroke should promote increased walking bouts of any length to increase physical activity after stroke.

The Utility of the 2-Minute Walk Test as a Measure of Mobility in People With Lower Limb Amputation

ObjectivesTo establish reference values for the 2-minute walk test (2-MWT) distance and gait speed in people with a lower limb amputation (LLA) who are prosthetic ambulators. Also, to describe the differences in distance and gait speed between sexes, causes of amputation, levels of amputation, health risk classification, functional levels, and age groups. DesignCross-sectional study. SettingNational meeting for people with lower limb amputation. ParticipantsA convenience sample of unilateral people (N=101; 47 men, 54 women; mean age ± SD, 50.9±14.3 y) with an LLA; 48 had a transtibial amputation and 53 had a transfemoral amputation. Participants were classified as either limited community ambulators, community ambulators, or those who exceed basic ambulation skills (K2, n=7; K3, n=70; K4, n=24). InterventionNot applicable. Main Outcome Measure2-MWT performance (ie, distance and gait speed). ResultsThe mean ± SD 2-MWT distance and gait speed for the entire sample was 143.8±37.5 meters (range, 49-259 m) and 72.1±18.8 meters per minute (range, 25-130 m/min), respectively. Men walked farther (distance: men, 154.2±34.2 m; women, 134.4±38.1 m) and faster (gait speed: men, 77.3±17.1 m/min; women, 67.4±19.1 m/min) than women (P<.05). The mean ± SD 2-MWT distance for K4, K3, and K2 level participants was 177.9±31.1 meters, 138.4±28.5 meters, and 81.7±26.9 meters, respectively. Functional level K4 participants performed better than K3 participants (P<.05), and K3 participants performed better than K2 participants (P<.05). People with transtibial amputation walked farther than those with transfemoral amputation (152.9±43.0 m vs 135.6±43.0 m) (P<.05). The distance and speed ambulated by those participants classified in the very high health risk group was worse than those categorized as being at an increased high health risk group (P<.05) and the no increase health risk group (P<.05). The performance of participants older than 70 years old was inferior to the performance of all younger age groups. ConclusionsReference values for the 2-MWT distance and gait speed were established in people with LLA who are prosthetic ambulators. Significant differences in the 2-MWT performance were found between sexes, causes of amputation, levels of amputation, health risk classification, functional levels, and age groups.

Levels and patterns of physical activity in stroke survivors with different ambulation status living in low-income areas of Cape Town, South Africa

ABSTRACT Background: Little is known about physical activity (PA) in people with stroke living in low-income areas. The aim of this study was to characterize and contrast the levels and patterns of PA between stroke survivors with different ambulation status living in low-income areas in Cape Town, South Africa. Methods: In this cross-sectional study, 45 community-dwelling stroke survivors living in low-income areas in Cape Town participated. Accelerometers (Actigraph wGT3X-BT) were used to assess PA levels (vector magnitude counts and number of steps) and time spent sedentary, in light and moderate-to-vigorous PA (MVPA). Total daily PA and within-day activity patterns were compared between limited community ambulators (gait speed: <0.8 m/s) and community ambulators (gait speed: ≥0.8 m/s). Results: Limited community ambulators (n = 23) took fewer steps per day (1091 vs. 3524 steps, P < .001), spent more time sedentary (80% vs 68%, P = .002) and less time in light PA (18% vs 25%, P = .008) and MVPA (1% vs 5%, P < .001) than community ambulators (n = 22). The limited ambulation group had a consistent pattern of PA across the day without any significant variations in PA levels or intensity, whereas the unlimited ambulating group was most active in the morning followed by a gradual reduction in PA throughout the day. Conclusions: Community ambulating stroke survivors showed greater PA levels and a more variable diurnal pattern in contrast to the limited ambulation group. Different interventions may be required to assist the different groups to start engaging in health-enhancing PA.

Low gait speed is associated with low physical activity and high sedentary time following stroke

Purpose This study describes physical activity levels and factors associated with physical activity at the end of stroke rehabilitation. Methods Primary stroke survivors were assessed at completion of physical rehabilitation. Outcomes included physical activity (e.g. step count, moderate-vigorous physical activity duration) and sedentary time measured with the Sensewear Armband, gait speed, and cognition. The number of participants meeting physical activity recommendations was calculated. Differences in physical activity were examined between household ambulators (gait speed <0.4 m/s), limited community ambulators (0.4–0.8 m/s), and unlimited community ambulators (>0.8 m/s). The influence of age, cognition, and gait speed on physical activity was determined by multiple regression. Results Seventy-nine stroke survivors participated. Twenty-one participants achieved 30 min/day of moderate-vigorous physical activity accumulated in 10 min bouts. Unlimited community ambulators took more steps/day (median 4975 vs. 469 limited, 355 household, p < 0.001), had higher moderate-vigorous physical activity (median 74 min/day vs. 22 limited, 31 household, p < 0.001) and lower sedentary time (mean 1105 vs. 1239 limited, 1232 household minutes/day, p < 0.001). Age, gait speed, and cognition predicted 21.3% of the variance in moderate-vigorous physical activity (p = 0.001); adding employment status to the model predicted 57.3% of the variance in step count (p < 0.001). Conclusions Physical activity is low following stroke and should be a target for treatment, particularly in those with gait speeds ≤0.8 m/s. Implications for rehabilitation Seventy-three percent of stroke survivors performed ≥30 minutes of moderate to vigorous physical activity throughout the day. Twenty-seven percent of stroke survivors accumulated ≥30 minutes of moderate to vigorous physical activity in 10 minute bouts. Despite relatively good physical ability, daily step count was low in this sample. Those with gait speeds ≤0.8 m/s had lower physical activity levels and higher sedentary time.

Improvements in skilled walking associated with kinematic adaptations in people with spinal cord injury

IntroductionIndividuals with motor-incomplete SCI (m-iSCI) remain limited community ambulators, partly because they have difficulty with the skilled walking requirements of everyday life that require adaptations in inter-joint coordination and range of motion of the lower limbs. Following locomotor training, individuals with SCI show improvements in skilled walking and walking speed, however there is limited understanding of how adaptations in lower limb kinematics following training contribute to improvements in walking.ObjectiveTo determine the relationship between changes in lower limb kinematics (range of motion and inter-joint coordination) and improvements in walking function (walking speed and skilled walking) following locomotor training.MethodsLower limb kinematics were recorded from 8 individuals with chronic m-iSCI during treadmill walking before and after a 3-month locomotor training program. Data were also collected from 5 able-bodied individuals to provide normative values. In individuals with SCI, muscle strength was used to define the stronger and weaker limb. Motion analysis was used to determine, hip, knee and ankle angles. Joint angle-angle plots (cyclograms) were used to quantify inter-joint coordination. Shape differences between pre-and post-training cyclograms were used to assess the changes in coordination and their relation to improvements in walking function. Walking function was assessed using the 10MWT for walking speed and the SCI-FAP for skilled walking. Comparing pre- and post-training cyclograms to the able-bodied pattern was used to understand the extent to which changes in coordination involved the recovery of normative motor patterns.ResultsFollowing training, improvements in skilled walking were significantly related to changes in hip-ankle coordination (ρ = − .833, p = 0.010) and knee range of motion (ρ = .833, p = 0.010) of the weaker limb. Inter-joint coordination tended to revert towards normative patterns, but not completely. No relationships were observed with walking speed.ConclusionLarger changes in hip-ankle coordination and a decrease in knee range of motion in the weaker limb during treadmill walking were related to improvements in skilled walking following locomotor training in individuals with SCI. The changes in coordination seem to reflect some restoration of normative patterns and the adoption of compensatory strategies, depending on the participant.

Prosthetic Knee Selection for Individuals with Unilateral Transfemoral Amputation: A Clinical Practice Guideline.

ABSTRACTIntroductionThis guideline was developed to present the evidence and provide clinical recommendations on prosthetic knee selection for unilateral amputation at the knee disarticulation or transfemoral level.MethodsThe guideline is based upon the best available evidence as it relates to prosthetic knee selection after unilateral knee disarticulation or transfemoral amputation. Recommendations are drawn from systematic review, meta-analysis, and additional published practice guidelines.ResultsRecommendation 1. Fluid knee benefits and indications: Knees with hydraulic or pneumatic swing resistance are indicated for active walkers, permitting increased walking comfort, speed, and symmetry.Recommendation 2. Microprocessor knee benefits: Compared with nonmicroprocessor knees:a) With respect to self-report indices and measures, microprocessor knees are indicated to reduce stumbles, falls, and associated frustrations as well as the cognitive demands of ambulation.b) With respect to self-report indices and measures, microprocessor knees are indicated to increase confidence while walking, self-reported mobility, satisfaction, well-being, and quality of life.c) With respect to physical performance indices and measures, microprocessor knees are indicated to increase self-selected walking speed, walking speed on uneven terrain, and metabolic efficiency during gait.Recommendation 3. Microprocessor knee equivalence: Given the comparable values observed with the use of microprocessor and nonmicroprocessor knees with regard to daily step counts, temporal and spatial gait symmetry, self-reported general health, and total costs of prosthetic rehabilitation, these parameters may not be primary indications in prosthetic knee joint selection.Recommendation 4. Microprocessor knees for limited community ambulators: Among limited community ambulators, microprocessor knees are indicated to enable increases in level ground walking speed and walking speed on uneven terrain while substantially reducing uncontrolled falls and increasing both measured and perceived balance.ConclusionsThese clinical practice guidelines summarize the available evidence related to prosthetic knee selection for individuals with unilateral knee disarticulation or transfemoral amputation. The noted clinical practice guidelines are meant to serve on as "guides." They may not apply to all patients and clinical situations.