Associations of components of sarcopenia with risk of fracture in the Osteoporotic Fractures in Men (MrOS) study.

Our aim was to evaluate the associations between the individual components of sarcopenia and fracture types. In this cohort, the risk of experiencing any clinical, hip, or major osteoporotic fracture is greater in men with slow walking speed in comparison to normal walking speed. INTRODUCTION: The association between the components of sarcopenia and fractures has not been clearly elucidated and has hindered the development of appropriate therapeutic interventions. Our aim was to evaluate the associations between the individual components of sarcopenia, specifically lean mass, strength, and physical performance and fracture (any fracture, hip fracture, major osteoporotic fracture) in the Osteoporotic Fractures in Men (MrOS) study. METHODS: The Osteoporotic Fractures in Men study (MrOS) recruited 5995 men ≥ 65 years of age. We measured appendicular lean mass (ALM) by dual-energy X-ray absorptiometry (low as residual value < 20th percentile for the cohort), walking speed (fastest trial of usual pace, values < 0.8 m/s were low), and grip strength (max score of 2 trials, values < 30 kg were low). Information on fractures was assessed tri-annually over an average follow-up of 12 years and centrally adjudicated. Cox proportional hazard models estimated the hazard ratio (HR) (95% confidence intervals) for slow walking speed, low grip strength, and low lean mass. RESULTS: Overall, 1413 men had a fracture during follow-up. Slow walking speed was associated with an increased risk for any HR = 1.39, 1.05-1.84; hip HR = 2.37, 1.54-3.63; and major osteoporotic, HR = 1.89, 1.34-2.67 in multi-variate-adjusted models. Low lean mass and low grip strength were not significantly associated with fracture. CONCLUSIONS: In this cohort of older adult men, the risk of experiencing any, hip, or major osteoporotic fracture is greater in men with slow walking speed in comparison to men with normal walking speed, but low grip strength and low lean mass were not associated with fracture.

Assessing interactions among multiple physiological systems during walking outside a laboratory: An Android based gait monitor.

Gait function is traditionally assessed using well-lit, unobstructed walkways with minimal distractions. In patients with subclinical physiological abnormalities, these conditions may not provide enough stress on their ability to adapt to walking. The introduction of challenging walking conditions in gait can induce responses in physiological systems in addition to the locomotor system. There is a need for a device that is capable of monitoring multiple physiological systems in various walking conditions. To address this need, an Android-based gait-monitoring device was developed that enabled the recording of a patient's physiological systems during walking. The gait-monitoring device was tested during self-regulated overground walking sessions of fifteen healthy subjects that included 6 females and 9 males aged 18-35 years. The gait-monitoring device measures the patient's stride interval, acceleration, electrocardiogram, skin conductance and respiratory rate. The data is stored on an Android phone and is analyzed offline through the extraction of features in the time, frequency and time-frequency domains. The analysis of the data depicted multisystem physiological interactions during overground walking in healthy subjects. These interactions included locomotion-electrodermal, locomotion-respiratory and cardiolocomotion couplings. The current results depicting strong interactions between the locomotion system and the other considered systems (i.e., electrodermal, respiratory and cardiovascular systems) warrant further investigation into multisystem interactions during walking, particularly in challenging walking conditions with older adults.

Harmonic ratios: a quantification of step to step symmetry.

The harmonic ratio (HR), derived from the Fourier analysis of trunk accelerations, has been described in various ways as a measure of walking smoothness, walking rhythmicity, or dynamic stability. There is an increasing interest in applying the HR technique to investigate the impact of various pathologies on locomotion; however, explanation of the method has been limited. The aim here is to present a clear description of the mathematical basis of HRs and an understanding of their interpretation. We present harmonic theory, the interpretation of the HR using sinusoidal signals, and an example using actual trunk accelerations and harmonic analyses during limb-loading conditions. We suggest that the HR method may be better defined, not as a measure of rhythmicity or stability, but as a measure of step-to-step symmetry within a stride.

A new approach of measuring muscle impairment during a functional task: quadriceps muscle activity recorded during chair stand.

BACKGROUND: Biologic changes are expected to occur prior to disability. Compared with physical disability measures, measures of muscle impairment may be an earlier indicator of functional decline. The purpose of this study was to describe a new approach of measuring muscle impairment during a functional task. METHODS: Right quadriceps muscle activity was recorded using surface electromyography (sEMG) from 160 older women (age 73.9 +/- 3.9 years, mean +/- SD). Specific patterns of muscle activity during the chair stand task were determined using an exploratory principal components factor analysis (PCFA). Muscle activity parameters were validated by comparison to the Physical Performance Test, gait speed, and the Functional Status Questionnaire. RESULTS: The PCFA indicated two factors (magnitude and timing) that represented important components of quadriceps muscle activity during chair stand, explaining 68.6% of the variance in performance. The slope of the rise of muscle activity represents a combination of the magnitude and timing components of muscle activity. Compared with women with a slope <1, women with a slope > or = 1 walked faster (1.17 m/s vs 1.09 m/s; p = .02) and reported less difficulty with activities of daily living (ADL) (98.6 vs 95.8; p = .003) and instrumental ADL (97.3 vs 92.2; p = .001). CONCLUSIONS: Quadriceps muscle activity recorded during chair stand is a valid and reliable measure of muscle performance during a functional task. As a biologic measure of muscle activation, sEMG may identify muscle impairment, which could indicate functional decline earlier than measures of functional status.

Making geriatric assessment work: selecting useful measures.

Often the goal of physical therapy is to reduce morbidity and prevent or delay loss of independence. The purpose of this article is to describe issues to consider when selecting measures of physical function for use with community-dwelling older adults over the age of 65 years. We chose 16 measures of physical function for review because they have been used in studies of community-dwelling older adults and some psychometric properties of reliability and validity have been described in the literature. Three major issues are discussed: (1) appropriateness of the measure for community-dwelling adults, (2) practical aspects of test administration, and (3) psychometric properties. These issues are illustrated using examples from the 16 measures. Two scenarios, applying the measures to the assessment of community-dwelling well older people and to the assessment of community-dwelling frail older people, are used to illustrate how this information can be used.

Gait variability in community-dwelling older adults.

OBJECTIVES: To describe gait variability at usual and fast walking speeds in community-dwelling older adults and to describe the effects of increasing gait speed on gait variability. DESIGN: Cross-sectional, descriptive study. SETTING: The Cardiovascular Health Study at the University of Pittsburgh. PARTICIPANTS: Ninety-five community-living older adults, 54 women and 41 men, age 65 and older (mean age +/- standard deviation 79.4 +/- 3.37). MEASUREMENTS: Gait measured at participant's usual and fast walking speed collected using an instrumented walkway. Step-length and step-width variability were determined using the coefficient of variation. RESULTS: Step-length variability was greatest in those who walked the slowest (r = -0.66, P < .001); step-width variability was smallest in those who walked the slowest (r -0.37, P < .001). Individuals who could not increase their walking speed (<0.10 m/second) on command had an increase in step-length variability and a decrease in step-width variability, whereas those who could increase their speed (>0.10 m/second) had an increase in step-width variability when walking at a faster speed. CONCLUSIONS: Step-length and step-width variability have opposite associations with gait speed in older adults. Improvement in step-length and step-width variability with attempted acceleration might be a key factor to examine in future studies of disability risk and therapeutic interventions.

Not all facial paralysis is Bell's palsy: a case report.

Bell's palsy or idiopathic facial paralysis is the most common cause of unilateral facial paralysis. This case report describes a patient referred for physical therapy evaluation and treatment with a diagnosis of Bell's palsy. On initial presentation in physical therapy the patient had unilateral facial paralysis, ipsilateral regional facial pain and numbness, and a history of a gradual, progressive onset of symptoms. The process of evaluating this patient in physical therapy, as well as the recognition of signs and symptoms typical and atypical of Bell's palsy, are described. This report emphasizes the importance of early recognition of the signs and symptoms inconsistent with a diagnosis of Bell's palsy, and indications for prompt, appropriate referral for additional diagnostic services.

Physical therapy for facial paralysis: a tailored treatment approach.

BACKGROUND AND PURPOSE: Bell palsy is an acute facial paralysis of unknown etiology. Although recovery from Bell palsy is expected without intervention, clinical experience suggests that recovery is often incomplete. This case report describes a classification system used to guide treatment and to monitor recovery of an individual with facial paralysis. CASE DESCRIPTION: The patient was a 71-year-old woman with complete left facial paralysis secondary to Bell palsy. Signs and symptoms were assessed using a standardized measure of facial impairment (Facial Grading System [FGS]) and questions regarding functional limitations. A treatment-based category was assigned based on signs and symptoms. Rehabilitation involved muscle re-education exercises tailored to the treatment-based category. OUTCOMES: In 14 physical therapy sessions over 13 months, the patient had improved facial impairments (initial FGS score= 17/100, final FGS score= 68/100) and no reported functional limitations. DISCUSSION: Recovery from Bell palsy can be a complicated and lengthy process. The use of a classification system may help simplify the rehabilitation process.

Validation of a treatment-based classification system for individuals with facial neuromotor disorders.

BACKGROUND AND PURPOSE: A method for linking treatments to signs and symptoms of facial neuromotor disorders is needed. We describe the construct validation of a treatment-based classification system for facial neuromotor disorders. SUBJECTS AND METHODS: Based on physical signs and symptoms, 148 patients (mean age = 48.9 years, SD = 16.1, range = 20-93) were assigned to treatment-based categories. The pattern of impairment and disability was compared with clinic expectations. RESULTS: The distribution of impairment and disability scores demonstrated the expected signs and symptoms of the treatment-based categories. Confirmatory principal-components factor analysis indicated 4 factors, corresponding to the treatment-based categories; the factor loadings confirmed the presence of the key sign or symptom characteristic of the categories. CONCLUSION AND DISCUSSION: Classifying facial neuromotor disorders into treatment-based categories appears to be a valid method for categorizing patients with specific impairments or disabilities and may be useful in linking treatments to outcomes.

Impairment and disability in patients with facial neuromuscular dysfunction.

Integration of impairment measures and disability measures may provide clinicians with an accurate and comprehensive picture of the patient's dysfunction. The purpose of this study was to indicate the usefulness of two new scales of measuring facial impairment and disability in describing characteristics of individuals with facial neuromuscular dysfunction. Fifty-one individuals with unilateral facial neuromuscular dysfunction and a House-Brackmann grade of III or higher were included in the study. The subjects' movement impairments were assessed using the Facial Grading System (FGS). The subjects reported their physical and social function on the Facial Disability Index (FDI). Nine variables were subjected to a confirmatory principal-components factor analysis to indicate important factors in describing patients with facial nerve disorders. The confirmatory principal-components factor analysis identified three factors, impairment, disability, and temporal characteristics of disease, accounting for 72% of the variance in describing individuals with facial neuromuscular dysfunction. Integration of these measures may provide clinicians with an accurate and comprehensive picture of the patient's dysfunction, thus aiding in the determination of intervention and the measurement of clinical outcomes.

Facial neuromuscular retraining for oral synkinesis.

The purpose of this paper is to describe the outcome of facial neuromuscular retraining for brow to oral and ocular to oral synkinesis in individuals with facial nerve disorders. Fourteen patients with unilateral facial nerve disorders and oral synkinesis who were enrolled in physical therapy for retraining were studied. Synkinesis was measured with quantitative video facial position analysis prior to the initiation of physical therapy and at regular intervals during retraining. Retraining included surface electromyographic biofeedback-assisted specific strategies for facial muscle reeducation and a home exercise program of specific facial movements. Twelve of 13 patients with brow to oral synkinesis and 12 of 14 patients with ocular to oral synkinesis reduced their synkinesis with retraining. Patients with a 1-year on greater duration of a facial neuromuscular disorder (excluding patients with unusually marked changes) demonstrated a significant decrease in brow to oral synkinesis and in ocular to oral synkinesis; there was a mean percentage decline in abnormal movement of 60.5 percent (SD = 26.48) and 30.1 percent (SD = 62.57), respectively. We conclude that brow to oral and ocular to oral synkineses associated with partial recovery from facial paralysis were reduced with facial neuromuscular retraining for individuals with facial nerve disorders.

The Facial Disability Index: reliability and validity of a disability assessment instrument for disorders of the facial neuromuscular system.

BACKGROUND AND PURPOSE: Disorders of the facial neuromuscular system can result in marked disfigurement of the face and difficulties in activities of daily living such as eating, drinking, and communicating. No systematic means of measuring the disability associated with facial nerve disorders exists. The purpose of this investigation was to examine the reliability and construct validity of the Facial Disability Index (FDI), a disease-specific, self-report instrument for the assessment of disabilities of patients with facial nerve disorders. SUBJECTS AND METHODS: The FDI was administered to 46 ambulatory patients of the University of Pittsburgh Medical Center's Facial Nerve Center. The relationship of the FDI subscale and total scores with clinical impairment measures was determined, and a comparison of the use of the FDI and subscales of the more general SF-36 was made. RESULTS: The FDI subscales produced reliable scores (theta reliability: physical function = .88; social/well-being function = .83). Construct validity of the FDI physical function subscale was demonstrated by a correlation with the clinician's physical examination of facial movement. The FDI social/well-being subscale was associated with the FDI physical function subscale and with a clinical assessment of psychosocial status within a subset of the sample (n = 14). The FDI represented the relationship between impairments, disability, and psychosocial status better than the generic SF-36 did. CONCLUSION AND DISCUSSION: The FDI subscales produce reliable measurements, with construct validity for measuring patient-focused focused disability of individuals with disorders of the facial motor system.

Measuring fatigue related to facial muscle function.

OBJECTIVE: The purpose of this study was to explore the expression of facial muscle fatigue in individuals without impaired muscle function using surface electromyography (EMG). DESIGN: Descriptive study of the expression of facial muscle fatigue in individuals without impaired muscle function. PARTICIPANTS: Convenience sample. Twenty individuals, 5 men and 15 women, between 20 and 50 years of age who volunteered to participate. OUTCOME MEASURES: Two tests of fatigue, a 10-second sustained contraction test, and a 25 repeated 3-second contractions test, were conducted on three facial expressions: brow raise, smile, and pucker. Surface EMG quantification of the muscle activity of the voluntary maximal facial muscle contractions was recorded during the fatigue tests. RESULTS: For the sustained fatigue test, all three expressions had a significant decline in activity (brow raise 34.51%, smile 22.96%, and pucker 29.05%); confirmed by a one-way ANOVA with repeated measures (brow raise df = 2, 38; f = 53.28; p = 0.00; smile df = 2, 38; f = 39.913; p = 0.00; pucker df = 2, 38; f = 76.002; p = 0.00). For the repeated fatigue test, percent fatigue was significant for smile (11.62%; df = 1, 19; f = 13.823; p = 0.001) but not for brow raise (7.27%; df = 1, 19; f = 1.945; p = 0.179) or pucker (4.22%; df = 1, 19; f = 2.508; p = 1.30). CONCLUSIONS: The muscle activity of sustained maximal voluntary muscle contractions of facial muscles fatigues significantly with time for brow raise, smile, and pucker expressions. The same facial muscles are more resistant to fatigue of muscle activity with repeated, brief contractions. Knowing the amount of facial muscle fatigue of individuals without impairment can be beneficial in developing outcome measures and goals for rehabilitation of individuals with facial neuromuscular dysfunction. Changes in fatigue tests of an individual with facial neuromuscular dysfunction with rehabilitation is reviewed for comparison.