Footwear characteristics and foot problems in community dwelling people with stroke: a cross-sectional observational study.

PURPOSE: To explore footwear characteristics and foot problems in community dwelling people with stroke as most research to date focused on the general elderly population. METHODS: Thirty people with mild to moderate stroke (nine men, mean age 68, mean time since onset 67 months) attended a single session to assess footwear and foot problems using established podiatry foot (wear) and ankle assessments. RESULTS: Most participants wore slippers indoors (n = 17, 57%) and walking shoes outdoors (n = 11, 37%). Over half wore unsupportive ill-fitting shoes indoors and 47% of outdoor shoes fitted badly. All participants had foot problems (mean 6.5 (3.1), 95% CI: 5.4-7.7), including impaired single limb heel raise (93%), reduced range of movement (77%), sensation (47%), and muscle strength (43%). Many had foot-pain, hallux valgus (both 50%), or swollen feet (40%). Foot problems were associated with reduced balance confidence, activity, and community participation (all p < 0.05). A greater proportion of fallers (13/16) than non-fallers (4/14) reported foot problems (p = 0.029). CONCLUSIONS: Many community-dwelling people with stroke wore poorly fitting shoes; all had foot problems. Foot problems were linked to reduced mobility. Finding more effective pathways to support people with stroke to select supportive, well-fitting indoor and outdoor footwear is indicated.Implications for rehabilitationPeople with stroke often wear unsupportive ill-fitting shoes and experience foot problems.Assessment of foot problems and footwear advice should be considered during stroke rehabilitation particularly when interventions target fall prevention or improvements in balance and mobility.Information on appropriate footwear and signposting that new shoe purchases should include measuring feet to ensure a good fit is recommended.

A novel approach for modelling and classifying sit-to-stand kinematics using inertial sensors.

Sit-to-stand transitions are an important part of activities of daily living and play a key role in functional mobility in humans. The sit-to-stand movement is often affected in older adults due to frailty and in patients with motor impairments such as Parkinson's disease leading to falls. Studying kinematics of sit-to-stand transitions can provide insight in assessment, monitoring and developing rehabilitation strategies for the affected populations. We propose a three-segment body model for estimating sit-to-stand kinematics using only two wearable inertial sensors, placed on the shank and back. Reducing the number of sensors to two instead of one per body segment facilitates monitoring and classifying movements over extended periods, making it more comfortable to wear while reducing the power requirements of sensors. We applied this model on 10 younger healthy adults (YH), 12 older healthy adults (OH) and 12 people with Parkinson's disease (PwP). We have achieved this by incorporating unique sit-to-stand classification technique using unsupervised learning in the model based reconstruction of angular kinematics using extended Kalman filter. Our proposed model showed that it was possible to successfully estimate thigh kinematics despite not measuring the thigh motion with inertial sensor. We classified sit-to-stand transitions, sitting and standing states with the accuracies of 98.67%, 94.20% and 91.41% for YH, OH and PwP respectively. We have proposed a novel integrated approach of modelling and classification for estimating the body kinematics during sit-to-stand motion and successfully applied it on YH, OH and PwP groups.

The trouble with footwear following stroke: a qualitative study of the views and experience of people with stroke.

Purpose: Foot problems and suboptimal footwear are risk factors for falls among the elderly. Footwear choice may, therefore, be important for people with balance impairment following stroke, but little is known about their experience. This study explored foot problems experienced following stroke, factors influencing footwear choices and views of footwear in use.Methods: Semi-structured interviews with 15 people with stroke, purposively sampled from respondents to a screening survey.Results: Participants typically experienced impaired mobility with balance problems and felt at risk of falling. Stroke related foot problems, including altered sensation, edema, and foot drop, predominantly on the stroke affected side, influenced footwear priorities. Footwear choices prioritized comfort, security, and convenience, sometimes in tension with concern about appearance. Challenges included choosing appropriate indoor footwear and finding shoes to accommodate their orthoses and edema. Participants highlighted perceived lack of footwear advice from health care professionals and variable experience of shoe shopping.Conclusions: Foot problems, as well as gait and balance impairment, have implications for footwear priorities following stroke, but people felt unsupported in making healthy footwear choices. Health care professionals could be trained to routinely deliver footwear assessment and advice and facilitate referrals to podiatrist, when appropriate.Implications for rehabilitationFoot problems, as well as gait and balance impairment, have implications for footwear priorities following stroke.People with stroke perceive a lack of professional advice about footwear and feel unsupported making healthy footwear choices.Health care professionals could be trained to routinely deliver an initial footwear assessment and advice as part of stroke rehabilitation.A greater transparency and knowledge of referral pathways into podiatry services for Health care professionals and patients would give access to specialist advice where appropriate.

Identifying balance impairments in people with Parkinson's disease using video and wearable sensors.

BACKGROUND: Falls and near falls are common among people with Parkinson's (PwP). To date, most wearable sensor research focussed on fall detection, few studies explored if wearable sensors can detect instability. RESEARCH QUESTION: Can instability (caution or near-falls) be detected using wearable sensors in comparison to video analysis? METHODS: Twenty-four people (aged 60-86) with and without Parkinson's were recruited from community groups. Movements (e.g. walking, turning, transfers and reaching) were observed in the gait laboratory and/or at home; recorded using clinical measures, video and five wearable sensors (attached on the waist, ankles and wrists). After defining 'caution' and 'instability', two researchers evaluated video data and a third the raw wearable sensor data; blinded to each other's evaluations. Agreement between video and sensor data was calculated on stability, timing, step count and strategy. RESULTS: Data was available for 117 performances: 82 (70%) appeared stable on video. Ratings agreed in 86/117 cases (74%). Highest agreement was noted for chair transfer, timed up and go test and 3 m walks. Video analysts noted caution (slow, contained movements, safety-enhancing postures and concentration) and/or instability (saving reactions, stopping after stumbling or veering) in 40/134 performances (30%): raw wearable sensor data identified 16/35 performances rated cautious or unstable (sensitivity 46%) and 70/82 rated stable (specificity 85%). There was a 54% chance that a performance identified from wearable sensors as cautious/unstable was so; rising to 80% for stable movements. SIGNIFICANCE: Agreement between wearable sensor and video data suggested that wearable sensors can detect subtle instability and near-falls. Caution and instability were observed in nearly a third of performances, suggesting that simple, mildly challenging actions, with clearly defined start- and end-points, may be most amenable to monitoring during free-living at home. Using the genuine near-falls recorded, work continues to automatically detect subtle instability using algorithms.

A survey exploring self-reported indoor and outdoor footwear habits, foot problems and fall status in people with stroke and Parkinson's.

BACKGROUND: Ill-fitting shoes have been implicated as a risk factor for falls but research to date has focused on people with arthritis, diabetes and the general older population; little is known about people with neurological conditions. This survey for people with stroke and Parkinson's explored people's choice of indoor and outdoor footwear, foot problems and fall history. METHODS: Following ethical approval, 1000 anonymous postal questionnaires were distributed to health professionals, leads of Parkinson's UK groups and stroke clubs in the wider Southampton area, UK. These collaborators handed out survey packs to people with a confirmed diagnosis of stroke or Parkinson's. RESULTS: Three hundred and sixty three completed surveys were returned (218 from people with Parkinson's and 145 from people with stroke). Most respondents wore slippers indoors and walking shoes outdoors and considered comfort and fit the most important factors when buying footwear. Foot problems were reported by 43 % (95 % confidence intervals 36 to 52 %; stroke) and 53 % (95 % confidence interval 46 to 59 %; Parkinson's) of respondents; over 50 % had never accessed foot care support. Fifty percent of all respondents reported falls. In comparison to non-fallers, a greater proportion of fallers reported foot problems (57 %), with greater proportions reporting problems impacting on balance and influencing choice of footwear (p < 0.01) in comparison to non-fallers in each case. Forty-seven percent of fallers with foot problems had not accessed foot care support. CONCLUSIONS: Many people with stroke and Parkinson's wear slippers indoors. A high percentage of these individuals reported both foot problems and falls impacting on footwear habits and choice of footwear; however many did not receive foot care support. These findings highlight that further exploration of footwear and foot problems in these populations is warranted to provide evidence based advice on safe and appropriate footwear to support rehabilitation and fall prevention.

Could In-Home Sensors Surpass Human Observation of People with Parkinson's at High Risk of Falling? An Ethnographic Study.

Self-report underpins our understanding of falls among people with Parkinson's (PwP) as they largely happen unwitnessed at home. In this qualitative study, we used an ethnographic approach to investigate which in-home sensors, in which locations, could gather useful data about fall risk. Over six weeks, we observed five independently mobile PwP at high risk of falling, at home. We made field notes about falls (prior events and concerns) and recorded movement with video, Kinect, and wearable sensors. The three women and two men (aged 71 to 79 years) having moderate or severe Parkinson's were dependent on others and highly sedentary. We most commonly noted balance protection, loss, and restoration during chair transfers, walks across open spaces and through gaps, turns, steps up and down, and tasks in standing (all evident walking between chair and stairs, e.g.). Our unobtrusive sensors were acceptable to participants: they could detect instability during everyday activity at home and potentially guide intervention. Monitoring the route between chair and stairs is likely to give information without invading the privacy of people at high risk of falling, with very limited mobility, who spend most of the day in their sitting rooms.

Physical inactivity post-stroke: a 3-year longitudinal study.

PURPOSE: To explore change in activity levels post-stroke. METHODS: We measured activity levels using the activPAL™ in hospital and at 1, 2 and 3 years' post-stroke onset. RESULTS: Of the 74 participants (mean age 76 (SD 11), 39 men), 61 were assessed in hospital: 94% of time was spent in sitting/lying, 4% standing and 2% walking. Activity levels improved over time (complete cases n = 15); time spent sitting/lying decreased (p = 0.001); time spent standing, walking and number of steps increased (p = 0.001, p = 0.028 and p = 0.03, respectively). At year 3, 18% of time was spent in standing and 9% walking. Time spent upright correlated significantly with Barthel (r = 0.69 on admission, r = 0.68 on discharge, both p < 0.01) and functional ambulation category scores (r = 0.55 on admission, 0.63 on discharge, both p < 0.05); correlations remained significant at all assessment points. Depression (in hospital), left hemisphere infarction (Years 1-2), visual neglect (Year 2), poor mobility and balance (Years 1-3) correlated with poorer activity levels. CONCLUSION: People with stroke were inactive for the majority of time. Time spent upright improved significantly by 1 year post-stroke; improvements slowed down thereafter. Poor activity levels correlated with physical and psychological measures. Larger studies are indicated to identify predictors of activity levels. Implications for Rehabilitation Activity levels (measured using activPAL™ activity monitor), increased significantly by 1 year post-stroke but improvements slowed down at 2 and 3 years. People with stroke were inactive for the majority of their day in hospital and in the community. Poor activity levels correlated with physical and psychological measures. Larger studies are indicated to identify the most important predictors of activity levels.

Postural alignment is altered in people with chronic stroke and related to motor and functional performance.

BACKGROUND AND PURPOSE: Trunk control is impaired after stroke but little is known about how changes in posture relate to other deficits. We examined spinal postural alignment in people with chronic stroke and explored the relationship between postural alignment and clinical measures. METHODS: Twenty-one subjects with stroke and 22 age-matched healthy comparison subjects participated in this observational, cross-sectional study. Data collection included measurements of thoracic, lumbar, sacral, and overall postural alignment in the sagittal plane in both sitting and standing. Measurements were made in different postures, including: upright, flexed forward, and extended backward. Clinical outcome measures included the Trunk Impairment Scale and its subscales, Fugl-Meyer Scale, Berg Balance Scale, Barthel Index, and Stroke Impact Scale. RESULTS: Significant deviations in postural alignment for participants with stroke compared with comparison subjects were apparent in sacral alignment (P < 0.02) and overall postural alignment (P < 0.01) in standing. These measurements were also significantly correlated with clinical outcome measures poststroke. Participants with stroke who had a more forward leaning posture when upright scored worse on the coordination subscale of the Trunk Impairment Scale (r = -0.61) and Berg Balance Scale (r = -0.64). Participants with greater anterior pelvic tilt when flexed forward and more overall inclination when flexed forward and extended backward scored better on the Trunk Impairment Scale, its subscales, and Berg Balance Scale (r = -0.6-0.7). DISCUSSION AND CONCLUSIONS: People with chronic stroke have altered postural alignment in standing compared with subjects without neurological deficits. Investigating interventions focusing on increasing anterior and posterior pelvic tilt seem warranted.Video Abstract available. See video (Supplemental Digital Content 1, http://links.lww.com/JNPT/A76) for more insights from the authors.

Sequence of onset latency of body segments when turning on-the-spot in people with stroke.

BACKGROUND: Turning around is a common activity of daily living. The location of a target may be known or unknown while angle and direction may vary prior to turning. A stroke can compromise coordination of body movement during turning. OBJECTIVES: To investigate the effect of target predictability, turn angle and turn direction on the kinematic sequence of rotation of body segments in people with stroke and healthy controls when turning on-the-spot. METHODS: Ten people with stroke (age: 66±10 years; 8 males) and 10 age-matched controls (age: 65±8 years; 6 males) were asked to either turn to a specific light (predictable condition) or locate and turn to a random light (unpredictable condition) placed at 45°, 90° or 135° to the right or left when a light in front extinguished. RESULTS: People with stroke initiated movement of the segments significantly later than the controls (p=0.014). The sequence of onset of rotation of the segments was not different between both groups. Target predictability affected the sequence of the segments; the eyes, head and shoulder started moving simultaneously when turning to unpredictable targets while the head and shoulder started moving before the eyes when turning to predictable targets. The sequence was also different across the three turn angles for each predictability condition. However, the sequence remained the same when turning to both sides in each group. CONCLUSION: Similarities between the groups may be because the time since the stroke was long and therefore some recovery of function may have occurred. Slowness of movement in people with stroke may predispose them to falls.

Psychometric properties of 3 functional mobility tests for people with Parkinson disease.

BACKGROUND: Standardized outcome measures with high clinical utility are of paramount importance for clinical practice. OBJECTIVE: The purpose of this study was to examine interrater and intrarater reliability, construct validity, discriminant ability, and smallest detectable differences of the sit-to-stand test (STS), Timed "Up & Go" Test (TUG), and bed mobility test for people with Parkinson disease (PD). DESIGN: A cross-sectional, psychometric evaluation study was conducted. METHODS: A group of individuals with PD (PD group) and a group of individuals who were healthy (control group) were recruited through local PD groups and assessed in a movement laboratory in their "on" phase. Measurements of time to perform one STS, TUG, and bed mobility test were collected based on video recordings of that single performance. RESULTS: Thirty-eight individuals with PD (Hoehn and Yahr stages I-IV) and 19 age-matched control participants were recruited. Intraclass correlation coefficients for interrater and intrarater reliability for the PD group ranged from .95 to .99. Bland-Altman plots showed mean differences close to zero and narrow confidence intervals. Construct validity was established by means of moderate to good Spearman rho correlation coefficients with part III of the Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr stage (range=.51-.63). Timings of all tests discriminated participants in the PD group from those in the control group and participants in the PD group in Hoehn and Yahr stages I and II from those in Hoehn and Yahr stages III and IV but did not discriminate "nonfallers" or those with single falls from repeat "fallers" or "nonfreezers" from "freezers." Applicable smallest detectable differences were established. LIMITATIONS: The results are not generalizable to people in the late stage of PD (Hoehn and Yahr stage IV: n=3). CONCLUSIONS: Timings of video recordings of 3 functional mobility tests with high clinical utility showed good psychometric properties for community-dwelling, ambulatory people with PD.

Functional electrical stimulation with exercises for standing balance and weight transfer in acute stroke patients: a feasibility randomized controlled trial.

OBJECTIVES: To test parameters needed for the design of a larger trial including the following: 1) identifying eligible participants, recruitment, and retention rates; 2) the feasibility and acceptability of delivering functional electrical stimulation (FES) to the gluteus maximus and quadriceps femoris for acute stroke patients in a hospital rehabilitation setting; 3) the outcome measures; 4) obtaining initial estimates of effect size; and 5) clarifying the relevant control group. MATERIALS AND METHODS: Twenty-one people with acute stroke-mean age = 68 (min to max: 33-87) years; weeks postonset = 4.6 (min to max: 1-14)-were randomized to three groups to receive two weeks of balance training with FES, balance training alone, or usual care. Symmetry in normal standing, weight transfer onto the affected limb, balance, mobility, and speed of walking were assessed before, shortly after the end of training, and two weeks later by a blinded assessor. RESULTS: 1) FES was successfully delivered but not with the planned eight sessions; 2) no trends in favor of FES were found; and 3) 4% of those screened took part but approaching 20% might be recruited in the future, no single outcome measure was suitable for all participants, and more routine physiotherapy was delivered to the control group. CONCLUSIONS: FES is feasible in this patient group but further feasibility and definitive trials are required.

Investigating head and trunk rotation in sitting: a pilot study comparing people after stroke and healthy controls.

BACKGROUND AND PURPOSE: Healthy individuals have a top-down coordination pattern when turning while walking; they first rotate the head, then the shoulders, the pelvis and, finally, the feet. The aim of this study was to compare spatial and temporal characteristics of head and trunk rotation in sitting between people early after stroke and healthy participants, and investigate change over time. METHODS: This was a pilot, quantitative, longitudinal study. We recruited participants from stroke wards and local groups. People with stroke were assessed at 3, 6 and 12 weeks after stroke. Healthy participants were examined with the same weekly intervals. Participants were in a seated position and were asked verbally to rotate their head and look at a visual signal placed at 90° to the left and to the right of the subject. CODAmotion (Charnwood Dynamics Ltd, Rothley, UK) was used for 3-D motion recording and analysis. RESULTS: Healthy participants (two women and four men; mean age 66 years) showed significant rotation of the head before rotation of the shoulders at all three time points; people with stroke (one woman and five men; mean age 71 years) did not show this top-down pattern of movement. There was no significant difference between start times of head and shoulder rotation at 3 (p = 0.167), 6 (p = 0.084) and 12 weeks after stroke (p = 0.062). Conclusions. The results of our pilot study warrant further investigation into the recovery and pattern of axial coordination after stroke. Future studies could provide insight into the mechanisms behind impaired postural control in people after stroke.

Kinematic analysis of head, trunk, and pelvis movement when people early after stroke reach sideways.

BACKGROUND: Sideways reaching with the unaffected arm while seated is a component of everyday activities and can be a challenging task early after stroke. Kinematic analysis of a lateral reach task may provide potential rehabilitation strategies. OBJECTIVE: The authors examined the difference between people with stroke and healthy controls in the movement sequence of head, trunk, and pelvis, as well as the difference in angle at maximum reach and peak velocity for each body segment during reach and return. METHODS: Twenty-four people within 12 weeks of a stroke and 20 healthy subjects performed a standardized lateral reach. Using CODAmotion, movement sequence was determined and angles and peak velocities were calculated. RESULTS: When reaching, people with stroke moved their pelvis first, followed by the trunk and head, whereas healthy controls started with their head and then moved their trunk and pelvis. Patients achieved significantly smaller angles at maximum reach compared with healthy subjects for all body segments and lower peak velocities during the reach (for head, trunk, and pelvis) and the return (for head and trunk). CONCLUSIONS: Lateral reaching to the unaffected side early after stroke revealed a different pattern than normal and patients reached less far and moved at a slower speed. Specific training strategies to improve reaching are needed.