The effects of combined transcranial brain stimulation and a 4-week visuomotor stepping training on voluntary step initiation in persons with chronic stroke-a pilot study.

Purpose: Evidence suggests that transcranial direct current stimulation (tDCS) can enhance motor performance and learning of hand tasks in persons with chronic stroke (PCS). However, the effects of tDCS on the locomotor tasks in PCS are unclear. This pilot study aimed to: (1) determine aggregate effects of anodal tDCS combined with step training on improvements of the neural and biomechanical attributes of stepping initiation in a small cohort of persons with chronic stroke (PCS) over a 4-week training program; and (2) assess the feasibility and efficacy of this novel approach for improving voluntary stepping initiation in PCS. Methods: A total of 10 PCS were randomly assigned to one of two training groups, consisting of either 12 sessions of VST paired with a-tDCS (n = 6) or sham tDCS (s-tDCS, n = 4) over 4 weeks, with step initiation (SI) tests at pre-training, post-training, 1-week and 1-month follow-ups. Primary outcomes were: baseline vertical ground reaction force (B-vGRF), response time (RT) to initiate anticipatory postural adjustment (APA), and the retention of B-VGRF and RT. Results: a-tDCS paired with a 4-week VST program results in a significant increase in paretic weight loading at 1-week follow up. Furthermore, a-tDCS in combination with VST led to significantly greater retention of paretic BWB compared with the sham group at 1 week post-training. Clinical implications: The preliminary findings suggest a 4-week VST results in improved paretic limb weight bearing (WB) during SI in PCS. Furthermore, VST combined with a-tDCS may lead to better retention of gait improvements (NCT04437251) (https://classic.clinicaltrials.gov/ct2/show/NCT04437251).

A Phase I Randomized Clinical Trial of Evidence-Based, Pragmatic Interventions to Improve Functional Recovery After Hospitalization in Geriatric Patients.

BACKGROUND: Physical function declines during hospitalization in geriatric patients, increasing the risk of loss of independence. There is a need for evidence-based, pragmatic interventions to improve functional recovery of older adults following acute hospitalization. Here, we report the results of a Phase I randomized clinical trial designed to determine safety and effect size of protein supplementation, exercise, and testosterone interventions on 30-day post-discharge functional recovery and readmissions in geriatric patients. METHODS: A total of 100 patients admitted to the University of Texas Medical Branch hospital for an acute medical illness were randomized to one of five intervention groups: isocaloric placebo, whey protein supplement, in-home rehabilitation + placebo, in-home rehabilitation + whey protein, or testosterone. Primary outcome measure was the change from baseline in short physical performance battery score at 1 and 4 weeks post-discharge. Secondary outcomes were changes in body composition, activities of daily living, and 30-day readmissions. Comparisons were made across study groups and between placebo and all active intervention groups. RESULTS: Four weeks post-discharge, the short physical performance battery total score and balance score increased more in active intervention groups than placebo group (p < .05). There were no significant differences in change in body composition or activities of daily living across groups or between active intervention groups and placebo group. Readmission rates were highest in placebo (28%), followed by rehabilitation + placebo (15%), whey protein (12%), rehabilitation + whey protein (11%), and testosterone (5%). There was a trend for lower readmission rates in all active intervention groups (11%) versus placebo group (28%). CONCLUSIONS: Findings from this Phase I clinical trial suggest that pragmatic, evidence-based interventions may accelerate recovery from acute hospitalization in geriatric patients. These data provide essential information to design larger randomized controlled trials to test the effectiveness of these interventions.

Mobility activity and its value as a prognostic indicator of survival in hospitalized older adults.

OBJECTIVES: To objectively assess total steps and minutes active in the first and last 24 hours of hospitalization and to examine associations with survival after discharge in hospitalized older adults. DESIGN: A prospective study. SETTING: A 20-bed Acute Care for Elders (ACE) hospital unit. PARTICIPANTS: Two hundred twenty-four older adults admitted to an ACE hospital unit. MEASUREMENTS: An activity monitor was used to collect information on total steps and minutes of activity in the first and last 24 hours of hospitalization. The main outcome was 2-year survival from hospital discharge date. RESULTS: Participants were active for approximately 80 minutes in the first 24 hours of hospitalization. Participants aged 65-84 were active approximately 28 minutes more in the last 24 hours of hospitalization, but activity levels were essentially unchanged for those aged 85 and older. The median step count for participants was low, with a median of 478 steps in the first 24 hours of hospitalization and 846 in the last 24 hours. Multivariate survival models showed that, in the first and last 24 hours of hospitalization, each 100-step increase was associated with a 2% (hazard ratio (HR) = 0.98, 95% confidence interval (CI) = 0.96-1.00) and 3% (HR = 0.97, 95% CI = 0.94-0.99) lower risk of death over 2 years, respectively. A decline in steps from first to last 24 hours of hospitalization was associated with a more than four times greater risk of death (HR = 4.21, 95% CI = 1.65-10.77) 2 years after discharge. CONCLUSION: Accelerometers could provide meaningful information about walking activity. The ability to apply objective information about the individual's functional status to improve the delivery of health care and health outcomes is important.

Relationship between test methodology and mean velocity in timed walk tests: a review.

OBJECTIVE: To assess the degree to which test methodology affects outcomes in clinical evaluations of walking speed. DATA SOURCES: Medline database and reference lists from relevant articles. STUDY SELECTION: We conducted electronic searches by using various combinations of terms related to clinical evaluations of walking speed. Resultant abstracts were then reviewed, and the methods and results section of promising full-text articles were searched for detailed descriptions of walk-test methodologies and results. Ultimately, articles were limited to the most common participant groups, older adults (aged) and individuals with neurologic conditions (neuro). The final sample included 46 studies. DATA EXTRACTION: Three aspects of test methodology (pace, starting protocol, distance timed) were extracted for use as independent variables. Group mean age was extracted for use as a covariate. Group mean velocity was extracted for use as the dependent variable. Data were extracted by a single investigator. DATA SYNTHESIS: Usual and/or comfortable pace was reported nearly twice as often as fast pace in both groups. Static-start protocols were more frequently used in aged studies, whereas dynamic (ie, rolling) starts were more common in neuro studies. Distances of 6 and 10m were most common in aged and neuro studies, respectively. Multivariate analyses (analysis of covariance) showed that only pace was significantly related to the mean velocity in both groups (aged: pace, P<.01; starting protocol, P=.21; distance, P=.05; neuro: pace, P=.01; starting protocol, P=.63; distance, P=.49). However, methodology-related differences in the distribution (95% confidence intervals) of performance scores across certain clinical standards were noted within all 3 methodology variables. CONCLUSIONS: Clinical assessments of walking velocity are not conducted uniformly. Common methodologic factors may influence the clinical interpretation of walk performances. Universal walk-test methodology is warranted to improve intergroup comparisons and the development of useful clinical criteria and consensus norms.

Assessing walking speed in clinical research: a systematic review.

OBJECTIVE: To provide a systematic review and describe how assessments of walking speed are reported in the health care literature. METHODS: MEDLINE electronic database and bibliographies of select articles were searched for terms describing walking speed and distances walked. The search was limited to English language journals from 1996 to 2006. The initial title search yielded 793 articles. A review of the abstracts reduced the number to 154 articles. Of these, 108 provided sufficient information for inclusion in the current review. RESULTS: Of the 108 studies included in the review 61 were descriptive, 39 intervention and 8 randomized controlled trials. Neurological (n=55) and geriatric (n=27) were the two most frequent participant groups in the studies reviewed. Instruction to walk at a usual or normal speed was reported in 55 of the studies, while 31 studies did not describe speed instructions. A static (standing) start was slightly more common than a dynamic (rolling) start (30 vs 26 studies); however, half of the studies did not describe the starting protocol. Walking 10, 6 and 4 m was the most common distances used, and reported in 37, 20 and 11 studies respectively. Only four studies included information on whether verbal encouragement was given during the walking task. CONCLUSIONS: Tests of walking speed have been used in a wide range of populations. However, methodologies and descriptions of walking tests vary widely from study to study, which makes comparison difficult. There is a need to find consensus for a standardized walking test methodology.