Utilizing three dimensional clinical gait analysis to optimize mobility outcomes in incomplete spinal cord damage.

BACKGROUND: Three-dimensional gait analysis (3DGA) has not previously been considered by consensus panels of spinal cord experts for use in studies of patients with spinal cord damage (SCD), yet it is frequently used in other neurological populations, such as stroke and cerebral palsy. RESEARCH QUESTION: How does 3DGA impairment based reporting guide individualised clinical decision-making in people with incomplete SCD? METHODS: Retrospective open cohort case series recruited 48 adults with incomplete SCD (traumatic or non-traumatic spinal cord dysfunction) referred to the Clinical Gait Analysis Service (CGAS), Melbourne, Australia. Three-dimensional gait data were used to identify gait impairments by the multidisciplinary clinical team. Gait patterns were classified using the plantarflexor-knee extension couple index and the Gait Profile Score (GPS). The reason for referral and the recommendations made post-3DGA were collated in decision trees to extrapolate the potential value of 3DGA in decision making for targeted intervention in this population. RESULTS: Participants with SCD generally walked at a reduced gait speed. When grouped by neurological level, the tetraplegia group had a significantly lower GPS, but no specific gait patterns emerged. Participants were primarily referred to the CGAS to direct clinical intervention decisions. The most frequent recommendation following 3DGA was the prescription of an ankle foot orthosis and in some cases, the recommendation was incongruent with the referrer's proposed intervention. SIGNIFICANCE: 3DGA can provide specific guidance in management plans for gait of patients with incomplete SCD and may help to avoid inappropriate or unnecessary interventions. This sample of patients referred to the CGAS demonstrates its clinical utility in guiding clinicians in their decision making to target individualised intervention.

Full length foot orthoses have an immediate treatment effect and modify gait of children with idiopathic toe walking.

BACKGROUND: There remains a substantial lack of evidence to support the use of foot orthoses as a conservative treatment option for idiopathic toe walking (ITW). Encouraging heel contact during gait is one of the primary goals of most interventions in paediatric ITW. RESEARCH QUESTION: Does the combined treatment of high-top boots and orthoses increase the number of heel contacts during gait and change spatio-temporal gait parameters? METHODS: This within subject designed randomised controlled trial recruited fifteen children diagnosed with ITW (n = 10 males). They were fitted with bilateral custom made rigid contoured carbon fibre foot orthoses placed inside high-top boots. To analyze the effect of this treatment, heel contacts and spatio-temporal parameters measured by an 8.3 m Gaitrite® mat were compared to barefoot walking and shod walking. RESULTS: An immediate increase in heel contact (p = 0.021) was observed in the combined treatment only. Gait changes included a large increase in stride time in the combined treatment condition compared to barefoot walking (p = 0.006). This was associated with a decrease in the percentage of swing phase in the gait cycle (p < 0.010), an increase in stance phase (p < 0.010) and an increase in double support time (p < 0.001). SIGNIFICANCE: These results suggest the hardness and thickness of the shoe and stiffness of the orthosis midsole may lead to improved local dynamic stability and foot position awareness with increased sensory feedback provided through the entire length of the foot. Further research is indicated to validate this treatment option on long term outcomes in this population group.

Cost of Living with Parkinson's Disease over 12 Months in Australia: A Prospective Cohort Study.

Background. Parkinson disease (PD) is a costly chronic condition in terms of managing both motor and nonmotor symptoms. The burden of disease is high for individuals, caregivers, and the health system. The aim of this study is to estimate the annual cost of PD from the household, health system, and societal perspectives. Methods. A prospective cohort study of newly referred people with PD to a specialist PD clinic in Melbourne, Australia. Participants completed baseline and monthly health resource use questionnaires and Medicare data were collected over 12 months. Results. 87 patients completed the 12-month follow-up assessments. The mean annual cost per person to the health care system was $32,556 AUD. The burden to society was an additional $45,000 per annum per person with PD. The largest component of health system costs were for hospitalisation (69% of total costs). The costs for people with moderate to severe disease were almost 4 times those with mild PD ($63,569 versus $17,537 p < 0.001). Conclusion. PD is associated with significant costs to individuals and to society. Costs escalated with disease severity suggesting that the burden to society is likely to grow with the increasing disease prevalence that is associated with population ageing.

Cathodal Transcranial Direct Current Stimulation (tDCS) to the Right Cerebellar Hemisphere Affects Motor Adaptation During Gait.

The cerebellum appears to play a key role in the development of internal rules that allow fast, predictive adjustments to novel stimuli. This is crucial for adaptive motor processes, such as those involved in walking, where cerebellar dysfunction has been found to increase variability in gait parameters. Motor adaptation is a process that results in a progressive reduction in errors as movements are adjusted to meet demands, and within the cerebellum, this seems to be localised primarily within the right hemisphere. To examine the role of the right cerebellar hemisphere in adaptive gait, cathodal transcranial direct current stimulation (tDCS) was administered to the right cerebellar hemisphere of 14 healthy adults in a randomised, double-blind, crossover study. Adaptation to a series of distinct spatial and temporal templates was assessed across tDCS condition via a pressure-sensitive gait mat (ProtoKinetics Zeno walkway), on which participants walked with an induced 'limp' at a non-preferred pace. Variability was assessed across key spatial-temporal gait parameters. It was hypothesised that cathodal tDCS to the right cerebellar hemisphere would disrupt adaptation to the templates, reflected in a failure to reduce variability following stimulation. In partial support, adaptation was disrupted following tDCS on one of the four spatial-temporal templates used. However, there was no evidence for general effects on either the spatial or temporal domain. This suggests, under specific conditions, a coupling of spatial and temporal processing in the right cerebellar hemisphere and highlights the potential importance of task complexity in cerebellar function.

Whole-Body Vibration Results in Short-Term Improvement in the Gait of Children With Idiopathic Toe Walking.

This study aimed to determine the impact of multiple doses of whole-body vibration on heel strike, spatial and temporal gait parameters, and ankle range of motion of children with idiopathic toe walking. Whole-body vibration was applied for 5 sets of 1 minute vibration/1 minute rest. Gait measures were collected pre intervention, 1, 5, 10, and 20 minutes postintervention with the GaitRite(®) electronic walkway. Ankle range of motion was measured preintervention, immediately postintervention, and 20 minutes postintervention. The mean (SD) age of the 15 children (n = 10 males) was 5.93 (1.83) years. An immediate increase in heel contact (P = .041) and ankle range of motion (P = .001 and P = .016) was observed. These changes were unsustained 20 minutes postvibration (P > .05). The gait improvement from whole-body vibration could potentially be due to a rapid increase in ankle range of motion or a neuromodulation response.

Effect of footwear on minimum foot clearance, heel slippage and spatiotemporal measures of gait in older women.

Footwear has been implicated as a factor in falls, which is a major issue affecting the health of older adults. This study investigated the effect of footwear with dorsal fixation, slippers and bare feet on minimum foot clearance, heel slippage and spatiotemporal variables of gait in community dwelling older women. Thirty women participated (mean age (SD) 69.1 (5.1) years) in a gait assessment using the GaitRITE and Vicon 612 motion analysis system. Conditions included footwear with dorsal fixation, slippers or bare feet. Footwear with dorsal fixation resulted in improved minimum foot clearance compared to the slippers and bare feet conditions and less heel slippage than slippers and an increase in double support. These features lend weight to the argument that older women should be supported to make footwear choices with optimal fitting features including dorsal fixation. Recommendations of particular styles and features of footwear may assist during falls prevention education to reduce the incidence of foot trips and falls.

A Randomized Controlled Trial to Reduce Falls in People With Parkinson's Disease.

BACKGROUND: Falls are common and disabling in people with Parkinson's disease (PD). There is a need to quantify the effects of movement rehabilitation on falls in PD. OBJECTIVE: To evaluate 2 physical therapy interventions in reducing falls in PD. METHODS: We randomized 210 people with PD to 3 groups: progressive resistance strength training coupled with falls prevention education, movement strategy training combined with falls prevention education, and life-skills information (control). All received 8 weeks of out-patient therapy once per week and a structured home program. The primary end point was the falls rate, recorded prospectively over a 12 month period, starting from the completion of the intervention. Secondary outcomes were walking speed, disability, and quality of life. RESULTS: A total of 1547 falls were reported for the trial. The falls rate was higher in the control group compared with the groups that received strength training or strategy training. There were 193 falls for the progressive resistance strength training group, 441 for the movement strategy group and 913 for the control group. The strength training group had 84.9% fewer falls than controls (incidence rate ratio [IRR] = 0.151, 95% CI 0.071-0.322, P < .001). The movement strategy training group had 61.5% fewer falls than controls (IRR = 0.385, 95% CI 0.184-0.808, P = .012). Disability scores improved in the intervention groups following therapy while deteriorating in the control group. CONCLUSIONS: Rehabilitation combining falls prevention education with strength training or movement strategy training reduces the rate of falls in people with mild to moderately severe PD and is feasible.

Obstacle crossing in Parkinson's disease: mediolateral sway of the centre of mass during level-ground walking and obstacle crossing.

BACKGROUND: Falls are common in idiopathic Parkinson's disease (PD) and frequently occur when walking and crossing obstacles. OBJECTIVE: To determine whether people with mild to moderately severe PD have abnormal centre of mass (CoM) motion in response to the perturbations of level-ground walking and obstacle crossing. METHOD: Mediolateral excursion and velocity of the CoM were measured using three-dimensional motion analysis and force platforms in 20 people with mild to moderately severe PD at the peak dose of their PD medication, and 20 age and sex matched healthy control participants. RESULTS: People with PD had greater sideways sway than healthy older adults when walking, particularly when walking over obstacles. People with PD also maintained their CoM more medial to their stance foot throughout the swing phase of gait compared to controls. The severity of motor symptoms in people with PD, measured using the UPDRS-III, was associated with faster sideways CoM motion but not increased CoM excursions. CONCLUSIONS: Environmental hazards, such as ground-based obstacles, may accentuate postural instability in people with PD. Increased mediolateral sway might be due to impaired postural responses or kinematic compensations to increase foot clearance. Fall prevention programs could benefit from inclusion of components educating people with PD about the risks associated with obstacle crossing when walking.

Determinants of health-related quality of life in people with Parkinson's disease: a path analysis.

PURPOSE: To identify the demographic factors, impairments and activity limitations that contribute to health-related quality of life (HRQOL) in people with idiopathic Parkinson's disease (PD). METHOD: Two hundred and ten individuals with idiopathic PD who participated in the baseline assessment of a randomized clinical trial were included. The Parkinson's Disease Questionnaire-39 summary index was used to quantify HRQOL. In order to provide greater clarity regarding the determinants of HRQOL, path analysis was used to explore the relationships between the various predictors in relation to the functioning and disability framework of the International Classification of Functioning model. RESULTS: The two models of HRQOL that were examined in this study had a reasonable fit with the data. Activity limitations were found to be the strongest predictor of HRQOL. Limitations in performing self-care activities contributed the most to HRQOL in Model 1 (ß = 0.38; p < 0.05), while limitations in functional mobility had the largest contribution in Model 2 (ß = -0.31; p < 0.0005). Self-reported history of falls was also found to have a significant and direct relationship with HRQOL in both models (Model 1 ß = -0.11; p < 0.05; Model 2 ß = -0.21; p < 0.05). CONCLUSIONS: Health-related quality of life in PD is associated with self-care limitations, mobility limitations, self-reported history of falls and disease duration. Understanding how these factors are inter-related may assist clinicians focus their assessments and develop strategies that aim to minimize the negative functional and social sequelae of this debilitating disease.

Health-related quality of life and strain in caregivers of Australians with Parkinson's disease: an observational study.

BACKGROUND: The relationship between health-related quality of life (HRQoL) in people with Parkinson's disease and their caregivers is little understood and any effects on caregiver strain remain unclear. This paper examines these relationships in an Australian sample. METHODS: Using the generic EuroQol (EQ-5D) and disease-specific Parkinson's Disease Questionnaire-39 Item (PDQ-39), HRQoL was evaluated in a sample of 97 people with PD and their caregivers. Caregiver strain was assessed using the Modified Caregiver Strain Index. Associations were evaluated between: (i) caregiver and care-recipient HRQoL; (ii) caregiver HRQoL and caregiver strain, and; (iii) between caregiver strain and care-recipient HRQoL. RESULTS: No statistically significant relationships were found between caregiver and care-recipient HRQoL, or between caregiver HRQoL and caregiver strain. Although this Australian sample of caregivers experienced relatively good HRQoL and moderately low strain, a significant correlation was found between HRQoL of people with PD and caregiver strain (rho 0.43, p < .001). CONCLUSION: Poor HRQoL in people with PD is associated with higher strain in caregivers. Therapy interventions may target problems reported as most troublesome by people with PD, with potential to reduce strain on the caregiver.

Feasibility, safety, and compliance in a randomized controlled trial of physical therapy for Parkinson's disease.

Both efficacy and clinical feasibility deserve consideration in translation of research outcomes. This study evaluated the feasibility of rehabilitation programs within the context of a large randomized controlled trial of physical therapy. Ambulant participants with Parkinson's disease (PD) (n = 210) were randomized into three groups: (1) progressive strength training (PST); (2) movement strategy training (MST); or (3) control ("life skills"). PST and MST included fall prevention education. Feasibility was evaluated in terms of safety, retention, adherence, and compliance measures. Time to first fall during the intervention phase did not differ across groups, and adverse effects were minimal. Retention was high; only eight participants withdrew during or after the intervention phase. Strong adherence (attendance >80%) did not differ between groups (P = .435). Compliance in the therapy groups was high. All three programs proved feasible, suggesting they may be safely implemented for people with PD in community-based clinical practice.

Falls and mobility in Parkinson's disease: protocol for a randomised controlled clinical trial.

BACKGROUND: Although physical therapy and falls prevention education are argued to reduce falls and disability in people with idiopathic Parkinson's disease, this has not yet been confirmed with a large scale randomised controlled clinical trial. The study will investigate the effects on falls, mobility and quality of life of (i) movement strategy training combined with falls prevention education, (ii) progressive resistance strength training combined with falls prevention education, (iii) a generic life-skills social program (control group). METHODS/DESIGN: People with idiopathic Parkinson's disease who live at home will be recruited and randomly allocated to one of three groups. Each person shall receive therapy in an out-patient setting in groups of 3-4. Each group shall be scheduled to meet once per week for 2 hours for 8 consecutive weeks. All participants will also have a structured 2 hour home practice program for each week during the 8 week intervention phase. Assessments will occur before therapy, after the 8 week therapy program, and at 3 and 12 months after the intervention. A falls calendar will be kept by each participant for 12 months after outpatient therapy.Consistent with the recommendations of the Prevention of Falls Network Europe group, three falls variables will be used as the primary outcome measures: the number of fallers, the number of multiple fallers and the falls rate. In addition to quantifying falls, we shall measure mobility, activity limitations and quality of life as secondary outcomes. DISCUSSION: This study has the potential to determine whether outpatient movement strategy training combined with falls prevention education or progressive resistance strength training combined with falls prevention education are effective for reducing falls and improving mobility and life quality in people with Parkinson's disease who live at home. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12606000344594.

Obstacle crossing in people with Parkinson's disease: foot clearance and spatiotemporal deficits.

This study investigates the effects of Parkinson's disease (PD) on foot trajectories and spatiotemporal gait adaptations when approaching and stepping over a ground-based obstacle. Twenty people with mild-moderate PD and 20 age and sex matched controls walked 10 steps at their preferred speed along a walkway and stepped over an obstacle (height 10% of leg length × 600 mm × 10 mm). Control participants also performed trials at the same speed and step length as their matched PD participant. People with PD approached and stepped over the obstacle slower and with smaller steps, but had a similar foot clearance. Those with PD were also more likely to step on the obstacle because they did not place their foot close enough to the front of the obstacle before crossing it to accommodate for their reduced step length. During the lead limb crossing step, people with PD increased their step width, whereas controls maintained a narrow step width. These findings indicate that people with PD have difficulty lengthening their step over the obstacle rather than increasing foot height. Increasing step width is a possible compensation strategy used to overcome postural instability during obstacle crossing in those with PD.

Obstacle crossing deficits in older adults: a systematic review.

This systematic review and critical evaluation of the literature investigates whether advanced age compromises obstacle crossing for unconstrained and time-constrained conditions. Eight electronic databases were searched for articles with terms relating to obstacle crossing during walking in their title, abstract or keywords. 15 articles were reviewed from an initial yield of 727 articles. The methodological quality of each article was critiqued and data extracted by two reviewers. Young and older adults were shown to contact obstacles infrequently when adequate time was available to adapt foot placement in relation to the obstacle. When less time was available to adjust the foot trajectory, older adults contacted obstacles more often than younger people. Older adults adopted a slower, more conservative obstacle crossing strategy. They demonstrated greater hip flexion during the swing phase of gait for the lead and trail limbs as well as greater hip flexion, hip adduction and ankle dorsiflexion during the stance phase for the lead and trail limbs. There was also evidence of reduced internal moments across the hip and ankle during key events in the obstacle crossing gait cycle in older adults. Despite using a more conservative obstacle crossing strategy, older adults are at greater risk of contacting obstacles for time-constrained conditions.

Quantifying the profile and progression of impairments, activity, participation, and quality of life in people with Parkinson disease: protocol for a prospective cohort study.

BACKGROUND: Despite the finding that Parkinson disease (PD) occurs in more than one in every 1000 people older than 60 years, there have been few attempts to quantify how deficits in impairments, activity, participation, and quality of life progress in this debilitating condition. It is unclear which tools are most appropriate for measuring change over time in PD. METHODS AND DESIGN: This protocol describes a prospective analysis of changes in impairments, activity, participation, and quality of life over a 12 month period together with an economic analysis of costs associated with PD. One-hundred participants will be included, provided they have idiopathic PD rated I-IV on the modified Hoehn & Yahr (1967) scale and fulfil the inclusion criteria. The study aims to determine which clinical and economic measures best quantify the natural history and progression of PD in a sample of people receiving services from the Victorian Comprehensive Parkinson's Program, Australia. When the data become available, the results will be expressed as baseline scores and changes over 3 months and 12 months for impairment, activity, participation, and quality of life together with a cost analysis. DISCUSSION: This study has the potential to identify baseline characteristics of PD for different Hoehn & Yahr stages, to determine the influence of disease duration on performance, and to calculate the costs associated with idiopathic PD. Valid clinical and economic measures for quantifying the natural history and progression of PD will also be identified. TRIAL REGISTRATION: ACTRN12609000008224.

Cost effectiveness of preventing falls and improving mobility in people with Parkinson disease: protocol for an economic evaluation alongside a clinical trial.

BACKGROUND: Cost of illness studies show that Parkinson disease (PD) is costly for individuals, the healthcare system and society. The costs of PD include both direct and indirect costs associated with falls and related injuries. METHODS: This protocol describes a prospective economic analysis conducted alongside a randomised controlled trial (RCT). It evaluates whether physical therapy is more cost effective than usual care from the perspective of the health care system. Cost effectiveness will be evaluated using a three-way comparison of the cost per fall averted and the cost per quality adjusted life year saved across two physical therapy interventions and a control group. CONCLUSION: This study has the potential to determine whether targetted physical therapy as an adjunct to standard care can be cost effective in reducing falls in people with PD. TRIAL REGISTRATION: No: ACTRN12606000344594.