Article

Assistive devices alter gait patterns in Parkinson disease: Advantages of the four-wheeled walker

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Gait abnormalities are a hallmark of Parkinson's disease (PD) and contribute to fall risk. Therapy and exercise are often encouraged to increase mobility and decrease falls. As disease symptoms progress, assistive devices are often prescribed. There are no guidelines for choosing appropriate ambulatory devices. This unique study systematically examined the impact of a broad range of assistive devices on gait measures during walking in both a straight path and around obstacles in individuals with PD. Quantitative gait measures, including velocity, stride length, percent swing and double support time, and coefficients of variation were assessed in 27 individuals with PD with or without one of six different devices including canes, standard and wheeled walkers (two, four or U-Step). Data were collected using the GAITRite and on a figure-of-eight course. All devices, with the exception of four-wheeled and U-Step walkers significantly decreased gait velocity. The four-wheeled walker resulted in less variability in gait measures and had less impact on spontaneous unassisted gait patterns. The U-Step walker exhibited the highest variability across all parameters followed by the two-wheeled and standard walkers. Higher variability has been correlated with increased falls. Though subjects performed better on a figure-of-eight course using either the four-wheeled or the U-Step walker, the four-wheeled walker resulted in the most consistent improvement in overall gait variables. Laser light use on a U-Step walker did not improve gait measures or safety in figure-of-eight compared to other devices. Of the devices tested, the four-wheeled-walker offered the most consistent advantages for improving mobility and safety.

No full-text available

... Most articles were open-label trials, 20,25-30 with a randomized design in 4/17 (23.52%). 21,23,31,34 Two articles (11.76%) 32,33 obtained a PEDro score of 0, because they were reports of individual cases. The items with lower scores were 2, 3, 4, 5, and 6. ...
... Table 2 in File S2 shows a summary of the main aspects of each article. [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] Sample and PD Characteristics ...
... GAITRite ® was the most frequent assessment for gait disturbances using a portable singlelayer pressure-sensitive walkway that measured temporal and spatial parameters. 21,23,26,27 ...
Full-text available
Article
Background: Gait abnormalities are a hallmark of Parkinson's disease and contribute to falling risk. As disease symptoms progress, assistive devices are often prescribed. However, there are no guidelines for choosing appropriate ambulatory devices for gait impairment. Objective: To review the scientific evidence on assistive devices for gait impairment in Parkinson's disease. Methods: We performed a systematic literature review for articles relating to parkinsonian gait impairment and assistive devices. We assessed the studies' methodological quality and risk of bias using the PEDro scale. Results: Seventeen articles were reviewed. Four articles (23.53%) showed that canes and standard and two-wheeled walkers without visual cues decreased gait speed and stride length, with no significant effects on freezing of gait or falls. Instead, improvements were observed with the use of visual [seven articles (41.18%)] and auditory cues [three articles (17.65%)], including decreased number of freezing episodes and increased stride length. Conclusions: Although assistive devices seem to improve confidence, there is still limited information about the efficacy of assistive devices on gait parameters and functional disability in Parkinson's disease. Further, longitudinal, multicenter, randomized, blinded, and controlled studies using assistive devices in a free-living context are required to provide the best scientific evidence.
... Characteristics of the included studies, gait aid prescription, testing conditions, and outcomes examined are presented in Table 2. Of the eight studies that met the threshold for inclusion, five used a pre and post-intervention design [16][17][18][19][20], one used mixed-methods [21] (case studies and interviews), and two were randomized controlled trials [22,23]. In terms of the participant samples included in the study, two studies compared the effect of gait aid use in older people with Alzheimer's disease and those without Alzheimer's disease, with one examining cane use [16], and the other examined 4-wheeled walker use [17]. ...
... In terms of the participant samples included in the study, two studies compared the effect of gait aid use in older people with Alzheimer's disease and those without Alzheimer's disease, with one examining cane use [16], and the other examined 4-wheeled walker use [17]. Other studies included people with Parkinson's disease [18], older people recently discharged from hospital who had chronic conditions or functional deterioration [23], a mixed sample of older adults posthospital discharge, and community-dwelling people who had multiple fall risk factors and mobility problems amenable to use of a wheeled walker [19], people with chronic stroke [20,22], and older people who were referred to a community-based rehabilitation service to receive an assessment for prescription of a gait aid [21]. In terms of other key participant characteristics, studies included only those people who were cognitively intact, except for the studies including Alzheimer's groups (i.e., Hunter et al. [16,17]) although Kegelmeyer et al. [18] did not specify the cognitive status of their participants with Parkinson's disease. ...
... Other studies included people with Parkinson's disease [18], older people recently discharged from hospital who had chronic conditions or functional deterioration [23], a mixed sample of older adults posthospital discharge, and community-dwelling people who had multiple fall risk factors and mobility problems amenable to use of a wheeled walker [19], people with chronic stroke [20,22], and older people who were referred to a community-based rehabilitation service to receive an assessment for prescription of a gait aid [21]. In terms of other key participant characteristics, studies included only those people who were cognitively intact, except for the studies including Alzheimer's groups (i.e., Hunter et al. [16,17]) although Kegelmeyer et al. [18] did not specify the cognitive status of their participants with Parkinson's disease. ...
Article
Purpose To integrate the evidence of gait aid prescription for improving spatiotemporal gait parameters, balance, safety, adherence to gait aid use, and reducing falls in community-dwelling older people. Methods Seven health databases were searched to June 2021. Experimental studies investigating gait aid prescription (provision and instruction for use) for older people, reporting gait parameters, balance, falls, and safety of or adherence to gait aid use was included. Mean differences with 95% confidence intervals of gait and balance outcomes in participants at the program’s last follow-up were analyzed. The safety of and adherence to gait aid use were described. Results Eight studies were included (N = 555 older people). No meta-analyses could be performed. Five studies used a single gait aid instruction session. Gait aid prescription had inconsistent effects on gait velocity, and no reported benefits in reducing gait variability in older people with mobility problems or fall risks, including Parkinson’s or Alzheimer’s disease. No study investigated gait aid prescription on falls and balance performance. Effects on safety and adherence to gait aid use were unclear. Conclusion Research is needed to investigate the benefits of extensive gait aid training in older people with mobility problems, including those with dementia or high falls risk. • IMPLICATIONS FOR REHABILITATION • There is little evidence currently addressing the benefits of gait aid prescription on gait and associated outcomes in older people with mobility problems or fall risks. • Gait aid prescription yielded inconsistent effects on increasing gait velocity and did not appear to reduce gait variability in older people with mobility problems or fall risks, nor in those with Parkinson’s disease or Alzheimer’s disease. • Clinicians may consider using a more extensive gait aid training approach to optimize learning of safe gait patterns and gait aid use, which may produce better outcomes.
... The most commonly studied spatiotemporal gait parameters (STPs) are stride velocity, stride length, and cadence [6,9,10,11]. Existing studies have associated slower stride velocity (gait speed), short stride length, and decreased cadence with poor balance, higher risk of falling, and increased physical efforts measured by O 2 consumption in elderly people and those with neurological conditions [6,9,10,11]. ...
... The most commonly studied spatiotemporal gait parameters (STPs) are stride velocity, stride length, and cadence [6,9,10,11]. Existing studies have associated slower stride velocity (gait speed), short stride length, and decreased cadence with poor balance, higher risk of falling, and increased physical efforts measured by O 2 consumption in elderly people and those with neurological conditions [6,9,10,11]. It is therefore important to investigate the effects of ADs on an individual's gait parameters. ...
... Most previous studies that investigated the impact of ADs on functional mobility and spatiotemporal parameters used the Timed Up and Go test (TUG) and the GAITRite system. For example, it was reported that the spatiotemporal gait parameters measured by GAITRite when using a four-wheeled walker were the closest to normal pattern in subjects with Parkinson's disease [10,11] and Huntington's disease [12]. Additionally, Schülein et al. [13] showed that spatiotemporal gait parameters improved when walking with a four-wheeled walker compared to free walking in hospitalized geriatric subjects with gait impairments. ...
Full-text available
Article
... Examples of non-pharmacologic interventions that can address OH symptoms, such as physical countermaneuvers and strength training are summarized in Table 4 [24,26,37,77,78,[85][86][87]. Non-pharmacologic interventions that are generally not effective include homebased resistance training and lower body-only compression garments (eg, knee-length compression stockings) [87,88]; in a study of non-pharmacologic interventions, water bolus ingestion, abdominal compression, and physical countermaneuvers were effective in preventing BP drops, while compression stocking did not affect BP drops [89]. ...
... Non-pharmacologic interventions that are generally not effective include homebased resistance training and lower body-only compression garments (eg, knee-length compression stockings) [87,88]; in a study of non-pharmacologic interventions, water bolus ingestion, abdominal compression, and physical countermaneuvers were effective in preventing BP drops, while compression stocking did not affect BP drops [89]. Although outcomes from the use of non-pharmacologic interventions for fall prevention in patients with PD and OH have not been extensively studied, some non-pharmacologic interventions are capable of reducing fall risk in PD [77,85,86]. In a study of elderly patients with PD, use of a 4-wheeled walker or the U-Step rollator (Instep Mobility, Skokie, IL) was associated with fewer episodes of freezing, near-falls, and completed falls compared with use of other assistive devices (eg, cane, standard walking frame, or a walking frame with 2 wheels) or no assistive device at all [86]. ...
... Although outcomes from the use of non-pharmacologic interventions for fall prevention in patients with PD and OH have not been extensively studied, some non-pharmacologic interventions are capable of reducing fall risk in PD [77,85,86]. In a study of elderly patients with PD, use of a 4-wheeled walker or the U-Step rollator (Instep Mobility, Skokie, IL) was associated with fewer episodes of freezing, near-falls, and completed falls compared with use of other assistive devices (eg, cane, standard walking frame, or a walking frame with 2 wheels) or no assistive device at all [86]. In another study, vestibular rehabilitation for 8 weeks significantly improved several measures of balance (eg, Berg Balance Scale, Activities-Specific Balance Confidence Scale scores) and gait (Dynamic Gait Index) of elderly patients with PD [85]. ...
Article
Parkinson disease (PD) is often associated with postural instability and gait dysfunction that can increase the risk for falls and associated consequences, including injuries, increased burden on healthcare resources, and reduced quality of life. Patients with PD have nearly twice the risk for falls and associated bone fractures compared with their general population counterparts of similar age. Although the cause of falls in patients with PD may be multifactorial, an often under-recognized factor is neurogenic orthostatic hypotension (nOH). nOH is a sustained decrease in blood pressure upon standing whose symptomology can include dizziness/lightheadedness, weakness, fatigue, and syncope. nOH is due to dysfunction of the autonomic nervous system compensatory response to standing and is a consequence of the neurodegenerative processes of PD. The symptoms associated with orthostatic hypotension (OH)/nOH can increase the risk of falls, and healthcare professionals may not be aware of the real-world clinical effect of nOH, the need for routine screening, or the value of early diagnosis of nOH when treating elderly patients with PD. nOH is easily missed and, importantly, healthcare providers may not realize that there are effective treatments for nOH symptoms that could help lessen the fall risk resulting from the condition. This review discusses the burden of, and key risk factors for, falls among patients with PD, with a focus on practical approaches for the recognition, assessment, and successful management of OH/nOH. In addition, insights are provided as to how fall patterns can suggest fall etiology, thereby influencing the choice of intervention.
... In four studies older patients with specific diseases, viz. knee osteoarthritis, Alzheimer disease or Parkinson's disease, were analysed [22,23,26,30]. ...
... Nine studies used the GAITRite® measurement system [2,7,21,23,24,[27][28][29]31]. In two studies an inertial sensor (Shimmer 2R) was additionally placed on the foot to collect data [2,28]. ...
... Comparison of gait parameters with and without the support of a rollator Eight studies analysed the influence of the use of a rollator on the spatio-temporal gait parameters. Two studies compared the gait parameters of FUs only [2,21], two studies combined FUs and FTUs to one group [28,29] and five studies analysed FTUs only [2,[23][24][25]27]. All studies investigating FUs revealed an increase in gait velocity, swing time and stride length when using a rollator, while these changes could not be found in FTUs. ...
Full-text available
Article
Background: The aging population increasingly needs assistive technologies, such as rollators, to function and live less dependently. Rollators are designed to decrease the risk of falls by improving the gait mechanics of their users. However, data on the biomechanics of rollator assisted gait of older adults are limited, or mostly derived from experiments with younger adults. Methods and results: This review summarises the data from 18 independent studies on the kinematic and kinetic gait parameters of assisted gait of older persons. All of these studies evaluated spatio-temporal parameters, but not joint angles or moments. Conclusion: Due to the limited research on rollator supported gait in older adults, the number of parameters that could be analysed in this systematic review was restricted. Further research in the analysis of spatio-temporal parameters and a higher standardisation in clinical research will be necessary.
... walking sticks), wheeled walkers (i.e. rollators) as well as manual and powered wheelchairs (117,120). Canes are usually suitable for those with milder disability, wheeled walkers for those with moderate disability and powered devices for those with severe disability (117). In experimental PD studies, wheeled walkers have been associated with improved safety and gait speed, and fewer freezing episodes (120,121). ...
... Canes are usually suitable for those with milder disability, wheeled walkers for those with moderate disability and powered devices for those with severe disability (117). In experimental PD studies, wheeled walkers have been associated with improved safety and gait speed, and fewer freezing episodes (120,121). Cane use has been reported to improve postural recovery from an unpractised slip, characterized by smaller lateral displacement of the body centre of mass in people with PD, compared to matched controls (122). Some MDs are available with a variety of customized features specific to PD, for example a laser-cane that might be helpful for those with start hesitation and freezing (117). ...
... Although MDs are used to compensate for gait and balance problems, several studies have indicated that some MDs may worsen gait characteristics in people with PD. For example, the use of a cane (or a two-wheeled walker) was associated with decreased gait speed (120,121), whereas gait speed was less impaired with a four-wheeled walker (120). Stride length was reduced when using a cane or nonwheeled walker as compared to walking without any devices (124). ...
Full-text available
Thesis
Background: Parkinson's disease (PD) is a chronic progressive neurodegenerative disease that results in functional loss and disability. People with PD have an increased risk of falling, and most of their falls occur while walking. As yet, there is limited knowledge concerning activity avoidance due to perceived risk of falling in people with PD. In order to quantitatively assess perceived walking difficulties, a psychometrically-sound instrument is necessary. Although the generic Walk-12 scale (the Walk-12G) seems promising, only one prior study has investigated its psychometric properties in people with PD. Moreover, little is known about factors that independently contribute to perceived walking difficulties in people with PD. No study has yet investigated the use and perceived needs of mobility devices (MDs) over a period of time in people with PD. Aim: The overarching aim of this PhD thesis was to gain increased knowledge regarding activity avoidance due to perceived risk of falling, perceived walking difficulties, and the use and perceived needs of MDs in people with PD. Methods: The thesis was based on a longitudinal cohort survey of participants with PD with a baseline data collection (n=255), using self-administered and structured questions/questionnaires, observations, and clinical assessments, and an equivalent 3-year follow-up (n=165). Statistical analyses included bivariate analyses (Study I), psychometric evaluation (Study II), multivariate analyses (Study III), and descriptive- and follow-upanalyses (Study IV). Main results: Study I: Activity avoidance due to perceived risk of falling was reported by 30% of the non-fallers whereas the corresponding rate was 57% in recurrent fallers (i.e. ≥2 falls). Twenty-four percent of participants with an early/mild PD stage reported activity avoidance due to the perceived risk of falling which rose to 74% among those in the most severe stages. Moreover, it was reported by 51% of participants with near falls (but no falls). Seventy percent of participants with fear of falling reported that they avoided activities due to the perceived risk of falling. Study II: In the PD sample, the Walk-12G had acceptable missing item responses and floor/ceiling effects, and corrected item-total correlations >0.60. Based on ordinal alpha and Cronbach’s alpha, values for internal consistency were >0.95. External construct validity was satisfactory. Study III: The strongest contributing factor to perceived walking difficulties (assessed with the Walk-12G) was freezing of gait, followed by general self-efficacy, fatigue, PD duration, lower extremity function, orthostatic hypotension, bradykinesia and postural instability. Study IV: Over the 3-year period, MD use increased significantly from 22% to 40% for indoor use, and from 48% to 66% for outdoor use. The perceived need of MDs increased from 5% to 21% in people with PD. Conclusion: Activity avoidance due to perceived risk of falling can be reported even when the person has mild PD. Thefindings imply that this aspect should not only be considered when the person has a history of falls, since a history of near falls appears also to be of importance.This thesis strengthens the recommendation for using the Walk-12G when assessing perceived walking difficulties in people with PD. It appears that freezing of gait and general self-efficacy should be the primary targets when addressing perceived walking difficulties in people with PD. The knowledge gained on the use and perceived needs of MDs over the 3-year period has implications for improving the provision and follow-ups of MDs, as well as for policy making, planning, and health services. However, the findings need to be replicated in other PD-samples as well as in different national contexts.
... From a biomechanical point of view, gait is a highly regular and cyclic movement, which makes it ideal for automated sensor-based detection and subsequent quantitative and qualitative analysis with a high biomechanical resolution. Body-worn inertial measurement units, comprising of the biosensors 3D accelerometer, gyroscope, and magnetometer are able to objectively measure changes of gait patterns in PD Klucken et al., 2013;Kegelmeyer, Parthasarathy, Kostyk, White, & Kloos, 2013;Schlachetzki et al., 2017). A new era in medical engineering is emerging, where objective real-time motion metrics in iPD could be obtained in virtually any environmental scenario by placing lightweight wearable sensors in the patient's clothes, and connecting them to a medical database through mobile devices such as cell phones or tablets (Pasluosta, Gassner, Winkler, Klucken, & Eskofier, 2015;Schlachetzki et al., 2017). ...
... Gait signals were recorded within a (tri-axial) accelerometer range of ±6 g (sensitivity 300 mV/g), a gyroscope range of ±500 degree/s (sensitivity 2 mV/ degree/s), and a sampling rate of 102,4 Hz. Sensor signals were transmitted via Bluetooth ® to a tablet computer and stored for subsequent data analysis (Kegelmeyer et al., 2013). Inertial sensor data were processed with a pattern recognition algorithm for calculating clinically relevant spatiotemporal gait parameters (e.g., stride length, F I G U R E 1 Spatiotemporal gait parameters (Mean ± SD) in patients with atypical Parkinson disorders (APD), patients with Parkinson's disease (iPD)-(matched by age, gender, age of onset, and Hoehn & Yahr disease stage), and healthy controls (matched by age and gender). ...
... However, it should be noticed that three PSP patients used a gait support device, two of them a wheeled walker, the other one crutches. It has been shown that a four-wheeled walker improves gait in iPD patients (Kegelmeyer et al., 2013) and in geriatric patients (Schülein et al., 2017). In our study, these two patients that used a wheeled walker showed the largest strides and highest gait speed within the PSP cohort indicating that the correlation is biased by the wheeled walker gait patterns. ...
Full-text available
Article
Background and Objectives Gait impairment and reduced mobility are typical features of idiopathic Parkinson's disease (iPD) and atypical parkinsonian disorders (APD). Quantitative gait assessment may have value in the diagnostic workup of parkinsonian patients and as endpoint in clinical trials. The study aimed to identify quantitative gait parameter differences in iPD and APD patients using sensor‐based gait analysis and to correlate gait parameters with clinical rating scales. Subjects and Methods Patients with iPD and APD including Parkinson variant multiple system atrophy and progressive supranuclear palsy matched for age, gender, and Hoehn and Yahr (≤3) were recruited at two Movement Disorder Units and assessed using standardized clinical rating scales (MDS‐UPDRS‐3, UMSARS, PSP‐RS). Gait analysis consisted of inertial sensor units laterally attached to shoes, generating as objective targets spatiotemporal gait parameters from 4 × 10 m walk tests. Results Objective sensor‐based gait analysis showed that gait speed and stride length were markedly reduced in APD compared to iPD patients. Moreover, clinical ratings significantly correlated with gait speed and stride length in APD patients. Conclusion Our findings suggest that patients with APD had more severely impaired gait parameters than iPD patients despite similar disease severity. Instrumented gait analysis provides complementary rater independent, quantitative parameters that can be exploited for clinical trials and care.
... powered wheelchairs. 3,6 Canes are usually suitable for those with milder disability, wheeled walkers for those with moderate disability, and motorized devices for those with severe disability. 3 Although MDs are used to better cope with walking difficulties and promote safety, there is research indicating that MD use in people with PD is associated with an increased number of falls 7,8 and more freezing episodes. ...
... 3 Although MDs are used to better cope with walking difficulties and promote safety, there is research indicating that MD use in people with PD is associated with an increased number of falls 7,8 and more freezing episodes. 6,9 Overall in PD research, studies targeting MD use are scarce. One of the few studies targeting such issues, based on a sample of very old community-living people in five European countries, described that persons with self-reported PD had a higher use of MDs (55%) than matched controls (30%), but no statistically significant difference regarding the perceived unmet need of MDs. 10 The actual use as well as the perceived unmet need of MDs most likely reflects the systems of provision and funding. ...
... Internal missing data: n = 0-2 for total sample at baseline, and n = 0-3 for the 3-year follow-up sample. associated with fewer freezing episodes, improved safety and gait speed, 6,9 whereas canes induced more freezing episodes. 6 Although most of our participants used a single MD, several did in fact use multiple MDs. ...
Full-text available
Article
Objectives This study aimed to investigate how the use and perceived unmet need of mobility devices (MD) in people with Parkinson's disease (PD) evolve over a 3‐year period. Methods The study reports baseline assessments (n = 255) and comparisons for participants with complete data at baseline and the 3‐year follow‐up (n = 165). Structured questions addressed the use and perceived unmet need of various MDs indoor and outdoor (eg, canes, wheeled walkers, and manual and powered wheelchairs). McNemar tests were used to investigate differences over time. Results In the total sample at baseline, 30% and 52% of the participants reported using MDs indoors and outdoors, respectively. Among those with complete data also at the 3‐year follow‐up, the proportion of participants using MDs increased significantly (P < .001) from 22% to 40% for indoors and from 48% to 66% for outdoors, with transition of MD toward more assistive potential (ie, wheeled walker and manual wheelchair). Wheeled walkers were the most commonly used MD indoors as well as outdoors on both occasions. Among the users of multiple MDs, the most common combination was cane and wheeled walker on both occasions. The proportion of participants who reported a perceived unmet need of MDs was 5% at baseline, whereas it was 21%, 3 years later. Conclusions The use and perceived unmet need of MDs in people with PD increase over time. There is a need for addressing MDs at clinical follow‐ups of people with PD, with continuous attention in primary health care and municipality contexts.
... Because Kegelmeyer et al. (2013) analyzed only the kinematic factors of gait, additional studies are needed to examine the distribution of foot pressure on the ground during gait because using assistive devices during gait would inevitably cause changes in foot pressure, which is in turn an important predictor of the risk of falling. Furthermore, as PD patients display severe gait deviations, examining coefficients of variation (CVs) during gait in patients using assistive devices could be conducive to identifying predictors of falls. ...
... It is calculated based on the data obtained from the GAITRite system and patients' physical measurements. The CV was computed by dividing the standard deviation by the arithmetic mean (Kegelmeyer et al., 2013). ...
... This is a result of the additional force required for handling a cane or a walker owing to the added weight (Kegelmeyer et al., 2013). In patients not using a gait assistive device, an increase of support time is generally a marker of an elevated risk of falling, as it indicates reduced balance (Chamberlin, Fulwider, Sanders & Medeiros, 2005;Kegelmeyer et al., 2013), however, an increase of support time in patients using assistive devices stabilizes gait motions, thereby preventing falls. ...
Article
Objective: There are no guidelines for choosing appropriate gait assistive devices. The aim of this study was to evaluate gait assistive devices in patients with Parkinsons disease. Method: We evaluated 15 individuals with Parkinsons disease who did or did not use one of two different devices including canes and two-wheeled walkers. Data were collected using the GAITRite system. Results: Participants in the group using canes and two-wheeled walkers had significantly increased double support time and decreased gait velocity, normalized gait velocity, and stride length compared with those who did not. Participants who used a two-wheeled walker had significantly decreased gait velocity, normalized gait velocity, and stride length compared with those who used a cane. Furthermore, participants who used a two-wheeled walker had significantly decreased coefficients of variation for step time, stride length, and swing time compared with those who used a cane. Conclusion: Our results indicated that the two-wheeled walker offered the most consistent advantages for decreasing the risk of falling.
... Studies about rollators revealed that these devices are safe and stable, providing an increase in confidence, as well as an improvement in balance and mobility (Kegelmeyer et al., 2013;Liu, 2009;Vogt et al., 2010). This AD also causes a lower variability in gait and it is easy to use (Kloos et al., 2012;Vogt et al., 2010;Wellmon et al., 2006). ...
... This AD also causes a lower variability in gait and it is easy to use (Kloos et al., 2012;Vogt et al., 2010;Wellmon et al., 2006). On the other hand, there are Volume , Number , p. , several authors indicating that this AD causes changes in posture and, an increased risk of fall (Kegelmeyer et al., 2013;Liu et al., 2009;Vogt et al., 2010). However, on this study forearm supports were added to the device in order to give more stability to the gait, better posture and increased support (Ishikura, 2001;Martins et al., 2013;Youdas et al., 2005). ...
... On the other hand, standard walker (SW) is known as the more stable device, supporting a greater percentage of body weight (Melis et al., 1999). Still, it provides a slow and varied gait, less mobility with higher metabolic cost due to reduced speed and repetitive motion for lifting it while moving forward (Kegelmeyer et al., 2013;Kloos et al., 2012;Melis et al., 1999;Priebe and Kram, 2011;Roomi et al., 1998). Crutches have upper limbs support and enable an easy climbing of the stairs (Van Hook et al., 2003). ...
Full-text available
Article
Introduction Nowadays Knee Osteoarthritis (KOA) affects a large percentage of the elderly, and one solution is to perform a Total Knee Arthroplasty (TKA). In this paper, one intends to study the gait and posture of these patients after the TKA, while walking with three assistive devices (ADs) (crutches, standard walker (SW) and rollator with forearm supports (RFS)). Methods Eleven patients were evaluated in 2 phases: 5 days and 15 days after surgery. This evaluation was conducted with two inertial sensors, one attached to the operated leg ankle, to measure spatiotemporal parameters, and the other at the sacrum, to measure posture and fall risk-related parameters. Multivariate analysis of variance (MANOVA) with repeated measures was performed to detect group differences. Results The MANOVA results show that all spatiotemporal parameters are significantly different (p<0.05) between the two phases of study. So, time has a significant influence on such parameters. In relation to the ADs, one observes that there are statistical significant effects on all spatiotemporal parameters, except for swing duration and step length (p>0.05). The interaction between time and ADs only affects significantly the velocity (p<0.05). In terms of fall risk parameters, time only significantly affects the antero-posterior direction (p<0.05) and ADs affects significantly root mean square in medio-lateral direction (p<0.05). In terms of interaction between time and ADs, there are no statistical significant differences. Conclusion This study concludes that depending on the state of recovery of the patient, different ADs should be prescribed. On the overall, standard walker is good to give stability to the patient and RFS allows the patient to present a gait pattern closer to a natural gait.
... The most common types of walkers based on the design are standard, front-wheeled and four-wheeled (rollator) walker as shown in Figures 1 to 3 [13]. Kegelmeyer et al. in their study examined the impact of assistive devices on gait and found that all the aforementioned augmentative assistive aids with the exception of four-wheeled walkers contribute significantly to reduction in gait [14]. For instance, a standard walker (a four-legged aluminum frame with rubber tips on each leg), though the most stable requires slow and controlled gait pattern and it is associated with the greatest demand for attention. ...
... Also, although front wheeled walkers maintain a more normal gait pattern, they are less stable. Hence, of all the walker types tested, the four-wheeled walkers have the least degenerative impact on the normal gait, they are the most consistent in improving safety and ambulatory abilities of users and the most consistent in improving overall gait variables [14], [15]. In spite of these numerous advantages of a four-wheeled walker or rollator over other types, it possesses some significant demerits which can make its usage cumbersome and unexciting. ...
Full-text available
Conference Paper
Gait disorder is a deviation from the smooth and normal walking pattern. Loss of balance which greatly contributes to fall, a prevalent cause of reduced life expectancy and premature death of aging persons, is closely related to a disordered gait. Augmentative assistive mobility devices such as canes, crutches and walkers, have been employed in the rehabilitation of gait dysfunction and other mobility impairments. The rate of abandonment of these devices due to difficulty and cumbersomeness in their usage has recently directed the focus of researchers in the area of design of robotic walkers. This paper presents a review of the different existing literatures in the area of the dynamic model of wheeled mobile robot, human-robot interface design, and control algorithm formulation for assistive mobility tasks as it relates to holonomic robotic walker design.
... Non-invasive sensors used for this purpose can be classified as either portable or stationary. Portable sensors may be attached to clothing [4,5] or to adequate supports [6][7][8][9][10][11][12]. They have the advantage of not limiting the PD patient's travel space. ...
... In [50], it is established that the frequency of FOG occurs in the bandwidth of 3 to 8 Hz. This range was placed within the detail coefficients of the first level (DC1), excluding from the analysis the coefficients in the frequency range of 3 to 4 Hz because they do not provide relevant information in FOG detection, but it is necessary to consider all the coefficients for the calculation of the total energy and energy levels of the subbands, as included in the Equations (6)- (8). Based on the above considerations, for calculations, processing and analysis, there is a spectrum of frequencies for the presence of FOG from 4 to 8 Hz, whose frequency ranges are contained by detail coefficients from level 1 (DC1) to detail coefficients of level 5 (DC5). ...
Full-text available
Article
A critical symptom of Parkinson’s disease (PD) is the occurrence of Freezing of Gait (FOG), an episodic disorder that causes frequent falls and consequential injuries in PD patients. There are various auditory, visual, tactile, and other types of stimulation interventions that can be used to induce PD patients to escape FOG episodes. In this article, we describe a low cost wearable system for non-invasive gait monitoring and external delivery of superficial vibratory stimulation to the lower extremities triggered by FOG episodes. The intended purpose is to reduce the duration of the FOG episode, thus allowing prompt resumption of gait to prevent major injuries. The system, based on an Android mobile application, uses a tri-axial accelerometer device for gait data acquisition. Gathered data is processed via a discrete wavelet transform-based algorithm that precisely detects FOG episodes in real time. Detection activates external vibratory stimulation of the legs to reduce FOG time. The integration of detection and stimulation in one low cost device is the chief novel contribution of this work. We present analyses of sensitivity, specificity and effectiveness of the proposed system to validate its usefulness.
... People with PD walked with slower gait speed and reduced stride length when using a cane and a wheeled walker compared to walking without any device [27]. However, PD subjects produced natural gait pattern when using a wheeled walker, by not slowing velocity or increasing variability as other devices do [28]. In our present study, we tested whether gait of people with PD would improve when following haptic speed cues from a self-propelled walker, self-navigating walker. ...
... While initial trial shows large variabilities, as the number of trials increases, GCT variability decreases. Our study provides further evidence that PD subjects exhibit a natural gait pattern, when using a wheeled walker without slowing down [28]. The subjects' gait performance under different haptic speed cues also provide insights on immediate gait modification under these speed cues conditions. ...
Full-text available
Article
Gait abnormalities are one of the distinguishing symptoms of patients with Parkinson’s disease (PD) that contribute to fall risk. Our study compares the gait parameters of people with PD when they walk through a predefined course under different haptic speed cue conditions (1) without assistance, (2) pushing a conventional rolling walker, and (3) holding onto a self-navigating motorized walker under different speed cues. Six people with PD were recruited at the New York Institute of Technology College of Osteopathic Medicine to participate in this study. Spatial posture and gait data of the test subjects were collected via a VICON motion capture system. We developed a framework to process and extract gait features and applied statistical analysis on these features to examine the significance of the findings. The results showed that the motorized walker providing a robust haptic cue significantly improved gait symmetry of PD subjects. Specifically, the asymmetry index of the gait cycle time was reduced from 6.7% when walking without assistance to 0.56% and below when using a walker. Furthermore, the double support time of a gait cycle was reduced by 4.88% compared to walking without assistance.
... interaction is very limited. Kegelmeyer et al. [10] studied 27 individuals with Parkinson's disease, finding that rollator use led to less variability in gait measures of velocity, stride length, percent swing and double support time compared to walking sticks, walking frames, two-wheeled walkers and U-Step walkers. Lindemann et al. [8] studied the gait of 22 rollator users (median age of 82) in a geriatric rehabilitation clinic in Germany. ...
... When the IMU and protocol were then brought to the SUE, the MS participant can be seen to tend to consistently initiate the push of the rollator around the heel strike of each foot. The MS participant demonstrates a smooth and less interfered gait with the help of the rollator, which has also been shown in past studies [8,10]. However, the MS participant's movement was interfered while walking up the step due in part to the physical constraint of lifting the rollator up or down the step. ...
Article
The use of walking aids is prevalent among older people and people with mobility impairment. Rollators are designed to support outdoor mobility and require the user to negotiate curbs and slopes in the urban environment. Despite the prevalence of rollators, analysis of their use outside of controlled environments has received relatively little attention. This paper reports on an initial study to characterise rollator movement. An inertial measurement unit (IMU) was used to measure the motion of the rollator and analytical approaches were developed to extract features characterising the rollator movement, properties of the surface, and push events. The analytics were tested in two situations, firstly a healthy participant used a rollator in a laboratory using a motion capture system to obtain ground truth. Secondly the IMU was used to measure the movement of a rollator being used by a user with multiple sclerosis (MS) on a flat surface, cross-slope, up and down slopes, and up and down a step. The results showed that surface inclination and distance travelled measured by the IMU have close approximation to the results from ground truth, therefore demonstrating the potential for IMU-derived metrics to characterise rollator movement and user’s pushing style in the outdoor environment.
... Regarding subjects with Parkinson's disease, some studies focused on interaction strategies to improve the experience during the task (Mou et al., 2012;Zhang et al., 2018). These kinds of studies evaluated the level of assistance provided by the device and how it influenced the speed, cadence, and stability of the users (Cubo et al., 2003;Kegelmeyer et al., 2013;Wu et al., 2020). However, exploration of the kinematic effects of robotic walkers in this population remains scarce. ...
Full-text available
Article
... Over time, PD patients may develop a fear of falling (FoF) [7] and Kegelmeyer et al. [8] found that, four-wheeled-walker can be a safe ambulatory device with greater consistency of improvement. With these issues in mind, the primary purpose of this project was to design and fabricate an innovative wheeled walker, also called a rollator, that would add values over the existing features of the currently available walkers in the market that might prove to be helpful for maintaining balance in case of Parkinsonian gait. ...
Full-text available
Article
A neurodegenerative disorder like Parkinson's disease (PD) causes tremor, rigidity, postural instability and gait problems in early stages and thus poses an undetermined threat to the social and personal lives of the elderly in developing countries due to insufficient survey and research activities. However, several types of assistive devices (AD) are available in the market and the real patients' requirements are often overlooked in their design. This paper presents the process of design and fabrication of an innovative walker for PD patients. This walker has a non-modular foldable design which incentivizes patients to stand up straight and walk without the help of others. A survey on patients battling parkinsonism and practicing doctors was performed in public hospitals in Dhaka, Bangladesh and relevant engineering data was derived from it using Quality Function Deployment (QFD) which can also help visualize further market research opportunities. A finite element analysis (FEA) was performed before the walker was constructed for safety. It was handed to several volunteers for use and their responses were satisfactory. The designed walker may serve as a low-cost AD which is likely to improve a patient's posture and overall lifestyle and therefore, it can act as a means of rehabilitation.
... However, no benefits were observed in patients with FOG (Cubo, Moore, Leurgans, & Goetz, 2003). When different types of frames were tested in PD patients, the use of four-wheeled frames resulted in less gait variability, associated with reduced falls risk, and had less impact on spontaneous unassisted gait patterns (Kegelmeyer, Parthasarathy, Kostyk, White, & Kloos, 2013). ...
Chapter
Assistive technology (AT), as defined by the World Health Organization, includes any product, instrument, equipment, or technology adapted or specifically designed for improving functioning of a disabled person and can range from low-tech (e.g., a walking stick) to more complex technologies (e.g., antitremor glove). When evaluating Parkinson's disease (PD) patients for AT, the focus should not be on the device, but rather on the process of service delivery that first identifies a need for AT, and then device selection, ending with outcome evaluation to ensure the patient's need is met. This chapter will outline this process in three major areas related to disabilities in PD (mobility, communication, and manipulation), with supporting scientific evidence of AT implementation and practical implications, when available. Although intended for physicians, this chapter's objective is to raise awareness of these devices and their potential roles in managing PD across the board so that appropriate referral to skilled therapists can be undertaken.
... Diferentemente da bengala, os andadores são geralmente prescritos para idosos com graves problemas de marcha. 8,9 Porém, o risco de quedas quando se utiliza um andador de forma inadequada é cerca de sete vezes maior quando comparado ao uso inadequado da bengala. 5 Dentre os diferentes tipos de andador, os requisitos para a indicação de um andador fixo é ainda maior do que de um andador com rodas. ...
Article
... Interestingly, a significant minority (≈ 15-30%) would not consider using a walking aid or wheelchair despite having falls. There are a number of possible reasons for this, including a desire to remain independent for as long as possible, but the stigma of being seen using assistive devices may also be a factor and is important to address when counselling patients about falls risk [58][59][60]. Many patients worry about becoming a burden to their family [61], and a majority of patients indicated that they would not mind residing in a nursing home if no longer able to independently carry out daily living activities. ...
Article
IntroductionLittle is known regarding the educational needs and perspectives of people living with Parkinson’s disease (PD), particularly in Asia.Objective To assess knowledge and perceptions regarding PD in a large multiethnic urban Asian cohort of patients and caregivers.Methods We conducted a survey at a university hospital neurology clinic, using a novel Knowledge and Perception of Parkinson’s Disease Questionnaire (KPPDQ).ResultsThe KPPDQ had satisfactory psychometric properties among patients and caregivers. Five hundred subjects were recruited with a 97% response rate (211 patients, 273 caregivers). Non-motor symptoms such as urinary problems, visual hallucinations and pain were relatively poorly recognized. Many (≈ 50–80%) respondents incorrectly believed that all PD patients experience tremor, that PD is usually familial, and that there is a cure for PD. About one-half perceived PD to be caused by something the patient had done in the past, and that PD medications were likely to cause internal organ damage. Issues of stigma/shame were relevant to one-third of patients, and 70% of patients perceived themselves to be a burden to others. Two-thirds of participants felt that PD imposed a heavy financial toll. Participants were about equally divided as to whether they would consider treatment with deep brain stimulation, tube feeding or invasive ventilation. Over three-quarters of patients expressed a preference to die at home.Conclusions Important knowledge gaps, misperceptions and perspectives on PD were identified, highlighting the need for further efforts to raise awareness and provide accurate information regarding PD, and to address patient’s and caregivers’ needs and preferences.
... Studies in which there was no active intervention and where participants received the usual medical therapy as a comparator or where there was unclear final statistical analysis were all lowquality, and therefore the interpretations of outcome conclusions were limited. 88,89 Overall, because of the conflicting outcomes (even allowing for variable techniques), there is "insufficient evidence" for technology-based movement strategies, and the implication for clinical practice is "investigational." 3. Formalized patterned exercise studies. ...
Full-text available
Article
Objective: The objective of this review was to update evidence‐based medicine recommendations for treating motor symptoms of Parkinson's disease (PD). Background: The Movement Disorder Society Evidence‐Based Medicine Committee recommendations for treatments of PD were first published in 2002 and updated in 2011, and we continued the review to December 31, 2016. Methods: Level I studies of interventions for motor symptoms were reviewed. Criteria for inclusion and quality scoring were as previously reported. Five clinical indications were considered, and conclusions regarding the implications for clinical practice are reported. Results: A total of 143 new studies qualified. There are no clinically useful interventions to prevent/delay disease progression. For monotherapy of early PD, nonergot dopamine agonists, oral levodopa preparations, selegiline, and rasagiline are clinically useful. For adjunct therapy in early/stable PD, nonergot dopamine agonists, rasagiline, and zonisamide are clinically useful. For adjunct therapy in optimized PD for general or specific motor symptoms including gait, rivastigmine is possibly useful and physiotherapy is clinically useful; exercise‐based movement strategy training and formalized patterned exercises are possibly useful. There are no new studies and no changes in the conclusions for the prevention/delay of motor complications. For treating motor fluctuations, most nonergot dopamine agonists, pergolide, levodopa ER, levodopa intestinal infusion, entacapone, opicapone, rasagiline, zonisamide, safinamide, and bilateral STN and GPi DBS are clinically useful. For dyskinesia, amantadine, clozapine, and bilateral STN DBS and GPi DBS are clinically useful. Conclusions: The options for treating PD symptoms continues to expand. These recommendations allow the treating physician to determine which intervention to recommend to an individual patient. © 2018 International Parkinson and Movement Disorder Society
... Handrails use artificially improves gait stability and walking sessions lasted 2 min while gait variability approaches are usually data-hungry techniques. Also, gait speed imposed on treadmill in the study of Frenkel-Toledo et al. corresponded to the gait speed of the walking session with a walker which is known to be not representative of the spontaneous gait pattern (Kegelmeyer et al., 2013). ...
Full-text available
Article
Variability raises considerable interest as a promising and sensitive marker of dysfunction in physiology, in particular in neurosciences. Both internally (e.g., pathology) and/or externally (e.g., environment) generated perturbations and the neuro-mechanical responses to them contribute to the fluctuating dynamics of locomotion. Defective internal gait control in Parkinson's disease (PD), resulting in typical timing gait disorders, is characterized by the breakdown of the temporal organization of stride duration variability. Influence of external cue on gait pattern could be detrimental or advantageous depending on situations (healthy or pathological gait pattern, respectively). As well as being an interesting rehabilitative approach in PD, treadmills are usually implemented in laboratory settings to perform instrumented gait analysis including gait variability assessment. However, possibly acting as an external pacemaker, treadmill could modulate the temporal organization of gait variability of PD patients which could invalidate any gait variability assessment. This study aimed to investigate the immediate influence of treadmill walking (TW) on the temporal organization of stride duration variability in PD and healthy population. Here, we analyzed the gait pattern of 20 PD patients and 15 healthy age-matched subjects walking on overground and on a motorized-treadmill (randomized order) at a self-selected speed. The temporal organization and regularity of time series of walking were assessed on 512 consecutive strides and assessed by the application of non-linear mathematical methods (i.e., the detrended fluctuation analysis and power spectral density; and sample entropy, for the temporal organization and regularity of gait variability, respectively). A more temporally organized and regular gait pattern seems to emerge from TW in PD while no influence was observed on healthy gait pattern. Treadmill could afford the necessary framework to regulate gait rhythmicity in PD. Overall, the results support the hypothesis of a greater dependence to regulatory inputs as an explanatory factor of treadmill influence observed in PD. Also, since treadmill misrepresents the gait as more healthy than it is, the present findings underline that gait analysis using treadmill devices should be cautiously considered in PD and especially for gait variability assessment in gait lab.
... It is frequent to find research works that are tested with healthy users, often students and scientist involved in the research [10], [25], [9], [26] or under simulation [27]. Other works focus on specific conditions like Parkinson's disease [28] or stroke [21]. Our target is to develop a general methodology to be used with rollator-users presenting any kind of disability. ...
Article
Patient condition during rehabilitation has been traditionally assessed using clinical scales. These scales typically require the patient and/or the clinician to rate a number of condition related items to obtain a final score. This is a timeconsuming task, specially if a large number of patients is involved. Furthermore, during rehabilitation, user condition is expected to change steadily in time, so assessment may require to run these scales several times to each user. To save time, much effort has been focused on developing clinical scales that require little time to be completed. This is usually achieved by measuring a reduced set of features i.e focusing the scales on specific features of a defined target population (Parkinson's disease, Stroke, etc.). However, these scales still require the therapist's intervention and may be tiresome for patients who have to fill them repeatedly. This paper proposes a novel approach to automatically obtain balance scales from the onboard sensors of a robotic rollator. These sensors are used to extract spatiotemporal gait parameters from patients using the rollator for support. These parameters are derived from the user forces on the rollator handles and its odometry. Resulting parameters are used to predict the Tinetti Mobility clinical scale on the fly, without therapist intervention. Our approach has been validated with nineteen rollator volunteers with a variety of physical and neurological disabilities at Hospital Civil (Malaga) and Fondazione Santa Lucia (Rome). Clinicians provided traditionally obtained Tinetti scores and the proposed system was used to estimate them on the fly. Results show a small root mean squared prediction error. This method can be used for any rollator-user anywhere in everyday walking conditions to obtain the Tinetti scores as often as desired and, hence evaluate their progress.
... Nordic poles could serve as walking aids that are commonly prescribed to maintain balance in people with PD. However, the propulsive use of poles could reduce any alteration of the gait pattern classically observed with usual walking aids [49,53,54]. Also, higher impulse values and higher knee and ankle moments in the sagittal plane compared to UW could indicate a more dynamic movement in NW [50,51]. ...
Full-text available
Article
Background Gait disorders of Parkinson’s disease (PD) are characterized by the breakdown of the temporal organization of stride duration variability that was tightly associated to dynamic instability in PD. Activating the upper body during walking, Nordic Walking (NW) may be used as an external cueing to improve spatiotemporal parameters of gait, such as stride length or gait variability, in PD. The aim of this study was to evaluate the beneficial effects of NW on temporal organization of gait variability and spatiotemporal gait variables in PD. Methods Fourteen mild to moderate PD participants and ten age-matched healthy subjects performed 2 × 12 min overground walking sessions (with and without pole in a randomized order) at a comfortable speed. Gait speed, cadence, step length and temporal organization (i.e. long-range autocorrelations; LRA) of stride duration variability were studied on 512 consecutive gait cycles using a unidimensional accelerometer placed on the malleola of the most affected side in PD patients and of the dominant side in healthy controls. The presence of LRA was determined using the Rescaled Range Analysis (Hurst exponent) and the Power Spectral Density (α exponent). To assess NW and disease influences on gait, paired t-tests, Z-score and a two-way (pathological condition x walking condition) ANOVA repeated measure were used. ResultsLeading to significant improvement of LRA, NW enhances step length and reduces gait cadence without any change in gait speed in PD. Interestingly, LRA and step length collected from the NW session are similar to that of the healthy population. Conclusion This cross-sectional controlled study demonstrates that NW may constitute a powerful way to struggle against the randomness of PD gait and the typical gait hypokinesia. Involving a voluntary intersegmental coordination, such improvement could also be due to the upper body rhythmic movements acting as rhythmical external cue to bypass their defective basal ganglia circuitries. Ethics committee’s reference numberB403201318916 Trial registrationNCT02419768
... Thirteen children diagnosed with CP, were examined before and 12 months after undergoing SDR (Table 1). One child, who presented a change in gait status from assisted to postoperative unassisted walking was excluded due to the known influence on parameters of gait variability [33,34]. As a result, twelve children (5 female, 7 male) with a mean age of 6.1 (61.3, range from 4.4 to 8.5) years, were analysed in this study. ...
... Other works focus on specific groups of users, e.g. Parkinson [19] or stroke [20]. Our goal is to define a general estimation of rollator user condition. ...
Conference Paper
The assistance to people during rehabilitation has to be adapted to their needs. Too little help can lead to frustration and stress in the user; an excess of help may lead to low participation and loss of residual skills. Robotic rollators may adapt assistance. The main challenge to cope with this issue is to estimate how much help is needed on the fly, because it depends not only on the person condition, but also on the specific situation that they are negotiating. Clinical scales provide a global condition based estimation, but no local estimator based on punctual needs. Condition also changes in time, so clinical scales need to be recalculated again and again. In this paper we propose a novel approach to estimate users' condition in a continuous way via a robotic rollator. Our work focuses on predicting the value of the well known Tinetti Mobility test from spatiotemporal gait parameters obtained from our platform while users walk. This prediction provides continuous insight on the condition of the user and could be used to modify the amount of help provided. The proposed method has been validated with 19 volunteers at a local hospital that use a rollator for rehabilitation. All volunteers presented some physical or mental disabilities. Our results successfully show a high correlation of spatiotemporal gait parameters with Tinetti Mobility test gait (R2 = 0.7) and Tinetti Mobility test balance (R2 = 0.6).
... A general exercise regimen, strength training, physical therapy or balance training with Tai Chi may improve functional motor ability in the PD population [36][37][38][39]. In later stages of PD, gait instability may be improved with assistive mobility devices, especially four-wheeled walkers [40]. A recent study showed that patients with PD have presbycusis [41], which may contribute to their increased risk of falls [42]. ...
Article
Purpose: The goal of our study was to determine if patients with Parkinson's disease (PD) are more susceptible to hospitalization for traumatic brain injury (TBI). Methods: The US Nationwide Inpatient Sample database was queried (2004-2011) to identify cohorts of patients with PD (N = 1 047 656) and without PD (N = 115 95 173). The age range of the study population was 60-89 years. The incidence of TBI among patients with PD was compared to the incidence of TBI in patients without PD. A multivariate logistic regression model, adjusted for all covariates that significantly differed in the bivariate analyses, was used to determine if PD was an independent predictor of TBI hospitalization. Results: The incidence of TBI hospitalization was significantly higher (relative risk: 1.76, 95% CI: 1.73-1.80) in the PD cohort. The PD cohort with TBI had fewer comorbidities and risk factors for falls/TBI compared to the non-PD cohort with TBI. The multivariable analysis, adjusting for other TBI risk factors, revealed that PD status increased the likelihood of TBI hospitalization (odds ratio: 2.99, 95% CI: 2.93-3.05). Conclusion: Our study shows that patients with PD are more susceptible to hospitalization for TBI. A greater proportion of fall-related TBI occurs in patients with PD compared to patients without PD. Further research is needed to prevent falls in PD patients to avoid TBI.
... The subjects in CANE and WHEELS walked with much lower gait speeds even at the fast walking pace, with far fewer vertical acceleration signals during walking. The use of assistive devices increased the coefficient of variation of step time, stride length, and swing time (Kegelmeyer, Parthasarathy, Kostyk, White, & Kloos, 2013), so any set sensitivity threshold could not be used because of the inevitable specificity/sensitivity trade-off. Therefore, the use of the cadence of walking (Ichinoseki-Sekine et al., 2006) or the movement of the feet by an ankle-worn accelerometer (Dijkstra et al., 2008;Macko et al., 2002) showed better accuracy than the use of vertical signals among older people or patients. ...
Full-text available
Article
The purpose of this study was to examine the accuracy of uni- and tri-axial accelerometers in monitoring step counts and gait intensity in older people who did or did not use an assistive device. Forty-nine healthy and frail older adults wore uni-axial (Lifecorder, Suzuken Co. Ltd.) and tri-axial accelerometers (Activity Monitor, Matsushita Electronic Works, Ltd., and Active Style Pro, Omron Healthcare Co., Ltd.) during three trials at different gait speeds. All accelerometers gave relatively accurate step counts for healthy older participants compared with direct observation; however, the error was greater for frail older people with assistive devices. Gait intensity detection error was unaffected by gait speed. Among frail older people with assistive devices, the gait intensity error was smaller than for step count error. To accurately assess the steps walked or the gait intensity among frail older people using assistive devices, more study is needed on these groups of participants.
... To date, several studies have evaluated the effects of using dynamic visual laser cues to improve gait among individuals with PD in both laboratory and home settings. Findings reveal that using the visual cues result in larger step lengths and faster walking times, and lead to a significant reduction in the number of freezing episodes and start hesitations experienced (Donovan et al., 2011;Kegelmeyer et al., 2013;Rahman et al., 2008;Van Gerpen et al., 2012). While these findings are promising, one limitation of this visual cueing approach is that standard protocol requires users to direct their attention downward towards the visual cue that is projected on the ground immediately in front of their feet. ...
Aims: To investigate the effect of manipulating the spatial location of a visual cue used to manage gait impairment among individuals with Parkinson's disease. Methods: Six individuals with Parkinson's disease who experience severe freezing of gait were asked to complete the Timed Up and Go test three times in each of the following conditions: no cue, cue presented at the users feet, cue presented at a distance equivalent to step length, and cue presented at a distance equivalent to stride length. Step length, velocity, walker positioning, and time taken to complete a 180 degree turn and the Timed Up and Go test were recorded. Results: Visual cueing led to an improvement in 4/5 outcome measures with magnitude of improvement being dependent upon the spatial location of cue presentation. Conclusions: Findings suggest that visual cueing and the spatial location of cue presentation are highly individualized in terms of managing gait disturbance.
... A variety of gait trainings in rehabilitation program for patients with PD have been performed to improve gait function and mobility by using a treadmill, assistive devices, and cueing strategies such as verbal, visual, or auditory cueing (Kegelmeyer et al., 2013;Spaulding et al., 2013). Recently, there is a growing interest on arm movements in patients with PD, such as arm-swing asymmetry or amplitude (Lewek et al., 2010;Roggendorf et al., 2012). ...
Article
Recently, arm facilitation has been interested in gait rehabilitation. However, there have been few studies concerning arm facilitation in patients with Parkinson's disease (PD). The aim of our study was to investigate the effect of increasing arm weights on gait pattern in patients with PD. Twenty-seven patients with PD were enrolled, and they underwent gait analysis using a three-dimensional motion capture system. Sandbags were applied to the distal forearms in all participants. We compared gait parameters including arm swing, pelvic motion, spatiotemporal data, and relative rotational angle between the weighted and unweighted gaits. The total arm-swing amplitude and pelvic rotation were significantly higher when walking with additional arm weights than without arm weights. Cadence, walking speed, stride length, and swing phase were significantly higher, whereas stride time, double-support time, and stance phase were significantly lower, when walking with additional arm weights than without arm weights. We conclude that adding weights to the arm during walking may facilitate arm and pelvic movements, which results in changes to gait patterns. The therapeutic use of additional arm weights could be considered for gait rehabilitation in PD to improve gait impairment. Arm-swing facilitation using weight load improved gait in Parkinson's disease. Copyright © 2015. Published by Elsevier Ireland Ltd.
... These systems are expensive to acquire and are limited to evaluation of only a few strides and as such are unsuitable for measuring gait variability which may be an important aspect of gait dysfunction in neurologic disease. 5 A more widely used tool for the study of gait in PD is the GaitRite ® system [6][7][8][9] which involves having a patient walk on a special mat embedded with sensors, and which produces similar results to a 3D camera system while requiring less setup time and cost. 10 However, such instrumented mat systems are unable to measure aspects of gait that do not involve contact of the foot with the ground, such as arm and trunk movements, which are known to be affected in PD. ...
Article
Objective: To assess the suitability of instrumented gait and balance measures for diagnosis and estimation of disease severity in PD. Methods: Each subject performed iTUG (instrumented Timed-Up-and-Go) and iSway (instrumented Sway) using the APDM(®) Mobility Lab. MDS-UPDRS parts II and III, a postural instability and gait disorder (PIGD) score, the mobility subscale of the PDQ-39, and Hoehn & Yahr stage were measured in the PD cohort. Two sets of gait and balance variables were defined by high correlation with diagnosis or disease severity and were evaluated using multiple linear and logistic regressions, ROC analyses, and t-tests. Results: 135 PD subjects and 66 age-matched controls were evaluated in this prospective cohort study. We found that both iTUG and iSway variables differentiated PD subjects from controls (area under the ROC curve was 0.82 and 0.75 respectively) and correlated with all PD severity measures (R(2) ranging from 0.18 to 0.61). Objective exam-based scores correlated more strongly with iTUG than iSway. The chosen set of iTUG variables was abnormal in very mild disease. Age and gender influenced gait and balance parameters and were therefore controlled in all analyses. Interpretation: Our study identified sets of iTUG and iSway variables which correlate with PD severity measures and differentiate PD subjects from controls. These gait and balance measures could potentially serve as markers of PD progression and are under evaluation for this purpose in the ongoing NIH Parkinson Disease Biomarker Program.
Chapter
This eighth edition of Dr Reichel's formative text remains the go-to guide for practicing physicians and allied health staff confronted with the unique problems of an increasing elderly population. Fully updated and revised, it provides a practical guide for all health specialists, emphasizing the clinical management of the elderly patient with simple to complex problems. Featuring four new chapters and the incorporation of geriatric emergency medicine into chapters. The book begins with a general approach to the management of older adults, followed by a review of common geriatric syndromes, and proceeding to an organ-based review of care. The final section addresses principles of care, including care in special situations, psychosocial aspects of our aging society, and organization of care. Particular emphasis is placed on cost-effective, patient-centered care, including a discussion of the Choosing Wisely campaign. A must-read for all practitioners seeking practical and relevant information in a comprehensive format.
Full-text available
Article
Background By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value. Objectives This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence. Search Methods We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov). Selection Criteria Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps. Data Collection and Analysis We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist. Main Results After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality. The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication. There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues. Authors' Conclusions There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.
Chapter
Canes, crutches, and walkers improve balance, assist walking, reduce load on the lower limbs, transmit sensory cues, and enable maneuvering in places inaccessible to a wheelchair. Assistive devices are manufactured in many designs. Canes differ by material, handle shape, and base. Crutches may have an axillary piece, a forearm cuff, or an upper arm support. Walkers can have wheels or rubber tips. Correct measurement is essential with any assistive device. Gait patterns used with assistive devices may be alternating (reciprocal), in which the user moves one foot at a time, or swinging (simultaneous), with patient moving both feet at the same time. Kinetic analyses indicate that the duration and amount of force applied to a device varies according to its purpose: balance, pain relief, or transferring the body through space. Kinematic analyses confirm that patients tend to walk faster when aided by a device. Heart rate and energy consumption are affected by the type of device and the way it is used. Benefits associated with device use include greater stability and reduced stress on the lower limbs. Assistive devices may, however, compress nerves in the upper limb and may embarrass the user.
Article
Patients with Parkinson’s disease suffer from gait disturbances, such as a shuffling and festinating gait, which reduces their quality of life. To circumvent this problem, external visual cues may be applied in gait training to maintain the integrity of motor function. However, conventional training methods, such as transverse lines stuck on the ground, are difficult to adjust and adapt to personalized gait ability. This study proposes a convenient instrumented wheel walker that provides gap adjustable visual cues and selectable projection modes onto the ground with and without motion relative to the user. Ten subjects with Parkinson’s disease were recruited, and the efficacy of the proposed device for their gait training was assessed. We demonstrated the applicability of our device to address personalized demands in gait guidance. With a personalized setting for patients with Parkinson’s disease, a significantly lengthened stride length may be achieved.
Conference Paper
Introduction: Adhesive resins are the most common human-synthetic material interface. Their application enables tooth restoration. Dental caries affects 90% of the world’s population. Clinical application of these materials has encountered durability limitations. The adhesive resin is attached to collagen fibers that are exposed on the hydroxyapatite surface. During the following years after restoration, pulp pressure infuses liquid in the dentinal channels defining an intricate frontier of wettability. In the long term, this interface allows activation of matrix metalloproteinases (MMPs) that degrade collagen fibers inducing failure of the restoration. The presence of endogenous MMPs have been identified has a main cause for restoration failure. Furthermore, inhibition of MMP is important for other diseases and cancer. Materials and methods: The workflow included (1) computational studies molecular docking of inhibitor to the MMP active site to define the most promising candidates for synthesis. (2) Organic chemistry synthesis of new compounds. (3) Biochemical test of enzymatic activity inhibition of the compounds towards different MMPs. (4) Cell toxicity evaluation of the compounds and in silico prediction of their potential passage of the blood brain barrier. (5) Tensile resistance of the hybrid tooth-resin and their fracture analysis by ultramicroscopy. Results: The initial proposed several hundred compounds had in common the same synthetic strategy of central moiety with two hydroxyl groups that are stepwise substituted with two side groups to yield the final molecule. Compounds were synthesized, purified and characterized. About 60 new molecules [1,2] with vinyl substituents that enable copolymerization with the current dental resins were obtained. Biochemical activity tests revealed the most promising inhibitors. A few selected molecules were included in the mechanical tensile resistance test of the tooth-resin interface, and an increased resistance was found in several samples aged up to 12 months. Discussion and conclusions: The copolymerization of the inhibitor with the resin limits its potential toxicity since most resin compounds were determined to pass the blood-brain barrier [3,4].
Full-text available
Preprint
Gait abnormalities are one of the distinguishing symptoms of patients with Parkinson's disease (PD) that contribute to fall risk. Our study compares the gait parameters of people with PD when they walk through a predefined course without assistance, with a conventional walker, and with a motorized walker under different speed cues. Six PD subjects were recruited at the New York Institute of Technology College of Osteopathic Medicine to participate in this study. Spatial posture and gait data of the test subjects were collected via a VICON motion capture system. We developed a framework to process and extract gait features and applied statistical analysis on these features to examine the significance of the findings. The results showed that motorized walkers with haptic cues significantly improved gait symmetry of PD subjects. Specifically, the asymmetry index of the gait cycle time was reduced from 6.7% when walking without assistance to 0.56% and below when using a walker. Furthermore, the double support time of a gait cycle was reduced by 4.88% compared to walking without assistance.
Article
Full-text available
Article
Kimmy G Su,1 Julie H Carter,1 Keiran K Tuck,2 Tony Borcich,3 Linda A Bryans,4 Lisa L Mann,1 Jennifer L Wilhelm,5 Erik K Fromme6 1Department of Neurology, Oregon Health & Science University, 2The Oregon Clinic-Neurology, 3Parkinson’s Resources of Oregon, 4Northwest Clinic for Voice and Swallowing, Oregon Health and Science University, 5Rehabilitation Services, Oregon Health & Science University, 6Palliative Care Section, OHSU Knight Cancer Institute, Portland, OR, USA Abstract: Late stage Parkinson’s and Parkinson-plus patients have increased needs beyond motor symptom management that cannot be fully addressed in a typical neurology clinic visit. Complicating matters are the concurrent increasing emotional and physical demands on caregivers, which, if addressed, further stretch clinic time constraints. The complex and extensive patient and caregiver needs warrant a dedicated clinic to provide the necessary interdisciplinary care. In contrast to a typical model where the neurology clinician refers the patient to various ancillary treatment groups resulting in multiple separate clinic visits, the interdisciplinary model supports direct communication between the different disciplines during the clinic visit, allowing for a more coordinated response that takes into account multiple perspectives. Such an interdisciplinary model has been utilized in neurologic disorders with complex end-stage disease needs, such as amyotrophic lateral sclerosis with notable improvement in quality of life and survival. The Oregon Health & Science University Parkinson Center and Movement Disorders Clinic has developed an interdisciplinary clinic called Next Step composed of neurology clinicians, a physical therapist, a speech pathologist, a social worker, and a nursing coordinator. The clinic focuses on palliative care issues, including complex late stage motor symptoms, nonmotor symptoms, and quality of life goals of both the patient and caregiver(s). This article describes the Next Step clinic structure and processes, while reviewing the literature and incorporating clinical expertise from the perspective of each discipline. Keywords: palliative care, Parkinson’s disease, caregiver burden, interdisciplinary team, late-stage Parkinson’s, quality of life
Chapter
Atypical dementias create unique and challenging issues for health-care providers and for the families caring for these patients. This chapter identifies the special challenges and offers suggestions for managing patient care. Issues common to all the dementias are outlined along with disease-specific information. For each of the atypical dementias, functional changes, safety concerns, and psychosocial adjustments are discussed. Information regarding the unique issues faced by the family caregivers is provided along with suggestions for preserving the caregiver's health and emotional well-being.
Conference Paper
Gait analysis provides insightful information about people condition, progress of rehabilitation treatments and fall risk. This analysis is frequently performed in very specific conditions, because it often implies the use of treadmills, cameras and/or wearable sensors. Alternatively, gait can be analyzed using a smart rollator, equipped with a basic set of sensors. This work proposes a methodology to obtain relevant gait parameters using a simple, cheap source of information: wheel odometry and handlebar force sensors. The main advantages of this approach are that users are not bothered with extra equipment. Besides, monitoring can be performed anywhere, even during everyday conditions and for extended periods of time. We have tested our system with a set of rehabilitation patients with different disabilities. Preliminary results have successfully proven that extracted parameters are coherent with reported effects of their specific condition.
Article
Full-text available
Article
Introduction: Variability in task output is a ubiquitous characteristic that results from non-continuous motor neuron firing during muscular force generation. However, variability can also be attributed to errors in control and coordination of the motor neurons themselves in diseases such as cerebral palsy (CP). Selective dorsal rhizotomy (SDR), a neurosurgical approach to sever sensory nerve roots, is thought to decrease redundant or excessive afferent signalling to intramedullary neurons. In addition to its demonstrated ability to reduce muscular spasticity, we hypothesised that SDR is able to decrease variability during gait, the most frequent functional motor activity of daily living. Methods: Twelve CP children (aged 6.1 ± 1.3 yrs), who underwent SDR and performed gait analysis pre- and 12 months postoperatively, were compared to a control group of eleven typically developing (TD) children. Coefficients of variability as well as mean values were analysed for: temporal variables of gait, spatial parameters and velocity. Results: Gait parameters of cadence (p = 0.006) and foot progression angle at mid-stance (p = 0.041) changed significantly from pre- to post-SDR. The variability of every temporal parameter was significantly reduced after SDR (p = 0.003-0.049), while it remained generally unchanged for the spatial parameters. Only a small change in gait velocity was observed, but variability in cadence was significantly reduced after SDR (p = 0.015). Almost all parameters changed with a tendency towards normal, but differences between TD and CP children remained in all parameters. Discussion: The results confirm that SDR improves functional gait performance in children with CP. However, almost exclusively, parameters of temporal variability were significantly improved, leading to the conjecture that temporal variability and spatial variability may be governed independently by the motor cortex. As a result, temporal parameters of task performance may be more vulnerable to disruption, but also more responsive to treatment success of interventions such as SDR.
Full-text available
Article
Full-text available
Article
To study immediate gait changes in persons with PD when walking with different assistive walking devices. Ten individuals with idiopathic PD participated in the study. Gait parameters were recorded while walking with a cane and a wheeled walker, and were compared to a free walk without a walking device. Persons with PD walked with slower gait speed when using a cane and a wheeled walker compared to walking without any device (p = 0.007, p = 0.002, respectively). Stride length reduced significantly when walking with a wheeled walker (p = 0.001). Walking with the assistive devices did not affect cadence, double support phase, heel to heel base of support, stride time, and stance period. Persons with PD immediately walked with slower gait speed when using either a cane or a wheeled walker, and with shorter stride length when walking with a wheeled walker. The results may lead to more cautious clinical practice in gait rehabilitation using ambulatory assisted devices.
Full-text available
Article
Identifying quantitative gait markers of falls in older adults may improve diagnostic assessments and suggest novel intervention targets. We studied 597 adults aged 70 and older (mean age 80.5 years, 62% women) enrolled in an aging study who received quantitative gait assessments at baseline. Association of speed and six other gait markers (cadence, stride length, swing, double support, stride length variability, and swing time variability) with incident fall rate was studied using generalized estimation equation procedures adjusted for age, sex, education, falls, chronic illnesses, medications, cognition, disability as well as traditional clinical tests of gait and balance. Over a mean follow-up period of 20 months, 226 (38%) of the 597 participants fell. Mean fall rate was 0.44 per person-year. Slower gait speed (risk ratio [RR] per 10 cm/s decrease 1.069, 95% confidence interval [CI] 1.001-1.142) was associated with higher risk of falls in the fully adjusted models. Among six other markers, worse performance on swing (RR 1.406, 95% CI 1.027-1.926), double-support phase (RR 1.165, 95% CI 1.026-1.321), swing time variability (RR 1.007, 95% CI 1.004-1.010), and stride length variability (RR 1.076, 95% CI 1.030-1.111) predicted fall risk. The associations remained significant even after accounting for cognitive impairment and disability. Quantitative gait markers are independent predictors of falls in older adults. Gait speed and other markers, especially variability, should be further studied to improve current fall risk assessments and to develop new interventions.
Full-text available
Article
To provide information on the advantages and possible disadvantages of using canes and walkers. English-language articles were identified by searching MEDLINE and PubMed (1966-May 2003) for key words cane or walker , excluding articles unrelated to mobility aids. Bibliographies were reviewed and ISI Web of Science citation searches were run to identify additional references. Over 1000 articles were selected for further evaluation. We extracted all studies of single-tip canes or pickup walkers addressing: (1) functional, biomechanic, or neuromotor benefits; (2) biomechanic, attentional, neuromotor, metabolic, or physiologic demands; and (3) falls, injuries, or other problems. We included approximately 10% of the articles originally identified. The methodology of each selected article, and findings relevant to the benefits, demands, or adverse effects of cane or walker use were summarized. Findings were synthesized by considering their relation to basic biomechanic principles. Some biomechanic findings appear to support the clinical view that canes and walkers can improve balance and mobility for older adults and people with other clinical conditions. However, a large proportion of users experience difficulties, and the use of such devices is associated with increased risk of falling. A small number of studies have characterized some of the specific demands and problems associated with using mobility aids. Clinical and biomechanic evaluations of canes and walkers confirm that these devices can improve balance and mobility. However, they can also interfere with ones ability to maintain balance in certain situations, and the strength and metabolic demands can be excessive. More research is needed to identify and solve specific problems. Such research may lead to improved designs and guidelines for safer use of canes and walkers.
Full-text available
Article
The rollator is a very popular walking aid. However, knowledge about how a rollator affects the walking patterns is limited. Thus, the purpose of the study was to investigate the biomechanical effects of walking with and without a rollator on the walking pattern in healthy subjects. The walking pattern during walking with and without rollator was analyzed using a three-dimensional inverse dynamics method. Sagittal joint dynamics and kinematics of the ankle, knee and hip were calculated. In addition, hip joint dynamics and kinematics in the frontal plane were calculated. Seven healthy women participated in the study. The hip was more flexed while the knee and ankle joints were less flexed/dorsiflexed during rollator walking. The ROM of the ankle and knee joints was reduced during rollator-walking. Rollator-walking caused a reduction in the knee extensor moment by 50% when compared to normal walking. The ankle plantarflexor and hip abductor moments were smaller when walking with a rollator. In contrast, the angular impulse of the hip extensors was significantly increased during rollator-walking. Walking with a rollator unloaded the ankle and especially the knee extensors, increased the hip flexion and thus the contribution of hip extensors to produce movement. Thus, rollator walking did not result in an overall unloading of the muscles and joints of the lower extremities. However, the long-term effect of rollator walking is unknown and further investigation in this field is needed.
Full-text available
Article
Radiofrequency ablation is an interventional technique that in recent years has come to be employed in very different medical fields, such as the elimination of cardiac arrhythmias or the destruction of tumors in different locations. In order to investigate and develop new techniques, and also to improve those currently employed, theoretical models and computer simulations are a powerful tool since they provide vital information on the electrical and thermal behavior of ablation rapidly and at low cost. In the future they could even help to plan individual treatment for each patient. This review analyzes the state-of-the-art in theoretical modeling as applied to the study of radiofrequency ablation techniques. Firstly, it describes the most important issues involved in this methodology, including the experimental validation. Secondly, it points out the present limitations, especially those related to the lack of an accurate characterization of the biological tissues. After analyzing the current and future benefits of this technique it finally suggests future lines and trends in the research of this area.
Article
We studied prospectively the epidemiology, clinical impact and prediction of falls in 59 moderately affected patients with Parkinson's disease (PD) (mean UPDRS motor score 31.5; mean age 61 years) and 55 controls (mean age 60 years). At baseline, balance and gait were evaluated extensively. The retropulsion test (response to sudden shoulder pull) was executed first unexpectedly and five more times following prior warning. All persons used standardised scoring forms to document their falls during six months. Thirty patients (50.8 %) and eight controls (14.5%) fell at least once (relative risk [RR] 6.1; 95% confidence interval [CI] 2.5-15.1, p < 0.001). Recurrent (> or = 2) falls occurred in 15 patients (25.4%), but in only two controls (RR 9.0; 95 % CI 2.0-41.7; p=0.001). Recurrent falls were more common among persons taking benzodiazepines (RR 5.0; 95% CI 1.6-15.5; p < 0.01). Sixty-two percent of the falls in patients caused soft tissue injuries, but no fractures occurred. A fear of future falls was common (45.8 % of patients) and was accompanied by restriction of daily activities (44.1 % of patients). Seventy percent of falls reported by patients were'intrinsic' (due to patient-related factors), but falls in controls were mainly (50%) 'extrinsic' (due to environmental factors). None of the baseline posture and gait variables predicted falls adequately. The first 'unexpected' retropulsion test was more often abnormal than all subsequent (predictable) tests. Irrespective of its method of execution, the retropulsion test did not predict falls. A combination of asking for prior falls, disease severity and the Romberg test yielded the best overall diagnostic utility (sensitivity 65 % and specificity 98 %). Recurrent fallers were best predicted by disease severity (RR for Hoehn and Yahr stage 3 was > 100; 95% CI 3.1-585) and asking for prior falls (RR 5.0; 95% CI 1.2-20.9). We conclude that falls are common and disabling, even in relatively early stage PD. Recurrent fallers were best predicted by disease severity and presence of prior falls. Strategies to prevent falls in PD should particularly focus at intrinsic (patient-related) factors, such as minimising the use of benzodiazepines.
Article
The RERC on Aging is conducting a longitudinal study of the needs of older persons with disabilities for assistive devices and environmental interventions. This paper presents an analysis of the results of interviews with 508 home-based seniors, focusing on their ownership, use, and satisfaction with assistive devices. While previous reports from this RERC-Aging study indicate a relatively high rate of satisfaction with devices, this paper primarily focuses on problems consumers are having with devices they use. This paper also reports the suggestions of study participants for new devices and modifications to existing devices.
Article
Freezing of gait (FOG) and falls are major sources of disability for Parkinson's disease (PD) patients, and show limited responsiveness to medications. We assessed the efficacy of visual cues for overcoming FOG in an open-label study of 26 patients with PD. The change in the frequency of falls was a secondary outcome measure. Subjects underwent a 1-2 month baseline period of use of a cane or walker without visual cues, followed by 1 month using the same device with the laserlight visual cue. The laserlight visual cue was associated with a modest but significant mean reduction in FOG Questionnaire (FOGQ) scores of 1.25 ± 0.48 (p = 0.0152, two-tailed paired t-test), representing a 6.6% improvement compared to the mean baseline FOGQ scores of 18.8. The mean reduction in fall frequency was 39.5 ± 9.3% with the laserlight visual cue among subjects experiencing at least one fall during the baseline and subsequent study periods (p = 0.002; two-tailed one-sample t-test with hypothesized mean of 0). Though some individual subjects may have benefited, the overall mean performance on the timed gait test (TGT) across all subjects did not significantly change. However, among the 4 subjects who underwent repeated testing of the TGT, one showed a 50% mean improvement in TGT performance with the laserlight visual cue (p = 0.005; two-tailed paired t-test). This open-label study provides evidence for modest efficacy of a laserlight visual cue in overcoming FOG and reducing falls in PD patients.
Article
Freezing is a disabling symptom in patients with Parkinson's disease. We investigated the effectiveness of a new rehabilitation strategy based on treadmill training associated with auditory and visual cues. Forty Parkinsonian patients with freezing were randomly assigned to two groups: Group 1 underwent a rehabilitation program based on treadmill training associated with auditory and visual cues, while Group 2 followed a rehabilitation protocol using cues and not associated with treadmill. Functional evaluation was based on the Unified Parkinson's Disease Rating Scale Motor Section (UPDRS III), Freezing of Gait Questionnaire (FOGQ), 6-minute walking test (6MWT), gait speed, and stride cycle. Patients in both the groups had significant improvements in all variables considered by the end of the rehabilitation program (all P = 0.0001). Patients treated with the protocol including treadmill, had more improvement than patients in Group 2 in most functional indicators (P = 0.007, P = 0.0004, P = 0.0126, and P = 0.0263 for FOGQ, 6MWT, gait speed, stride cycle, respectively). The most striking result was obtained for 6MWT, with a mean increase of 130 m in Group 1 compared with 57 m in Group 2. Our results suggest that treadmill training associated with auditory and visual cues might give better results than more conventional treatments. Treadmill training probably acts as a supplementary external cue.
Article
The aetiology of gait disturbances in Parkinson's disease (PD) is not fully understood. Recently, it was shown that in patients with PD, bilateral coordination of gait is impaired and that walking while being simultaneously engaged in a cognitive task is detrimental to their gait. To assess whether cognitive function influences the bilateral coordination of gait in PD, this study quantified left-right stepping coordination using a phase coordination index (PCI) that evaluates both the variability and inaccuracy of the left-right stepping phase (phi) generation (where the ideal phi value between left and right stepping is 180 degrees ). This report calculated PCI values from data obtained from force sensitive insoles embedded in subjects' shoes during 2 min of walking in a group of patients with PD (n = 21) and in an age matched control group (n = 13). All subjects walked under two walking conditions: usual walking and dual tasking (DT) (ie, cognitive loading) condition. For patients with PD, PCI values were significantly higher (ie, poorer coordination) during the DT walking condition compared with usual walking (p<0.001). In contrast, DT did not significantly affect the PCI of the healthy controls (p = 0.29). PCI changes caused by DT were significantly correlated with changes in gait variability but not with changes in gait asymmetry that resulted from the DT condition. These changes were also associated with performance on a test of executive function. The present findings suggest that in patients with PD, cognitive resources are used in order to maintain consistent and accurate alternations in left-right stepping.
Article
There are few data on the effect of walkers on gait and mobility or on comparisons of different walker types. We compared a commonly used 4-legged, 2-wheeled walker and a newer 3-legged, 3-wheeled walker in measures of gait, mobility, and patient satisfaction. Cross-over controlled trial. In the Physical Therapy Department of a Veterans Affairs hospital. Subjects were 15 male and female frail elderly veterans (mean age, 82 years), both inpatients and outpatients, consecutively enrolled from a sample of 35 patients referred to the Physical Therapy Department for mobility problems. Subjects met the following criteria: age 65 or over, ambulatory, no prior use of a wheeled walker, stable medical condition, and informed consent. Subjects were evaluated without either walker and with each of the two walkers on a 15-foot walkway and a 60-foot obstacle course. Subjects were asked which walker they preferred. Outcome measures were stride length on the walkway, time on an obstacle course, and walker preference. Stride length was 1.4 inches (3.6 cm) greater with the 3-wheeled walker than with the 2-wheeled walker (P = 0.016 by Wilcoxon signed-rank test). Time on the obstacle course was 16.0 seconds less with the 3-wheeled walker than the 2-wheeled walker (P = 0.002). The 3-wheeled walker was subjectively preferred. The 3-wheeled walker appears to have a greater positive impact on gait and mobility than the 2-wheeled walker.
Article
In this population-based retrospective cohort study, the 138 Olmsted County, Minnesota residents first diagnosed with Parkinson's disease during 1967–79 were matched by age and sex to an equal number of control subjects from the community. Fractures were assessed through review of each subject's complete (inpatient and outpatient) medical records. At the time of diagnosis, County residents with parkinsonism were no more likely to have a history of selected fractures than control subjects (32% in each group). Subsequently, 33% of cases and 20% of controls experienced one or more new fractures during 696 person-years of follow-up (p=0.008). The greatest increase in risk was seen for proximal femur fractures, confirming previous case-control studies. By 10 years after diagnosis, an estimated 27% of the parkinsonism cohort had experienced a new hip fracture. The pattern of fractures that was observed suggested that the increased risk was due more to specific types of falls than to disuse osteoporosis.
Article
Although even in the elderly most falls are not associated with fractures, over 90 percent of hip fractures are the result of a fall. Few studies have assessed whether the risk factors for falls are also important risk factors for hip fracture. To examine the importance of risk factors for falls in the epidemiology of hip fracture, we performed a case-control study of 174 women (median age, 80 years) admitted with a first hip fracture to 1 of 30 hospitals in New York and Philadelphia. Controls, matched to the case patients according to age and hospital, were selected from general surgical and orthopedic surgical hospital services. Information was obtained by direct interview. As measured by the odds ratio, increased risks for hip fracture were associated with lower-limb dysfunction (odds ratio = 1.7; 95 percent confidence interval, 1.1 to 2.8), visual impairment (odds ratio = 5.1; 95 percent confidence interval, 1.9 to 13.9), previous stroke (odds ratio = 2.0; 95 percent confidence interval, 1.0 to 4.0), Parkinson's disease (odds ratio = 9.4; 95 percent confidence interval, 1.2 to 76.1), and use of long-acting barbiturates (odds ratio = 5.2; 95 percent confidence interval, 0.6 to 45.0). Of the controls, 44 (25 percent) had had a recent fall. The case patients were more likely than these controls to have fallen from a standing height or higher (odds ratio = 2.4; 95 percent confidence interval, 1.0 to 5.7). Of those with hip fracture the younger patients (less than 75 years old) were more likely than the older ones (greater than or equal to 75 years old) to have fallen on a hard surface (odds ratio = 1.9; 95 percent confidence interval, 1.04 to 3.7). A number of factors that have been identified as risk factors for falls are also associated with hip fracture, including lower-limb dysfunction, neurologic conditions, barbiturate use, and visual impairment. Given the prevalence of these problems among the elderly, who are at highest risk, programs to prevent hip fracture should include measures to prevent falls in addition to measures to slow bone loss.
Article
Interrater reliability of the Unified Parkinson's Disease Rating Scale (UPDRS) motor examination was assessed by three neurologists experienced in the administration of this scale. Intraclass correlation coefficients indicated good-to-excellent agreement for speeded repeated movements, resting tremor, arising from a chair, and gait; moderate agreement for action tremor, rigidity, posture, postural stability, and bradykinesia; and poor agreement for speech disorder and facial immobility. Overall, these results indicate that satisfactory interrater reliability is attainable with the UPDRS motor examination.
Article
Ambulatory assistive device use can improve functional independence following spinal cord injury and, potentially, quality of life. However, the interaction between aids and user in this population is poorly understood. To determine the influence of walkers, crutches and canes on assisted-gait following incomplete spinal cord injury. Outcome parameters evaluated in ten individuals included orthogonal forces exerted on instrumented assistive devices, walking speed, cadence, step length, trunk and thigh angles, as well as knee and ankle joint angles. Kinetic data included axial compressive force, and medio/lateral and antero/posterior bending forces. Canada. Results indicated that walkers (n= 5) provided the greatest vertical support (up to 100% body weight), but resulted in slow gait with a forward flexed posture. Elbow crutch users (n = 3) walked faster (greater step length and cadence) and had a more upright posture than the walker users. Crutches supported up to 50% of the subject's body weight, granted lateral stability, and provided restraint in the antero/posterior direction. Canes (n = 2) offered restraining and propulsive assistance, some lateral stability, and the least amount of vertical support. Ambulatory devices affected posture and walking speed while fulfilling various assistive functions during locomotion. The conclusion drawn is that rehabilitation specialists are advised to match device characteristics to user needs when prescribing walking aids. Natural Sciences and Engineering Research Council of Canada (NSERC).
Article
To measure "on" freezing during unassisted walking (UW) and test if two devices, a modified inverted stick (MIS) and a visual laser beam stick (LBS) improved walking speed and number of "on" freezing episodes in patients with Parkinson's disease (PD). Multiple visual cues can overcome "off' freezing episodes and can be useful in improving gait function in parkinsonian patients. These devices have not been specifically tested in "on" freezing, which is unresponsive to pharmacologic manipulations. Patients with PD, motor fluctuations and freezing while "on," attempted walking on a 60-ft track with each of three walking conditions in a randomized order: UW, MIS, and LBS. Total time to complete a trial, number of freezes, and the ratio of walking time to the number of freezes were compared using Friedman's test. Twenty-eight patients with PD, mean age 67.81 years (standard deviation [SD] 7.54), mean disease duration 13.04 years (SD 7.49), and mean motor Unified Parkinson's Disease Rating Scale score "on" 32.59 (SD 10.93), participated in the study. There was a statistically significant correlation of time needed to complete a trial and number of freezes for all three conditions (Spearman correlations: UW 0.973, LBS 0.0.930, and MIS 0.842). The median number of freezes, median time to walk in each condition, and median walking time per freeze were not significantly different in pairwise comparisons of the three conditions (Friedman's test). Of the 28 subjects, six showed improvement with the MIS and six with the LBS in at least one outcome measure. Assisting devices, specifically based on visual cues, are not consistently beneficial in overcoming "on" freezing in most patients with PD. Because this is an otherwise untreatable clinical problem and because occasional subjects do respond, cautious trials of such devices under the supervision of a health professional should be conducted to identify those patients who might benefit from their long-term use.
Article
Evidence suggests that individuals with early and mid-stage Parkinson disease (PD) have diminished range of motion (ROM). Spinal ROM influences the ability to function. In this investigation, the authors examined available spinal ROM, segmental excursions (the ROM used) during reaching, and their relationships in community-dwelling adults with and without PD. The subjects were 16 volunteers with PD (modified Hoehn and Yahr stages 1.5-3) and 32 participants without PD who were matched for age, body mass index, and sex. Range of motion of the extremities was measured using a goniometer, and ROM of the spine was measured using the functional axial rotation (FAR) test, a measure of unrestricted cervico-thoracic-lumbar rotation in the seated position. Motion during reaching was determined using 3-dimensional motion analysis. Group differences were determined using multivariable analysis of variance followed by analysis of variance. Contributions to total reaching distance of segmental excursions (eg, thoracic rotation, thoracic lateral flexion) were determined using forward stepwise regression. Subjects with PD as compared with subjects without PD had less ROM (FAR of 98.2 degrees versus 110.3 degrees, shoulder flexion of 151.9 degrees versus 160.1 degrees) and less forward reaching (29.5 cm versus 34.0 cm). Lateral trunk flexion and total rotation relative to the ground contributed to reaching, with the regression model explaining 36% of the variance. These results contribute to the growing body of evidence demonstrating that spinal ROM is impaired early in PD.
Article
There is a growing body of research related to prescription of mobility devices. This research enables clinicians and clients to make clinical decisions related to mobility based on sound research. Unfortunately, there is little research investigating appropriate prescriptions in degenerative disorders such as multiple sclerosis (MS). In this article we will review the literature on mobility devices in MS and how it can be used to assist with clinical decision-making considering the progressive nature of this condition. In addition, we will review other research not conducted on individuals with MS that is relevant to this population. Finally we will present a call for future research that should help address this critical area.
Article
The GAITRite is a portable gait analysis tool for automated measurement of spatiotemporal gait parameters. Although frequently used for clinical and research purposes, the concurrent validity of GAITRite has not been validated against a criterion measure. The aim of this experiment was to investigate the concurrent validity and test retest reliability of the GAITRite carpet walkway system for quantification of spatial and temporal parameters of the footstep pattern. Twenty-five healthy adults aged 21-71 years (mean 40.5 years, S.D. 17.2) performed three walk trials at self-selected pace, three at fast pace and three at slow pace. For each trial, data were simultaneously collected from the GAITRite and a Clinical Stride Analyzer, which has established reliability and validity. At preferred, slow and fast walking pace there were very high correlations between the two measurement systems for gait speed (ICC (2,1)=0.99), stride length (ICC (2,1)=0.99) and cadence (ICC (2,1)=0.99). Correlations between the electronic carpet and the stride analyser were moderate to high for single limb support (SLS) time (ICC (2,1)=0.69-0.91) and weak for the proportion of the gait cycle spent in double limb support (ICC (2,1)=0.44-0.57). The reliability of repeated measures for the GAITRite was good at preferred and fast speed for speed (ICC (3,1)=0.93-0.94), cadence (ICC (3,1)=0.92-0.94), stride length (ICC (3,1)=0.97), single support (ICC (3,1)=0.85-0.93) and the proportion of the gait cycle spent in double limb support (ICC (3,1)=0.89-0.92). The repeatability of the GAITRite measures were more variable at slow speed (ICC (3,1)=0.76-0.91). These results indicate that the GAITRite system has strong concurrent validity and test retest reliability, in addition to being a portable, simple clinical tool for the objective assessment of gait.
Article
Patients with Parkinson's disease (PD) have an increased risk of falling that has yet to be fully explained. To better understand the gait disturbance in PD and the factors that contribute to falls, we quantitatively evaluated: (1) the relationship between gait variability (a marker of fall risk in other populations), fall history, and other parkinsonian features, and (2) the effects of levodopa on these relationships. The average stride time and stride-to-stride variability were measured using force-sensitive insoles during comfortable walking. Fall frequency, motor control, function, and mental health were measured using the Unified Parkinson's Disease Rating Scale (UPDRS), the Mini-Mental State Exam (MMSE), and the timed motor tests of the Core Assessment Program for Intracerebral Transplantations (CAPIT) in 32 subjects with idiopathic PD, in an "off" (unmedicated) state and again in an "on" (medicated) state. Average stride time was not associated with any UPDRS or CAPIT measure and was similar in fallers and non-fallers in "off" and "on" states (p>0.27). Stride time variability was significantly associated with fall frequency as well as with total scores on the CAPIT and the UPDRS, ADL abilities, and motor function. Stride time variability and falls were not related to tremor, rigidity or bradykinesia in the "off" state. 41% of subjects reported one or more falls. Stride time variability was 8.8+/-7.9% in fallers and 4.2+/-1.3% in non-fallers (p<0.009). Stride time variability significantly improved in response to levodopa, both in fallers and non-fallers, but remained increased in fallers (vs. non-fallers). The patho-physiology responsible for impaired stride-to-stride regulation of gait timing is apparently independent of other cardinal features of PD, i.e., tremor, rigidity, or bradykinesia, but is responsive to levodopa. Stride-to-stride variability is especially impaired among PD subjects with a history of falls, suggesting, for the first time, the possibility of exaggerated impairment of internal clock function in PD fallers.
Article
Compare the efficacy of two walking assistance devices (wheeled walker and standard walker) to unassisted walking for patients with PD and gait freezing. Although numerous walking devices are used clinically, their relative effects on freezing and walking speed have never been systematically tested. Nineteen PD patients (14 non-demented) walked under three conditions in randomized order: unassisted walking, standard walker, and wheeled walker. Patients walked up to three times in each condition through a standard course that included rising from a chair, walking through a doorway, straightway walking, pivoting, and return. Total walking time, freezing time and number of freezes were compared for the three conditions using mixed models (walking time) and Friedman's test (freezing). The wheeled walker was further studied by comparing the effect of an attached laser that projected a bar of light on the floor as a visual walking cue. Use of either type of device significantly slowed walking compared to unassisted walking. Neither walker reduced any index of freezing, nor the laser attachment offered any advantage to the wheeled walker. The standard walker increased freezing, and the wheeled walker had no effect on freezing. Among the non-demented subjects (n=14), the same patterns occurred, although the walking speed was less impaired by the wheeled walker than the standard walker in this group. Though walkers may stabilize patients and increase confidence, PD patients walk more slowly when using them, without reducing freezing. Because the wheeled walker was intermediate for walking time and does not aggravate freezing, if walkers are used for these subjects, this type of walker should be favored.
Article
Cognitive function and the performance of a secondary, dual task may affect certain aspects of gait, but the relationships between cognitive function and gait are not well understood. To better understand the motor control of gait and the relationship between cognitive function and gait, we studied cognitive function and the effects of different types of dual tasking on the gait of patients with Parkinson's disease (PD) and controls, contrasting measures of gait automaticity and rhythmicity with other features. Patients with idiopathic PD (n=30; mean age 71.8 year) with moderate disease severity (Hoehn and Yahr Stage 2--3) were compared to age and gender-matched healthy controls (n=28). Memory and executive function were also assessed. In both groups, gait speed decreased in response to dual tasking, in a parallel fashion. For the PD group only, gait variability increased compared to usual walking. Executive function was significantly worse in the PD group, while memory was not different in the two groups. Executive function measures were significantly correlated with gait variability during dual tasking, but not during usual walking. These findings demonstrate that regulation of gait variability and rhythmicity is apparently an automatic process that does not demand attention in healthy adults. In patients with PD, however, this ability becomes attention-demanding and worsens when subjects perform secondary tasks. Moreover, the associations between executive function and gait variability suggest that a decline in executive function in PD may exacerbate the effects of dual tasking on gait, potentially increasing fall risk.
Article
Limited research exists on fear of falling and its affect on gait parameters. Studies have shown a relationship between fear of falling and restriction of activities. The purpose of this study was to determine if a fear of falling in elderly persons was associated with changes in spatial and temporal gait parameters, independent of a history of falls. It was hypothesized that, in elderly persons, gait changes would be associated with a preexisting fear of falling. Ninety-five community-dwelling adults, aged 60-97 years (mean age = 74, standard deviation = 8.5) participated in this study. Participant scores on the Modified Falls Efficacy Scale determined an individual's placement into the "fearful" or "fearless" category. Spatial and temporal gait parameters of speed, stride length, step width, and double limb support time were assessed using the GAITRite system, a computerized electronic walkway. The fearful group had a significantly slower gait speed (p <.05) and shorter stride length (p <.05) when compared to the fearless group. Stride width was significantly longer (p =.05) and double limb support time was significantly prolonged (p <.05) in the fearful participants when measured against the fearless participants. The results of this study support the hypothesis that fear of falling does influence spatial and temporal gait parameter changes in elderly persons. Slower gait speed, shorter stride length, increased stride width, and prolonged double limb support time were found to be associated with a preexisting fear of falling.
Article
Article
While it is known that certain pathologies may impact on left–right symmetry of gait, little is known about the mechanisms that contribute to gait symmetry or how high in the hierarchy of the control of gait symmetry is regulated in humans. To assess the contribution of cognitive function to gait symmetry, we measured gait asymmetry (GA) in three subject groups, patients with Parkinson’s disease (PD, n = 21), idiopathic elderly fallers (n = 15), and healthy elderly controls (n = 11). All subjects walked under two walking conditions: usual walking and dual tasking (cognitive loading) condition. For each subject, the swing time (SW) was calculated and averaged across strides for the left and right feet (SWL and SWR). GA was defined as: $$100 \times {\left| {\ln ({\text{SWR}}/{\text{SWL}})} \right|.}$$ For both the PD patients and the elderly fallers GA values were significantly higher during the usual walking condition, as compared with the control group (P < 0.01). In addition, for both the PD patients and the elderly fallers, GA significantly increased when they walked and performed a dual task, compared with the usual walking condition (P < 0.003). In contrast, dual tasking did not affect the GA of the healthy controls (P = 0.518). GA was associated with gait speed and gait variability, but no correlations were found between GA and the asymmetry of the classic PD motor symptoms. Thus, the results suggest that the ability to generate a steady, rhythmic walk with a bilaterally coordinated gait does not rely heavily on mental attention and cognitive resources in healthy older adults. In contrast, however, when gait becomes impaired and less automatic, GA apparently relies on cognitive input and attention.
Diagnosing Dementia with Lewy Bodies and Parkinson's Disease Dementia, Mangurian Family Fund, Co-Investigator; Impact of Xenazine on gait and functional activity in individuals with Huntington's disease, Lundbeck, Inc. Co-Principal Investigator. Acknowledgements We would like to acknowledge Dr
• A D Kloos
Full financial disclosures for the past year for A.D. Kloos: Diagnosing Dementia with Lewy Bodies and Parkinson's Disease Dementia, Mangurian Family Fund, Co-Investigator; Impact of Xenazine on gait and functional activity in individuals with Huntington's disease, Lundbeck, Inc. Co-Principal Investigator. Acknowledgements We would like to acknowledge Dr. Thomas H. and Mrs. Kelly Mallory and Robert A. Vaughan Family Funds for supporting this research and Yi Ding and Amanda Hartman for their assistance with data collection. References
Risk factors for falls as a cause of hip fracture in women. The Northeast Hip Fracture Study Group
• Kelsey J Jl Grisso
• Bl Strom
• Chiu Gy
• O G Maislin
• La Brien
Grisso J, Kelsey JL, Strom BL, Chiu GY, Maislin G, O'Brien LA. et al. Risk factors for falls as a cause of hip fracture in women. The Northeast Hip Fracture Study Group. The New England Journal of Medicine 1991;324:1326–31.
Product comparison and evaluation: canes, crutches and walkers Rehabilitation Engineering Center at the National Rehabili-tation Hospital
• Aarp
AARP. Product comparison and evaluation: canes, crutches and walkers. Washington, DC: Rehabilitation Engineering Center at the National Rehabili-tation Hospital; 1990, AARP Walker Product Report.
Pr0- spective .SX3ismmt of f~1s in Parkinson's disease. journ
• Sr Bloem
• Va Crimbcrgcn
• M Cramer
• M Willemsen
• Ah Zwindmnan
Bloem SR. Crimbcrgcn VA, Cramer M, Willemsen M, ZWindmnan AH. Pr0- spective.SX3ismmt of f~1s in Parkinson's disease. journ.al of Neurology 2001 :248:950-8.
Quantit.ltive gait markers and inddent fall risk in older adults
• J Vergbese
• R Holtzer
• R D Lipton
• C Wang
Vergbese J, Holtzer R. lipton RD, Wang C. Quantit.ltive gait markers and inddent fall risk in older adults. journals of GerontolOlY Series A Biological Sciences and Medical Sciences 2009;64:896-901.
Pr0-spective .SX3ismmt of f~1s in Parkinson's disease
• S R Bloem
• V A Crimbcrgcn
• M Cramer
• M Willemsen
• A H Zwindmnan
Bloem SR. Crimbcrgcn VA, Cramer M, Willemsen M, ZWindmnan AH. Pr0-spective.SX3ismmt of f~1s in Parkinson's disease. journ.al of Neurology 2001 :248:950-8.
Risk fKton (or falls as a cause ofhip fracture in women. The Northeast Hlp Fracture Study Group
• G Y Chiu
• G Maililin
• O 'brien La
Chiu GY. Maililin G, O'Brien lA et aI. Risk fKton (or falls as a cause ofhip fracture in women. The Northeast Hlp Fracture Study Group. The New England Journal of Medicine 1991;324:1326-31.
Gait changes with walking devices In persons with Parkinson's disease
• M S Bryant
• A Thrasher
Bryant MS. Pourmoshaddam A. Thrasher A. Gait changes with walking devices In persons with Parkinson's disease. Disability ilnd Rehabilitation Assistlve TechnoloJY 2011;7:149-52.
Laserlight cues for gait freezing in Parkinson's disease: an open-label study
• Donovan S Urn
• C Diaz
• N Browner
• N Rose
• P Sudarsky
• L R Et
Donovan S. Urn C. Diaz N, Browner N, Rose P, SUdarsky LR. et 011. Laserlight cues for gait freezing in Parkinson's disease: an open-label study. Parkinsonism and Related Disordm: 2011;17:240-5.
wbeeled walker in a geriatric population
• J Mahoney
• R Eutwdy
• M Clmes
Mahoney J, Eutwdy R. Clmes M. A comparison ola two-wheel.ed walker and a thref...wbeeled walker in a geriatric population. journal of the American Geriatrics Society 1992;40:208-12.
Ray L Spinal movement and performance of a standing reach task in partidpanu with and without Parkinson disease
• M Schenianan
• K Clark
• T Xie
• M Kuchibhatla
• M Shinberg
Schenianan M, Clark K, Xie T, Kuchibhatla M, Shinberg M, Ray L Spinal movement and performance of a standing reach task in partidpanu with and without Parkinson disease. Physical Therapy 2001 ;81 : 1 400-1 1.
Rehabilitadon Engineering Center at the National Rehabilitation Hospitoll
MRP. Product comparison and enluatlon: canes, crutches and walkers. Washington, DC: Rehabilitadon Engineering Center at the National Rehabilitation Hospitoll; 1990, MRP Walker Product Report.
On" freezing in Parkinson's disease: resis~nce to visual cue walkina: devices
• K Kompoliti
• C G Goetz
• S Lcurgans
• M Morrissey
• Siegel
Kompoliti K, Goetz CG, Lcurgans S, Morrissey M. Siegel 1M. "On" freezing in Parkinson's disease: resis~nce to visual cue walkina: devices. Movement Disorders 2000;15:309-12.