ArticleLiterature Review

Is there a relationship between postural alignment and mobility for adults after acquired brain injury? A systematic review

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Abstract

Primary objective: To examine the relationship between postural alignment and mobility skills for adults after acquired brain injury (ABI). Methods: Systematic review of the literature. Seven electronic databases, grey literature and reference lists of the shortlisted publications were searched. Studies were included if participants were adults with ABI, both postural alignment and mobility were measured and analysis included a relationship between alignment and mobility. Those that met the inclusion criteria were assessed with a critical appraisal tool. The review was registered with PROSPERO, registration number CRD42015019867. Results: Seven observational studies were included that had examined a relationship between postural alignment and mobility after ABI. Critical appraisal scores were moderate to strong. While some studies reported that improved postural alignment was related to improved mobility after ABI, results varied and there was insufficient evidence to answer the primary question. Heterogeneous study designs did not allow meta-regression. Conclusions: A small amount of observational evidence exists for a relationship between postural alignment and mobility after ABI. Results vary, with some studies reporting that a more stable, upright trunk correlates with better mobility, and others providing conflicting or ambiguous results. Further research is needed to establish the relationship between postural alignment and mobility skills after ABI.

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... However, clinically, it is common to see changes involving the whole body after ABI, including marked changes in postural alignment (Karnath, 2007). While upright postural alignment is usual in healthy standing and walking (Cromwell et al., 2001;Ferreira et al., 2011), the implications of impaired postural alignment have not been investigated, as alignment of body segments after ABI has received little attention in biomechanical research (Mills, McDonnell, Thewlis and Mackintosh, 2017). Clinical guidelines advocate that postural issues are problematic after brain injury, however, evidence is needed to support this Postural measures used in previous clinical studies include body segment angle measured between two landmarks (Amabile et al., 2016;Krawczky, Pacheco and Mainenti, 2014), centre of gravity displacement in sitting and standing (Lafosse et al., 2007), measurement of inclination of the trunk and head (Piscicelli et al., 2016) and visual evaluation of trunk tilt in sitting (Taylor, Ashburn and Ward, 1994). ...
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Purpose: Determine how mobility changes over 6 months in people unable to walk at 8-weeks post-Acquired Brain Injury (ABI); if there is an association over time between postural alignment and mobility post-ABI; and if alignment after ABI becomes closer to healthy alignment over time. Methods: Fourteen adults with ABI, evaluated over 6 months, and a reference sample of 30 healthy adults were studied. The primary measure for changes in mobility was the Clinical Outcome Variables Scale (COVS). Secondary measures were sit-to-stand, timed standing holding rails, independent walking speed and number of testing conditions achieved. The Functional Independence Measure (FIM) was scored at rehabilitation admission and discharge. To analyze postural alignment, participants were recorded in sitting and standing, each repeated holding rails, and walking if able. Three-dimensional kinematic data were used to quantify whole-body postural alignment, equal to mean segment displacements from the base of support in the transverse plane. Associations between three-dimensional kinematic alignment scores and COVS scores were calculated using Linear Mixed-Effects Models. Results: Participants made significant improvements in COVS scores, most secondary mobility scores, and FIM scores over time (p ≤ .001). Relationships between increasing COVS scores and decreasing sitting and standing mal-alignment scores were statistically significant. Visual analysis of graphed segment positions indicated that sitting and standing alignment became more similar to healthy alignment over time; this was not clear for walking. Conclusion: Improvement in postural alignment may be a factor for improving mobility in people with severe impairments after ABI.
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To examine the frequency and factors associated with patients with stroke in Australian hospitals receiving documented rehabilitation assessments; the criteria used when rehabilitation was not recommended; and whether being assessed for rehabilitation affected access to rehabilitation. Retrospective medical record audit of patients with a diagnosis of stroke who were discharged consecutively between 2013 and 2014. 10 acute care public hospitals in Australia. Adults with stroke (n=333) receiving care in the participating hospitals INTERVENTIONS: Not applicable. Documented assessment regarding patient suitability for rehabilitation during the acute hospitalisation. Data from 292 patients were included for analysis (60% male, mean age 72). 42% of patients were assessed for rehabilitation by a health professional providing care in the hospital. 43% of patients were assessed for rehabilitation by a representative from a rehabilitation service. 37% of patients did not receive any documented rehabilitation assessment. In multivariable analysis, patients were significantly more likely to be assessed for rehabilitation if they lived in the community before their stroke, had moderate severity strokes, or received occupational therapy during the hospital admission. Rehabilitation was not recommended in 9% of assessments despite the presence of stroke-related symptoms. Patients not assessed for rehabilitation were significantly less likely to access rehabilitation than patients who were assessed. More than one third of the patients were not assessed for rehabilitation. When assessed, rehabilitation was not consistently recommended for patients with stroke-related symptoms. This study highlights factors that increase the likelihood of being assessed for rehabilitation. Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
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Background & objective: This study was executed to find out correlation between postural alignment in sitting measured through photogrammetry and postural control in sitting following stroke. Methods: A cross-sectional study with convenient sampling consisting of 45 subjects with acute and sub-acute stroke. Postural alignment in sitting was measured through photogrammetry and relevant angles were obtained through software MB Ruler (version 5.0). Seated postural control was measured through Function in Sitting Test (FIST). Correlation was obtained using Spearman's Rank Correlation co-efficient in SPSS software (version 17.0). Results: Moderate positive correlation (r = 0.385; p < 0.01) was found between angle of lordosis and angle between acromion, lateral epicondyle and point between radius and ulna. Strong negative correlation (r = -0.435; p < 0.01) was found between cranio-vertebral angle and kyphosis. FIST showed moderate positive correlation (r = 0.3446; p < 0.05) with cranio-vertebral angle and strong positive correlation (r = 0.4336; p < 0.01) with Brunnstrom's stage of recovery in upper extremity. Conclusion: Degree of forward head posture in sitting correlates directly with seated postural control and inversely with degree of kyphosis in sitting post-stroke. Postural control in sitting post-stroke is directly related with Brunnstrom's stage of recovery in affected upper extremity in sitting.
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Background: The restoration of trunk function following stroke is a key component of rehabilitation, however there is limited evidence of the efficacy of additional trunk training. Objectives: To evaluate the efficacy of trunk exercises added to conventional rehabilitation on functional outcomes. Methods: Relevant randomised controlled trials (RCTs), published up to July 2012, evaluating the effect of the addition of trunk exercises to conventional rehabilitation on functional outcomes were identified in Medline, Cinahl, Embase, Pubmed, PEDro, Web of Science and Scopus databases. Findings were summarised across studies as mean or standardised mean differences (MD or SMD) with 95% confidence intervals. Results: Six RCTs with 155 participants and a mean PEDro score of 6.5 (range 6 to 8) were included. Data from two to five studies were pooled in meta-analyses that showed a moderate, non-significant effect of additional trunk exercise on trunk performance, (SMD=0.50; 95% CI -0.25, 1.25; P=0.19); large effects on standing balance, SMD=0.72 (95%CI -0.01, 1.45 P=0.05); and walking ability, (SMD = 0.81; 95% CI 0.30, 1.33. P=0.002) and a small, non-significant effect, MD=10.03 (95% CI -15.70, 35.75. P=0.44) on functional independence. Conclusions: There is moderate evidence that the addition of specific trunk exercise to conventional early stroke rehabilitation significantly improved standing balance and mobility after stroke; however the evidence was weak for the effect of additional trunk exercise on trunk performance and in functional independence.
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Trunk control has been identified as an important early predictor of functional outcome after stroke but there is insufficient evidence that proximal stability of the trunk is a pre-requisite for sitting and standing balance, walking, and functional activities. We systematically reviewed the literature on trunk training exercises (TTE) in adult patients with stroke. To establish if TTE can improve trunk performance and sitting balance. CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro, REHABDATA Database, Scielo, Scopus, Web of Science, Trip Database, and Epistemonikos were searched and reference lists screened to identify randomised controlled trials (RCTs) of trunk training exercises in stroke survivors. Two reviewers independently screened references, selected relevant studies, extracted data, and assessed trial quality. The primary outcomes were trunk performance and sitting balance. Due to the heterogeneity of included studies meta-analysis was not possible. A total of 11 studies with 317 participants were analysed. Trunk training exercises showed a moderate evidence to improve trunk performance and dynamic sitting balance. Trunk training exercises, performed with either stable or unstable surface, could be a good rehabilitation strategy and might help improving trunk performance and dynamic sitting balance after stroke.
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The purpose of this study was to review the literature relating to the psychosocial costs associated with traumatic brain injury (TBI). Nine online journal databases, including MEDLINE, CINAHL, PsychINFO, and PUBMED, were queried for studies between July 2010 and May 2012 pertaining to the economic burden of head injuries. Additional studies were identified through searching bibliographies of related publications and using Google internet search engine. One hundred and eight potentially relevant abstracts were identified from the journal databases. Ten papers were chosen for discussion in this review. All but two of the chosen papers were US studies. The studies included a cost-benefit analysis of the implementation of treatment guidelines from the US brain trauma foundation and a cost-effectiveness analysis of post-acute traumatic brain injury rehabilitation. Very little research has been published on the economic burden that mild and moderate traumatic brain injury patients pose to their families, careers, and society as a whole. Further research is needed to estimate the economic burden of these patients on healthcare providers and social services and how this can impact current health policies and practices.
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Background Stroke severely affects walking ability and assessment of gait kinematics is important in defining diagnosis, planning treatment, and evaluating interventions in stroke rehabilitation. Although observational gait analysis is the most common approach to evaluate gait kinematics, tools useful for this purpose have received little attention in scientific literature and have not been thoroughly reviewed.Objectives The aims of this systematic review were to identify tools proposed to conduct observational gait analysis in adults with a stroke, to summarize evidence concerning their quality, and to assess their implementation in rehabilitation research and clinical practice.Methods An extensive search was performed of original papers reporting on visual/observational tools developed to investigate gait kinematics in adults with a stroke. Two reviewers independently selected studies, extracted data, assessed quality of included studies, and scored metric properties and clinical utility of each tool. Rigor in reporting metric properties and dissemination of the tools were also evaluated.ResultsFive tools were identified, not all of which had been tested adequately for their metric properties. Evaluation of content validity was partially satisfactory; reliability was poorly investigated in all but one tool; concurrent validity and sensitivity to change were shown for three and two tools respectively. Overall, adequate levels of quality were rarely reached. The dissemination of the tools was poor.Conclusions Based on critical appraisal, the Gait Assessment and Intervention Tool shows a good level of quality that leads us to recommend its use in stroke rehabilitation. Rigorous studies are needed for the other tools, in order to establish their usefulness.
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Participation rates and quality-of-life (QoL) have been a major focus of rehabilitation programmes and outcome studies following traumatic brain injury (TBI). The extent to which mobility limitations impact on participation rates and QoL has not been thoroughly explored. The main aim of this study was to investigate the relationship between mobility limitations, participation rates and QoL following TBI. Thirty-nine people who had sustained an extremely severe TBI were recruited from a major rehabilitation facility. Mobility was quantified using the high-level mobility assessment tool (HiMAT). The Brain Injury Community Rehabilitation Outcome (BICRO-39) and Community Integration Questionnaire (CIQ) were used to measure participation rates and the shorter version of the World Health Organization Quality of Life (WHOQoL-BREF) and Assessment of Quality-of-Life (AQoL-2) were used to measure QoL. Mobility was most strongly correlated with the total BICRO-39 score (r = -0.60, p < 0.001) and the mobility domain (r = -0.59, p < 0.001) of the BICRO-39. Although mobility had a significant relationship with health-related QoL, AQoL-2 (r = 0.60, p < 0.001), it was most strongly related to the AQoL-2 independent living domain (r = 0.79, p < 0.001). Greater capacity to mobilize was associated with higher participation rates and better QoL.
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The purpose of this study was to analyze kinematic trunk motion data in normal adults and to investigate gender effect. Kinematic trunk motion data were obtained for 20 healthy subjects (11 men and 9 women; age from 21 to 40 years) during walking a 9 m long lane at a self selected speed, namely, motions in the sagittal (tilt), coronal (obliquity), and transverse (rotation) planes, which were all expressed as motions in global (relative to the ground) and those in pelvic reference frame (relative to pelvis), i.e., tilt (G), obliquity (G), rotation (G), tilt (P), obliquity (P), rotation (P). Range of tilt (G), obliquity (G) and rotation (G) showed smaller motion than that of tilt (P), obliquity (P) and rotation (P), respectively. When genders were compared, female trunks showed a 5 degree more extended posture during gait than male trunks (p = 0.002), which appeared to be caused by different lumbar lordosis. Ranges of coronal and transverse plane motion appeared to be correlated. In gait cycle, the trunk motion appeared to counterbalance the lower extremity during swing phase in sagittal plane, and to reduce the angular velocity toward the contralateral side immediate before the contralateral heel strike in the coronal plane. Men and women showed different lumbar lordosis during normal gait, which might be partly responsible for the different prevalence of lumbar diseases between genders. However, this needs further investigation.
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To investigate how many people return to work (RTW) after acquiring brain injury (ABI) due to traumatic or non-traumatic causes. Secondary objectives were to investigate the differences in outcome between traumatic and non-traumatic causes, the development of RTW over time and whether or not people return to their former job. A systematic literature search (1992-2008) was performed using terms of ABI and RTW. The methodological quality of the studies was determined. An overall estimation of percentage RTW 1 and 2 years post-injury was calculated by data pooling. Finally, 49 studies were included. Within 2 years post-injury, 39.3% of the subjects with non-traumatic ABI returned to work. Among people with traumatic ABI, 40.7% returned to work after 1 year and 40.8% after 2 years. No effect of cause or time since injury was found. Some people with traumatic ABI who returned to work were not able to sustain their job over time. Changes of occupation and job demands are common among people with ABI. About 40% of the people with traumatic or non-traumatic ABI are able to return to work after 1 or 2 years. Among those with acquired traumatic brain injury a substantial proportion of the subjects were either not able to return to their former work or unable to return permanently.
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Steering of locomotion is a complex task involving stabilizing and anticipatory orienting behavior essential for the maintenance of balance and for establishing a stable frame of reference for future motor and sensory events. How these mechanisms are affected by stroke remains unknown. To compare locomotor steering behavior between stroke and healthy individuals and to determine whether steering abilities are influenced by walking speed, turning direction and walking capacity in stroke individuals. Gaze and body kinematics were recorded in 8 stroke and 7 healthy individuals while walking and turning in response to a visual cue. Horizontal orientation of gaze, head, thorax, pelvis, and feet with respect to spatial and heading coordinates were examined. Temporal and spatial coordination of gaze and body movements revealed stabilizing and anticipatory orienting mechanisms in the healthy individuals. Changing walking speed affected the onset time but not the sequencing of segment reorientation. In the individuals with stroke, abnormally large and uncoordinated head and gaze motion were observed. The sequence of gaze, head, thorax and pelvis horizontal reorientation also was also disrupted. Alterations in orienting behaviors were more pronounced at the slowest walking speeds and turning to the nonparetic side in 3 of the most severely disabled individuals. The results in this convenience sample of slow and faster walkers suggest that stroke alters the stabilizing and orienting behavior during steering of locomotion. Such alterations are not caused by the inherently slow walking speed, but rather by a combination of biomechanical factors and defective sensorimotor integration, including altered vestibulo-ocular reflexes.
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To date, reviews of rehabilitation efficacy after traumatic brain injury (TBI) have overlooked the impact on sense of self, focusing instead on functional impairment and psychological distress. The present review sought to address this gap by critically appraising the methodology and efficacy of intervention studies that assess changes in self-concept. A systematic search of PsycINFO, Medline, CINAHL and PubMed was conducted from inception to September 2013 to identify studies reporting pre- and post-intervention changes on validated measures of self-esteem or self-concept in adults with TBI. Methodological quality of randomised controlled trials (RCTs) was examined using the Physiotherapy Evidence Database (PEDro) scale. A total of 17 studies (10 RCTs, 4 non-RCT group studies, 3 case studies) was identified, which examined the impact of psychotherapy, family-based support, cognitive rehabilitation or activity-based interventions on self-concept. The findings on the efficacy of these interventions were mixed, with only 10 studies showing some evidence of improvement in self-concept based on within-group or pre-post comparisons. Such findings highlight the need for greater focus on the impact of rehabilitation on self-understanding with improved assessment and intervention methodology. We draw upon theories of identity reconstruction and highlight implications for the design and evaluation of identity-oriented interventions that can supplement existing rehabilitation programmes for people with TBI.
Article
Background and purpose: Trunk control is impaired after stroke but little is known about how changes in posture relate to other deficits. We examined spinal postural alignment in people with chronic stroke and explored the relationship between postural alignment and clinical measures. Methods: Twenty-one subjects with stroke and 22 age-matched healthy comparison subjects participated in this observational, cross-sectional study. Data collection included measurements of thoracic, lumbar, sacral, and overall postural alignment in the sagittal plane in both sitting and standing. Measurements were made in different postures, including: upright, flexed forward, and extended backward. Clinical outcome measures included the Trunk Impairment Scale and its subscales, Fugl-Meyer Scale, Berg Balance Scale, Barthel Index, and Stroke Impact Scale. Results: Significant deviations in postural alignment for participants with stroke compared with comparison subjects were apparent in sacral alignment (P < 0.02) and overall postural alignment (P < 0.01) in standing. These measurements were also significantly correlated with clinical outcome measures poststroke. Participants with stroke who had a more forward leaning posture when upright scored worse on the coordination subscale of the Trunk Impairment Scale (r = -0.61) and Berg Balance Scale (r = -0.64). Participants with greater anterior pelvic tilt when flexed forward and more overall inclination when flexed forward and extended backward scored better on the Trunk Impairment Scale, its subscales, and Berg Balance Scale (r = -0.6-0.7). Discussion and conclusions: People with chronic stroke have altered postural alignment in standing compared with subjects without neurological deficits. Investigating interventions focusing on increasing anterior and posterior pelvic tilt seem warranted.Video Abstract available. See video (Supplemental Digital Content 1, http://links.lww.com/JNPT/A76) for more insights from the authors.
Article
Background: Findings from prognostic studies of functional and psychosocial recovery after traumatic brain injury (TBI) reported to date have been limited by the restricted timeframe for prediction, generally within the first 5 years post-trauma. This investigation examined prediction of functional and psychosocial recovery in the medium-term (6 years post-trauma; Time 1) and long-term (23 years post-trauma; Time 2). Methods: The participants comprised a consecutive series of the first 100 patients with severe TBI receiving their primary rehabilitation at a regionally based unit. At the 23-year follow-up, 91% of the sample was traced: 17 had died, 5 declined participation, and 69 were interviewed, with 68 participating at both Time 1 and Time 2. Five outcome domains were examined: mobility, self-care, employability, relationships and living skills. Results: Very few of seven pre-injury variables were significantly correlated with any of the outcome variables. A series of logistic regression analyses successfully predicted levels of recovery in all domains using four predictor variables: pre-injury occupational status, duration of post-traumatic amnesia, and physical and neuropsychological disability at rehabilitation discharge. At Time 1, 60% or more of the variance was accounted for in four of the five domains, and at Time 2, more than 40% of the variance was accounted for in all domains. Sensitivity ranged from 62% (self-care) to 90% (mobility). With a single exception (employability at Time 2), specificity was also high, ranging from 80% (relationships) to 98% (mobility). Comparable accuracy rates were also found for positive and negative predictive power. Conclusions: These results demonstrate impressive predictive capacity of early post-trauma variables for the very long-term levels of recovery. They provide guidance for the tailoring of individual rehabilitation programs and the identification of people who may require special supports after rehabilitation discharge.
Article
The common denominator in the assessment of human balance and posture is the inverted pendulum model. If we focus on appropriate versions of the model we can use it to identify the gravitational and acceleration perturbations and pinpoint the motor mechanisms that can defend against any perturbation.We saw that in quiet standing an ankle strategy applies only in the AP direction and that a separate hip load/unload strategy by the hip abd/adductors is the totally dominant defence in the ML direction when standing with feet side by side. In other standing positions (tandem, or intermediate) the two mechanisms still work separately, but their roles reverse. In the tandem position ML balance is an ankle mechanism (invertors/evertors) while in the AP direction a hip load/unloading mechanism dominates.During initiation and termination of gait these two separate mechanisms control the trajectory of the COP to ensure the desired acceleration and deceleration of the COM. During initiation the initial acceleration of the COM forward towards the stance limb is achieved by a posterior and lateral movement of the COP towards the swing limb. After this release phase there is a sudden loading of the stance limb which shifts the COP to the stance limb. The COM is now accelerated forward and laterally towards the future position of the swinging foot. Also ML shifts of the COP were controlled by the hip abductors/adductors and all AP shifts were under the control of the ankle plantar/dorsiflexors. During termination the trajectory of both COM and COP reverse. As the final weight-bearing on the stance foot takes place the COM is passing forward along the medial border of that foot. Hyperactivity of that foot's plantarflexors takes the COP forward and when the final foot begins to bear weight the COP moves rapidly across and suddenly stops at a position ahead of the future position of the COM. Then the plantarflexors of both feet release and allow the COP to move posteriorly and approach the COM and meet it as quiet stance is achieved. The inverted pendulum model permitted us to understand the separate roles of the two mechanisms during these critical unbalancing and rebalancing periods.During walking the inverted pendulum model explained the dynamics of the balance of HAT in both the AP and ML directions. Here the model includes the couple due to the acceleration of the weight-bearing hip as well as gravitational perturbations. The exclusive control of AP balance and posture are the hip extensors and flexors, while in the ML direction the dominant control is with the hip abductors with very minor adductor involvement. At the ankle the inverted pendulum model sees the COM passing forward along the medial border to the weight-bearing foot. The model predicts that during single support the body is falling forward and being accelerated medially towards the future position of the swing foot. The model predicts an insignificant role of the ankle invertors/evertors in the ML control. Rather, the future position of the swing foot is the critical variable or more specifically the lateral displacement from the COM at the start of single support. The position is actually under the control of the hip abd/adductors during the previous early swing phase.The critical importance of the hip abductors/adductors in balance during all phases of standing and walking is now evident. This separate mechanism is important from a neural control perspective and clinically it focuses major attention on therapy and potential problems with some surgical procedures. On the other hand the minuscule role of the ankle invertors/evertors is important to note. Except for the tandem standing position these muscles have negligible involvement in balance control.
Article
This study was undertaken to describe and compare the forward and lateral trunk flexion strength of 20 patients with stroke and hemiparesis and 20 matched controls. Trunk flexion strength was measured with a hand-held dynamometer while subjects were seated upright. Analysis of variance procedures showed trunk strength, whether lateral or forward, to be decreased significantly in the patients relative to controls. The greatest difference between groups was in forward flexion strength. The patients also demonstrated weakness of the trunk on the paretic relative to the nonparetic side. The results show that trunk muscle strength is impaired multidirectionally in patients with stroke. Such impairments have the potential to affect function.
Article
It has been observed that some patients, often with unilateral neglect, have difficulty sitting with their trunk symmetrically and tend to lean towards their affected side. The aim of the study was to see whether this inability to achieve midline sitting existed, and if it did whether there was any relationship with motor function and unilateral neglect. The sample consisted of 38 stroke patients assessed at one, three and six weeks post stroke. Of these 17 had a right hemiplegia and 21 a left hemiplegia. Data were collected using the Rivermead Motor Assessment (RMA), star cancellation tests and a measure of midline position. By six weeks most (28) of the subjects sat with their trunk in the midline or towards their unaffected side (group A). Nine subjects sat with their trunk leaning to their affected side (group B). Most of this group (eight) showed signs of unilateral neglect. Chi-square statistics showed that there were more subjects with unilateral neglect in group B than group A ( p <0.001). In the gross function section of the RMA Mann-Whitney statistics showed that group B scored significantly worse than group A at three and six weeks post stroke ( p = 0.029, p = 0.008). There were no differences in the groups in terms of leg/trunk or arm scores. The findings suggest that there is a group of stroke patients who tend to sit with their trunk leaning towards their affected side and that these patients tend to have unilateral neglect and a poorer functional outcome.
Article
Primary objectives: The aim of this study was to identify the type and incidence of running abnormalities following TBI when compared to a group of healthy controls (HC) and report if these abnormalities were similar to those which are present during gait. Research design: A convenience sample of 44 people with TBI receiving therapy for mobility limitations and a sample of 15 healthy controls (HCs). Main outcomes and results: Spatio-temporal, kinematic and kinetic data at self-selected walking and running speeds were collected. People with TBI ran at significantly slower self-selected speeds than HCs. At matched running speeds, people with TBI used a higher cadence and shorter step length. The most commonly observed biomechanical abnormalities occurred at the knee during stance phase. Few trunk, pelvic or hip abnormalities were detected. Ankle power generation at push-off was significantly reduced, whereas hip extensor power generation at initial contact was significantly increased. Conclusion: Many people with TBI may actually be capable of running, despite the presence of significant biomechanical abnormalities during gait. A stable trunk may be an important requirement for people following TBI to achieve running.
Article
Background and purpose: Decreased walking speed after stroke may be related to changes in temporal and distance gait factors, endurance, and balance. Functional gait deficits may also be related to changes in coordination, specifically between transverse (yaw) plane trunk movements. Our aim was to determine the relationship between intersegmental coordination during gait and functional gait and balance deficits in individuals with stroke. Methods: Eleven individuals with chronic stroke and 11 age-matched subjects without disability participated in 2 sessions. In Session 1, clinical evaluations of trunk/limb impairment (Chedoke-McMaster Stroke Assessment), functional gait (Functional Gait Assessment), and balance (BesTest) were performed. In Session 2, gait kinematics during eight 30-second walking trials on a self-paced treadmill at 2 speeds (comfortable and equivalent) were recorded. Equivalence of walking speeds was obtained by asking subjects without disability to walk approximately 20% slower and subjects with stroke to walk approximately 20% faster than their comfortable speed. Thorax and pelvis 3-dimensional angular ranges of motion (ROMs) and intersegmental coordination using the continuous relative phase were analyzed. Results: Comfortable walking speed was slower in subjects with stroke (0.78 m/s) than in subjects without disability (1.22 m/s), despite matched cadences. At both comfortable and equivalent walking speeds (0.97-0.98 m/s), participants with stroke used more thoracic ROM than pelvic transverse ROM in comparison with subjects without disability. Transverse thorax-pelvis coordination was similar between groups when walking speeds were equivalent, but there was more in-phase coordination in participants with stroke walking at their comfortable, slower speed. In subjects with stroke, thoracic ROM and continuous relative phase were correlated with several clinical functional gait and balance measures. Discussion and conclusion: Changes in segmental transverse ROM and coordination were associated with poor gait and with balance abilities in individuals with stroke. Interventions focusing on recovery of these movement characteristics may lead to better clinical outcomes.
Article
Lower extremity mobility difficulties often result from common medical conditions and can disrupt both physical and emotional well-being. To assess the national prevalence of mobility difficulties among noninstitutionalized adults and to examine associations with demographic characteristics and other physical and mental health problems. Cross-sectional survey using the 1994-1995 National Health Interview Survey-Disability Supplement (NHIS-D). We constructed measures of minor, moderate, and major lower extremity mobility difficulties using questions about ability to walk, climb stairs, and stand, and use of mobility aids (e.g., canes, wheelchairs). Age and gender adjustment used direct standardization methods in Software for the Statistical Analysis of Correlated Data (SUDAAN). Noninstitutionalized, civilian U.S. residents aged 18 years and older. National Health Interview Survey sampling weights with SUDAAN provided nationally representative population estimates. An estimated 19 million people (10.1%) reported some mobility difficulty. The mean age of those with minor, moderate, or major difficulty ranged from 59 to 67 years. Of those reporting major difficulties, 32% said their problems began at aged 50 years or younger. Adjusted problem rates were higher among women (11.8%) than men (8.8%), and higher among African American (15.0%) than whites (10.0%). Persons with mobility difficulties were more likely to be poorly educated, living alone, impoverished, obese, and having problems conducting daily activities. Among persons with major mobility difficulties, 30.6% reported being frequently depressed or anxious, compared to 3.8% for persons without mobility difficulties. Reports of mobility difficulties are common, including among middle-aged adults. Associations with poor performance of daily activities, depression, anxiety, and poverty highlight the need for comprehensive care for persons with mobility problems.
Article
Background: Reduced balance, spasticity, contractures, muscle weakness, and motor skill levels may all contribute to mobility limitations after traumatic brain injury (TBI), yet the key physical impairments that contribute to mobility limitations remain unclear. Objective: The aim of this study was to determine which physical impairments best predict mobility performance after a period of 6 months of rehabilitation. Participants: Participants with TBI were selected if they were receiving therapy for mobility limitations but were able to walk without physical assistance. Outcome measures: The clinical assessment included measures of balance, spasticity, and contracture, and 3-dimensional quantitative gait analysis was used to quantify joint power generation and motor skill level on 31 adults with severe TBI. Mobility outcome was quantified with the high-level mobility assessment tool. Results: Two variables, ankle joint power generation during the push-off phase of gait and motor skill level, explained 66.5% of the variability in mobility outcome. Balance, strength, and mobility performance, all improved significantly over the 6 months of rehabilitation. Only 2 participants had contractures, which affected mobility. Balance disorders were prevalent and improved with rehabilitation, yet they contributed to only a limited extent to the level of recovery in mobility. Conclusion: Ankle joint power generation at push-off was the strongest predictor of mobility outcome after 6 months of rehabilitation in ambulant people with TBI.
Article
The purpose of this study was to systematically assess three-dimensional trunk kinematics during level walking in normal subjects, to establish a preliminary baseline for comparison to future research in gait analysis, and aid in the identification of pathological gait. Seventeen volunteers between the ages of 20 and 50, who met criteria for normal subjects, participated. Trunk kinematic data were collected using an optoelectronic technique. An ensemble average of trunk kinematic data in each of the cardinal planes was plotted in degrees of motion versus percentage of gait cycle. A distinct pattern of trunk kinematics during gait was found in this study. These data, along with information from past researchers, were used to identify the critical trunk kinematic events which occur during walking.
Article
Regaining poststroke mobility is considered a primary goal of the stroke patient in early rehabilitation. Predictive recovery of poststroke mobility is clinically important, and provides important information to healthcare professionals, patients and their families. We conducted a systematic review aimed at identifying the predictive or associated baseline factors, assessed within one-week of stroke onset, and the recovery of poststroke mobility within 30 days. A comprehensive search strategy was applied to all major electronic databases to identify potentially relevant studies. Included in the review are two studies that evaluate the predictive value of baseline factors by developing a prognostic model, and three studies that assess the baseline factors that were associated with the outcome by univariate analysis. Walking is the most commonly assessed mobility outcome; age, the severity of paresis, reduced leg power, presence of hemianopia, size of brain lesion and type of stroke were shown to be predictive or associated with walking within 30 days poststroke. This review has identified the potential predictors of the recovery of mobility poststroke. There is a need to explore and validate these predictors in other patient cohorts, and consider additional factors believed to be associated with mobility. The recovery of mobility other than walking also needs investigation. In order to move prognostic research in stroke forward, a collaborative approach to sharing and collecting data is recommended.
Article
To explore factors that may influence exercise adherence in adults with traumatic brain injury (TBI) within the International Classification of Functioning, Disability and Health (ICF) theoretical model. Thirty participants with TBI who had been randomized to a home-based exercise programme in a recently conducted randomized controlled trial. Impairments in body functions, environmental factors and personal factors were explored as predictors for exercise adherence. Significant variables were entered into binary logistic regression analyses to determine their combined power to predict exercise adherence. Greater injury severity, older age and a pre-injury exercise history of walking or jogging positively influenced exercise adherence. As a combined set the three predictor variables accurately classified 82% of participants as adherent or non-adherent and were able to explain 49% of the variance (sensitivity = 67%; specificity = 89%). These results demonstrate people with severe injuries are able to exercise independently and suggest that in order to maximize adherence to an exercise programme, clinicians need to consider exercise history when prescribing the type of exercise. The results also provide factors within the ICF theoretical model to investigate in a large-scale study of exercise adherence after TBI.
Article
To examine the contribution of subjective balance confidence, balance ability, motor impairments and muscle strength to the timed 'Up & Go' (TUG) scores of 78 subjects with chronic stroke using cross-sectional design. Functional mobility was measured in terms of TUG scores. Balance ability and subjective balance confidence were assessed with the Berg Balance Scale (BBS) and the activities-specific balance confidence (ABC) scale, respectively. Stroke-specific motor impairment and muscle strength of lower extremity were measured using the Fugl-Meyer Motor Assessment lower extremity (FMA-LE) scores and hand-held dynamometer. We found that the TUG scores had the highest negative correlation with subjective balance confidence. After controlling for use of walking aids, significant partial correlations were identified between the TUG scores and subjective balance confidence and balance ability. Applying linear regression model, the TUG scores showed association with subjective balance confidence and balance ability, independently. The motor impairments and muscle strength, however, were not significant predictors of TUG scores. The whole model could explain 63.0% of the variance in the TUG scores. Our results support that improving both subjective balance confidence, in addition to functional balance training could be crucial in promoting functional mobility of community-dwelling stroke survivors.
Article
 To expand understanding of informal stroke care-giving, validated tools previously used in Hong Kong and in the U.K. were used with Australian stroke carers to assess their stroke-related knowledge, perceived needs, satisfaction with services received and sense of burden after stroke patients' discharge home from acute hospital care.  Record audit and telephone interviews with two cohorts of 32 carers recruited in Sydney and Brisbane 1 and 3 months post-hospital discharge, using validated scales and open questions in May-July 2006.  Female carers, those with prior care-giving responsibility, and those interviewed at three compared to one month post-discharge reported greatest needs and burden from the care-giving role; needs alone significantly predicted burden. Getting information and being prepared for life after discharge were central concerns. Some felt this was accomplished, but inadequate information giving and communication mismatches were apparent.  Service providers need to develop partnership working with stroke families and provide a network of services and inputs that cut across conventional boundaries between health and social care, public, private and voluntary organisations, with care plans that deliver what they delineate. Stroke care-givers have common issues across countries and healthcare systems; collaborative research-based service development is advocated.
Article
Gait training is a major focus of rehabilitation for many people with neurological disorders, yet systematic reviews have failed to identify the most effective form of gait training. The main objective of this study was to compare conditions for gait training for people with acquired brain injury (ABI). Seventeen people who had sustained an ABI and were unable to walk without assistance were recruited as a sample. Each participant was exposed to seven alternative gait training conditions in a randomized order. These were: (1) therapist manual facilitation; (2) the use of a gait-assistive device; (3) unsupported treadmill walking; and (4) four variations of body weight support treadmill training (BWSTT). Quantitative gait analysis was performed and Gait Profile Scores (GPS) were generated for each participant to determine which condition most closely resembled normal walking. BWSTT without additional therapist or self-support of the upper limbs was associated with more severe gait abnormality [Wilks' lambda = 0.20, F(6, 6) = 3.99, p = 0.047]. With the exception of therapist facilitation, the gait training conditions that achieved the closest approximation of normal walking required self-support of the upper limbs. When participants held on to a stable handrail, self-selected gait speeds were up to three times higher than the speeds obtained for over-ground walking [Wilks' lambda = 0.17, F(6, 7) = 5.85, p < 0.05]. The provision of stable upper-limb support was associated with high self-selected gait speeds that were not sustained when walking over ground. BWSTT protocols may need to prioritize reduction in self-support of the upper limbs, instead of increasing treadmill speed and reducing body weight support, in order to improve training outcomes.
Article
To develop a prediction rule for acutely identifying patients at risk for extended rehabilitation length of stay (LOS) after traumatic brain injury (TBI) by using demographic and injury characteristics. Retrospective cohort study. Traumatic Brain Injury Model Systems. Sample of TBI survivors (N=7284) with injuries occurring between 1999 and 2009. Not applicable. Extended rehabilitation LOS defined as 67 days or longer. A multivariable model was built containing FIM motor and cognitive scores at admission, preinjury level of education, cause of injury, punctate/petechial hemorrhage, acute-care LOS, and primary payor source. The model had good calibration, excellent discrimination (area under the receiver operating characteristic curve = .875), and validated well. Based on this model, a formula for determining the probability of extended rehabilitation LOS and a prediction rule that classifies patients with predicted probabilities greater than 4.9% as at risk for extended rehabilitation LOS were developed. The current predictor model for TBI survivors who require extended inpatient rehabilitation may allow for enhanced rehabilitation team planning, improved patient and family education, and better use of health care resources. Cross-validation of this model with other TBI populations is recommended.
Article
To investigate the effectiveness of isokinetic strength training of ankle and knee muscles in adults with chronic acquired brain injury (ABI). Series of single case studies. Twelve people with ABI participated in a 2.5-week baseline, 12-week intervention and a 4-week follow-up phase. Concentric isokinetic exercise, twice a week, for plantarflexors (PFs), dorsiflexors (DFs), knee flexors (KFs) and knee extensors (KEs). Peak torque and power at 60 and 90° s⁻¹, PFs and KFs tone at 60° s⁻¹, gait speed and timed chair rises. For single case analyses strength improvements were noted in 11/12 participants' PFs, 5/12 participants' DFs and 7/12 participants' KEs and KFs. Gait speed improved in 8/12 participants and chair rise time improved in 7/12 participants. PFs tone increased in three participants, KFs tone increased in six participants and three participants reported knee pain. For group analyses, peak torque of PFs and KEs, fast gait speed and timed chair rises demonstrated improvement (p < 0.05). Isokinetic strength training may be effective to improve lower limb muscle strength; however, care needs to be taken in selecting suitable candidates as some individuals reported knee pain with this intensive programme.
Article
Stroke is a leading cause of long-term disability, and impaired balance after stroke is strongly associated with future function and recovery. Until recently there has been limited evidence to support the use of balance training to improve balance performance in this population. Information about the optimum exercise dosage has also been lacking. This review evaluated recent evidence related to the effect of balance training on balance performance among individuals poststroke across the continuum of recovery. On the basis of this evidence, we also provide recommendations for exercise prescription in such programs. A systematic search was performed on literature published between January 2006 and February 2010, using multiple combinations of intervention (eg, "exercise"), population (eg, "stroke"), and outcome (eg, "balance"). Criteria for inclusion of a study was having at least 1 standing balance exercise in the intervention and 1 study outcome to evaluate balance. Twenty-two published studies met the inclusion criteria. We found moderate evidence that balance performance can be improved following individual, "one-on-one" balance training for participants in the acute stage of stroke, and either one-on-one balance training or group therapy for participants with subacute or chronic stroke. Moderate evidence also suggests that in the acute stage, intensive balance training for 2 to 3 times per week may be sufficient, whereas exercising for 90 minutes or more per day, 5 times per week may be excessive. This review supports the use of balance training exercises to improve balance performance for individuals with moderately severe stroke. Future high-quality, controlled studies should investigate the effects of balance training for individuals poststroke who have severe impairment, additional complications/comorbidities, or specific balance lesions (eg, cerebellar or vestibular). Optimal training dosage should also be further explored. Studies with long-term follow-up are needed to assess outcomes related to participation in the community and reduction of fall risk.
Article
The restoration of normal posture is an important aspect of stroke physiotherapy, because normal activity is thought essential for effective function. However, there is little evidence to support (or refute) this belief. To test this, suitable measurement tools are needed. They need to be reliable, valid, sensitive, and suitable for all settings applicable to a wide range of stroke severity. A systematic review of methods to measure posture was undertaken to identify suitable measurement tools. CINAHL, Medline and Embase databases were searched for measurement tools which measured posture and could be used in clinical settings with stroke patients. Four groups of tools were identified: (i) ordinal scales; (ii) goniometry; (iii) devices to measure the distance between bony points; and (iv) miscellaneous others. All had some information about their psychometric properties, but few had been rigorously tested. None fulfilled all the assessment criteria. Therefore, future studies will attempt to devise a measurement tool which does meet all required criteria.
Article
Clinicians commonly assess posture in persons with musculoskeletal disorders and tend to do so subjectively. Evidence-based practice requires the use of valid, reliable and sensitive tools to monitor treatment effectiveness. The purpose of this article was to determine which methods were used to assess posture quantitatively in a clinical setting and to identify psychometric properties of posture indices measured from these methods or tools. We conducted a comprehensive literature review. Pertinent databases were used to search for articles on quantitative clinical assessment of posture. Searching keywords were related to posture and assessment, scoliosis, back pain, reliability, validity and different body segments. We identified 65 articles with angle and distance posture indices that corresponded to our search criteria. Several studies showed good intra- and inter-rater reliability for measurements taken directly on the persons (e.g., goniometer, inclinometer, flexible curve and tape measurement) or from photographs, but the validity of these measurements was not always demonstrated. Taking measurements of all body angles directly on the person is a lengthy process and may affect the reliability of the measurements. Measurement of body angles from photographs may be the most accurate and rapid way to assess global posture quantitatively in a clinical setting.
Article
Traumatic brain injury (TBI) is the primary cause of death and disability for 18- to 45-year-olds. High-level mobility is important for many of the social, leisure, sporting, and employment roles of young adults. The aim of these case reports was to evaluate a conceptual framework for retraining high-level mobility after TBI. The progression of 2 patients who had sustained a severe TBI but had contrasting clinical presentations was monitored over 6 months. Patient 1 presented with left hemiplegia following a TBI 10 years earlier, whereas patient 2 presented with ataxia 2 months following a TBI. Quantitative gait analysis and clinical measures of mobility were used to evaluate outcomes of a 6-month intervention phase. Intervention strategies were based on a conceptual framework comprising 2 main elements: (1) the hierarchical ordering of high-level mobility tasks and (2) the key biomechanical features of able-bodied running. Both patients achieved the ability to run by the end of the intervention phase. Patient 1 displayed improved gait symmetry associated with improved high-level mobility, despite the long-standing duration of his injury. Patient 2 demonstrated improved postural control and stability in gait that resulted in an ability to run, skip, hop, and jump. Findings of these case reports provide evidence supporting "proof of concept" that clinical interventions can lead to improvement in high-level mobility following severe TBI.
Article
To identify the key biomechanical gait abnormalities resulting from traumatic brain injury (TBI) and determine whether the abnormalities support a system for the classification of gait disorders. Systematic review with data from quantitative studies synthesized in a narrative format. Adults with TBI. Spatiotemporal, kinematic, and kinetic parameters of classification systems. The search identified 38 articles that reported on various methods for gait assessment in TBI. Three-dimensional gait analysis (3DGA) was used in 15 studies, primarily to quantify spatiotemporal parameters. Results revealed that people with a TBI walked more slowly with shorter steps and greater mediolateral sway following TBI. Stepping over obstacles, walking with eyes closed, or performing dual tasks accentuated gait deficits. Only one small study reported kinematic data for the major lower limb joints in 8 well recovered patients. One further study used 3DGA to classify the gait patterns of people with TBI but this classification was based on methods developed for stroke and cerebral palsy. No studies attempted to develop a classification system on the basis of the gait disorders of people with TBI. Although the studies were generally of high quality, little is known about the nature of gait disorders following TBI. Classification based on systematic description of gait disorders following TBI has not been attempted.
Article
Reduced gait speed is common following traumatic brain injury (TBI). Several studies have found that people with TBI display increased lateral movement in their center of mass while walking. It has been hypothesized that reduced gait speed following TBI is a consequence of increased caution and postural instability, but reduced ankle power generation at push-off may also play a contributing role. To determine whether postural instability or reduced muscle power were associated with reduced gait speed following TBI. A convenience sample of 55 people with TBI receiving physiotherapy for gait disorders were assessed using 3D gait analysis at self-selected and fast walking speeds. A comparison group of 10 healthy controls performed walking trials at a speed matched to the mean TBI self-selected speed and at a fast walking speed. When matched for speed, people with TBI walked with similar cadence and step length but with reduced ankle power generation at push-off and increased hip power generation both in early stance and in preswing compared with healthy controls. Width of base of support and postural instability were also significantly increased for people with TBI. The differences between the 2 groups at the matched speed remained for the fast speed condition. Postural stability did not deteriorate with increasing gait speed in either group. Reduced gait speed following TBI appears to be attributable to biomechanical deficiencies such as reduced ankle power generation rather than reduced postural stability and increased caution.
Article
Outcome measurement is an integral part of delivering rehabilitation services in community settings. However, measurement is of little value if instruments are chosen ad hoc and are not administered consistently. The purpose of this study was to develop and test a participatory process of outcome measure selection which would engender consistent use of robust and appropriate instruments. The ICF provided the conceptual framework for a systematic review of the literature for relevant outcome measures. A summary of the critical appraisal of the clinimetric properties of the identified instruments was created. The summaries were reviewed and vetted by stakeholders including clinicians, researchers, and managers/policy makers. From the 300 identified and appraised measures, 28 were chosen and made available in a Compendium of Clinical Measures for Community Rehabilitation. The Compendium contains three core measures to be used routinely with all rehabilitation clients and a further 25 that cover particular discipline and client needs. This resource is now available to all clinicians working in the participating rehabilitation services. A participatory process combining rigorous review of the literature, expert opinion, and clinician feedback is recommended in the selection and implementation of outcome measures in rehabilitation settings in the community.
Article
A new clinical measure of postural adaptation, the Advanced Mobility and Balance Scale (AMBS), was developed to assess balance capacities of stroke patients in standing and walking. In the first pilot study, involving 12 stroke patients and 6 healthy subjects, we found excellent interrater reliability and reasonable discriminative capacity of the AMBS. However, high-level functioning stroke subjects could not be differentiated from healthy subjects. In order to refine the scoring of the AMBS for better discrimination, we conducted a kinematic analysis of head turning while walking in 10 stroke patients and 5 age-matched healthy subjects. Results showed that stroke patients manifested disrupted head-trunk-pelvis coordination and increased footpath deviation during head turns towards the paretic side. These abnormal patterns are likely due to compensations and altered sensorimotor integration processes.
Article
After stroke, physiotherapy can promote brain reorganization and motor recovery. Combining muscle strength and functional training (functional strength training, FST) may be beneficial. The aim of the authors was to compare FST with conventional physiotherapy (CPT) while controlling for the potential confounder of therapy intensity in a multicenter, randomized controlled observer-blind trial. The mean age of the participants was 68.3 (standard deviation [SD] = 12.03) years at a mean of 34 (SD = 20) days after stroke, with mean peak paretic knee extension torque (torque) of 22 (SD = 25) Nm. The estimated sample size was 102 to detect a between-group difference of 0.2 m/s in walking speed. After baseline measures, participants were allocated randomly to CPT or CPT + CPT or CPT + FST for 6 weeks. Additional experimental therapy was provided for up to 1 hour a day, 4 times each week. Outcomes were measured 6 weeks after baseline and at follow-up 12 weeks thereafter. MEASURES: included walking speed, knee extensor torque, and functional mobility (Rivermead). At outcome, both extraintensity groups showed greater increases in walking speed than the CPT group, but this reached significance only for the CPT + CPT group (P = .031). The CPT + CPT group also had a greater number of participants who walked at 0.8 m/s or above. No significant differences were observed for torque about the knee or for the Rivermead score. At follow-up, no significant differences were observed. These phase I results justify a subsequent trial of CPT + CPT versus CPT + FST.
Article
Comparisons of treadmill and overground walking following stroke indicate that symmetry in temporal-distance measures is better on the treadmill suggestive of better gait economy. We examined this issue by examining the kinematic, kinetic and metabolic demands associated with overground and treadmill walking at matched speeds and also explored the effect of increasing treadmill speed. Ten people with hemiparesis walked overground at their preferred speed which was matched on the treadmill. Belt speed was then increased 10% and 20% above preferred speed. Temporal-distance outcomes, angular kinematics and vertical ground reaction forces were recorded during steady state (stable heart rate and oxygen uptake). Step and stance times were longer when walking overground but the degree of symmetry was comparable for both surfaces. In contrast kinematic data revealed significant interlimb asymmetry with respect to all lower limb joint excursions during overground walking accompanied by higher vertical ground reaction forces at push-off. The metabolic demands, however, were lower when walking overground than on the treadmill. Increasing the belt speed increased angular displacements and the vertical forces associated with both limbs such that symmetry remained unchanged. Metabolic demands increased significantly. People with stroke adopt a more symmetrical kinematic walking pattern on the treadmill which is maintained at faster belt speeds. Surprisingly, at matched speed the metabolic cost was significantly higher with treadmill walking. We suggest further research to explore whether an increased reliance on the hip musculature to compensate lower push-off forces could explain the higher the energy cost.
Article
To identify the most common gait abnormalities presenting after traumatic brain injury (TBI) and quantify their incidence rate. Case series. Biomechanics laboratory. A convenience sample of 41 people with TBI receiving therapy for gait abnormalities, and a sample of 25 healthy controls. Three-dimensional gait analysis. Spatiotemporal, kinematic, and kinetic data at a self-selected walking speed. People with TBI walked with a significantly slower speed than matched healthy controls. There was a significant difference between groups for cadence, step length, stance time on the affected leg, double support phase, and width of base of support. The most frequently observed biomechanical abnormality was excessive knee flexion at initial foot contact. Other significant gait abnormalities were increased trunk anterior/posterior amplitude of movement, increased anterior pelvic tilt, increased peak pelvic obliquity, reduced peak knee flexion at toe-off, and increased lateral center of mass displacement. Ankle equinovarus at foot-contact occurred infrequently. People with TBI were found to have multijoint gait abnormalities. Many of these abnormalities have not been previously reported in this population.
Article
To determine the accuracy of clinicians' visual observations of gait disorders following traumatic brain injury (TBI). 30 ambulant participants (sample of convenience) receiving physiotherapy for mobility limitations following TBI and 25 age, height, weight and sex matched healthy unimpaired controls (HC) were recruited. Kinematic and ground reaction force data during gait were captured and video recordings were concurrently collected. Participants with TBI walked at self-selected speed whilst HCs walked at preferred speed as well as the mean TBI speed for comparison. 40 doctors, experienced physiotherapists, new graduate physiotherapists and novices were observers. Each viewed and rated 36 gait variables for a randomized sub-sample of 10 participants with TBI. Observer inaccuracy was calculated for each gait variable. Overall the accuracy of observational gait analysis was low and there was considerable variability in observations between clinicians. For most kinematic variables, observer inaccuracy ranged from 30% to 50%. Although experienced observers were generally more accurate, average inter-item correlations were low, indicating that experience did not consistently improve the accuracy of visual observations. Observational plane, gait variable type, the joint or the segment had little effect on accuracy of observations. Observational gait analysis for adults with TBI has relatively low accuracy. Some of the gait abnormalities evident from quantitative gait analysis were not detected by observational gait analysis.
Article
Three-dimensional kinematic measures of gait are routinely used in clinical gait analysis and provide a key outcome measure for gait research and clinical practice. This systematic review identifies and evaluates current evidence for the inter-session and inter-assessor reliability of three-dimensional kinematic gait analysis (3DGA) data. A targeted search strategy identified reports that fulfilled the search criteria. The quality of full-text reports were tabulated and evaluated for quality using a customised critical appraisal tool. Fifteen full manuscripts and eight abstracts were included. Studies addressed both within-assessor and between-assessor reliability, with most examining healthy adults. Four full-text reports evaluated reliability in people with gait pathologies. The highest reliability indices occurred in the hip and knee in the sagittal plane, with lowest errors in pelvic rotation and obliquity and hip abduction. Lowest reliability and highest error frequently occurred in the hip and knee transverse plane. Methodological quality varied, with key limitations in sample descriptions and strategies for statistical analysis. Reported reliability indices and error magnitudes varied across gait variables and studies. Most studies providing estimates of data error reported values (S.D. or S.E.) of less than 5 degrees , with the exception of hip and knee rotation. This review provides evidence that clinically acceptable errors are possible in gait analysis. Variability between studies, however, suggests that they are not always achieved.
Article
In hemiparetic individuals, sit-to-stand (STS) transfer is characterized by asymmetric weight-bearing and altered trunk kinematics that can be improved by positioning the affected foot behind the nonaffected one. To examine the influence of frontal trunk kinematics on medio-lateral displacements of the center of pressure (CP) during STS performed with the feet placed in 2 different positions, as well as relationships between these parameters, medio-lateral stability, and clinical scores of the participants. Eighteen patients with chronic stroke and 15 control individuals were evaluated during sit-to-stand transfers either in spontaneous foot position or with their affected or dominant foot placed behind, respectively. Medio-lateral CP, pelvis, and shoulder displacement were analyzed using 3D kinematic and kinetic data recordings of the whole task. Motor and sensory impairment, spasticity, muscle strength, and equilibrium were evaluated by standard scales. The possible time during which a participant could prevent a fall (minimal time-to-contact) was used as a stability index. Spontaneously, the deviation of the CP of stroke participants paralleled the tilt of the trunk toward the nonaffected side, as early as the first third of the task. With the affected foot placed behind, trunk position did not differ from those of control participants who executed the transfer spontaneously. Hemiparetic participants were less stable than control participants. Placement of the feet had no significant effect on the stability of either group. Stability was strongly associated with better motor scores on the Chedoke-McMaster Stroke Assessment. In hemiparetic individuals, improving STS symmetry by positioning the affected foot behind the nonaffected one did not decrease medio-lateral stability, which was associated with the level of stroke-related motor impairments.