Four weeks of inpatient comprehensive prosthetic rehabilitation achieves contrasting results in different groups of prosthetic users

BACKGROUND

This study explored how inpatient exercise rehabilitation affected prosthetic mobility, function, and ambulation in persons with lower limb loss.

METHODS

In this explorative prospective nonrandomized intervention study, experienced (EXP-INT, n = 20) and new prosthetic users (NEW-INT, n = 18) completed a 4-week rehabilitation intervention. A control group of experienced prosthetic users (n = 19) received no intervention. Tests were performed at baseline (pretest) and after 4 weeks (posttest). A step-monitoring device recorded ambulatory activity.

RESULTS

For the primary outcome measure, Prosthetic Limb Users Survey of Mobility, the between-group analysis revealed significant differences (χ 2 = 10.91, df = 2, p < 0.01). Within-group Prosthetic Limb Users Survey of Mobility T-scores improved by 8.1% for the EXP-INT ( p < 0.01) and 15.1% for NEW-INT ( p < 0.01). Significant between-group differences were observed for the Amputee Mobility Predictor, L-test, 2-minute walk test, and 10-meter walk test. Within-group analysis demonstrated nonsignificant changes for the EXP-INT except for Prosthetic Limb Users Survey of Mobility, while the NEW-INT improved by 24.1% ( p < 0.001), 34.0% ( p < 0.01), 46.5% ( p < 0.05), and 31.0% ( p < 0.01), respectively. The number of steps during the last 7 d of rehabilitation showed significant differences between the groups (χ 2 = 13.99, df = 2, p < 0.001). The NEW-INT improved by 138% ( p < 0.05) compared with the first 7 d of rehabilitation, while the EXP-INT had nonsignificant changes.

CONCLUSIONS

A 4-week rehabilitation intervention substantially increased prosthetic mobility, function, and ambulation activity for new prosthetic users but less so for experienced users. The results of the NEW-INT at discharge signify a considerable functional improvement.

Overestimation of Balance Ability Among Older Adults at Risk for Falls

Objective: This study examined alignment of subjective balance confidence with Stopping Elderly Accidents, Deaths and Injuries (STEADI) fall risk. Methods: Cross-sectional analysis of 155 community-dwelling adults (60 + y/o) from 2016 to 2018 who completed a STEADI fall assessment. Descriptive statistics, Chi-Square analysis, and biserial point correlations were applied. Results: Adults who overestimate balance confidence, 55.6% (n = 50) reported a fall in the past year, 62.2% (n = 56) were worried about falling, 48.9% (n = 44) felt unsteady when standing/walking, and 70.0% (n = 63) had a score of ≥4 on the Stay Independent Questionnaire (SIQ). Physical performance for these adults were mean TUG score 10.9s (SD = 3.4), mean 30 second chair stands 10.8 (SD = 3.5), and mean 4-stage balance score 3.1 (SD = .76). Discussion: Older adults are more likely to overestimate their subjective balance confidence. Individuals are equally likely to have reported a fall in the past year if they were "at fall risk," regardless of their subjective balance confidence.

An enhancement of the Genium™ microprocessor-controlled knee improves safety and different aspects of the perceived prosthetic experience for unilateral and bilateral users

Introduction

Bilateral microprocessor-controlled prosthetic knee (MPK) users have unique needs in traversing environmental barriers compared to unilateral users. An enhancement to the Genium™/Genium X3™ MPK which included an updated ruleset, hydraulics, and new bilateral parameter presets was made to improve safety while stumbling and the smoothness of gait for all users while also improving the experience of bilateral users. The purpose of the study was to evaluate the effectiveness of the enhancements in a sample with unilateral and bilateral amputation.

Methods

A convenience sample of MPK users was recruited from two sites in the USA in two phases. Assessments included the L-Test of Functional Mobility, Activity-specific Balance Confidence Scale, Prosthetic Limb User Survey of Mobility, a study-specific questionnaire, and the Comparative Activities of Daily Living (ADL) Questionnaire. Statistical significance of extracted data was tested with the Wilcoxon Rank-Sum Test for independent data and Wilcoxon Signed-Rank for paired data with an a priori significance level of p < 0.05. Unilateral subjects were age-matched to the group of bilateral subjects for between-groups and within-groups analyses.

Results

Twenty-six subjects (n = 26) were enrolled. Stumble frequency reduced 85% from 16.0 ± 39.7 to 2.4 ± 2.3 (p = 0.008) between baseline and final assessment overall. The bilateral group reported 50% (p = 0.009) and 57% (p = 0.009) greater relative improvement in patient-reported ease and safety, respectively, of completing ADLs compared to the unilateral group. The unilateral group reported residual limb pain and low back pain reduced from 2.3 to 1.4 (p = 0.020) and 3.8 to 1.8 (p = 0.027), respectively, whereas the bilateral group did not.

Discussion

Substantial reductions in stumbles, residual limb pain, and back pain were shown overall. These reductions were driven by the unilateral group who also showed improvements in comfort, exertion, and concentration while walking. The enhancements to the knee likely reduced some gait asymmetry for unilateral users. Improvements in patient-reported ease and safety of completing ADLs were shown overall and were driven by the bilateral group. This study shows further improvement in patient experience is achievable through innovation in MPK technology even for patients who appear to be functioning well.

Reliability, concurrent validity and minimal detectable change of the L test in patients with total knee arthroplasty

PURPOSE

The L test is a modified version of the timed up and go test (TUG), extending the walking distance from 6 to 20 meters and also requiring participants to make four turns in both (right/left) direction. It could be a useful measurement method in assessment of functional mobility for patients with Total Knee Arthroplasty (TKA). The aim of the study was to determine reliability, concurrent validity, and minimal detectable change (MDC) of L test in patients with TKA.

MATERIALS AND METHODS

The study included 43 patients with TKA. The Intraclass Correlation Coefficient (ICC) was used to assess the intra-rater reliability of the L test. The correlations of the L test with TUG were assessed for concurrent validity.

RESULTS

Intra-rater (ICC 0.97) reliability of the L test was determined to be excellent. The SEM and MDC95 values of intra-rater reliability were 1.03 and 2.84, respectively. A high correlation was found between the L test and TUG (r: 0.75).

CONCLUSION

The L test is a valid and reliable method in the assessment of functional mobility in patients with TKA. The L test can be used to quantify changes in functional mobility level in patients with TKA.Implications for rehabilitationThe L test is a reliable and valid measurement tool that can be used to assess functional mobility in patients with TKA.Clinicians and researchers can use a greater change than 2.84 seconds for the L test as a meaningful change in patients with TKA.

Clinical Walking Tests and Gait Pattern Characterization During 6-Minute Walk Test Using Inertial Sensors: Follow-Up in Individuals With Lower Limb Amputation

Inertial measurement units and normative values enable clinicians to quantify clinical walking tests and set rehabilitation goals. Objectives of this study were (1) to compare time- and distance-based walking tests in individuals with lower limb amputation (iLLA) and normative values following rehabilitation discharge (T1) and 6 weeks after discharge (T2) and (2) to investigate spatiotemporal and foot kinematic parameters over a 6-minute walk test using inertial measurement units. Twelve iLLA participated in this study. Distance, cadence, stance ratio, loading rate ratio, push-up ratio, path length, and minimum toe clearance were analyzed during 6-minute walk test. Nonparametric repeated-measures analysis of variance tests, Bonferroni corrections, were performed. Time of distance-based walking tests diminished at T2 (P < .02). Compared with normative values, walking performance in iLLA was reduced. Cadence at T2 increased significantly (P = .026). Stance ratio increased in both legs at T2 (P < .05). Push-up ratio tended to decrease at T2 in the amputated leg (P = .0003). Variability of path length and minimum toe clearance at T2 were less than at T1 in the nonamputated leg (P < .05). Spatiotemporal improvement at T2 could be due to prosthesis adaptation in iLLA. The lower performance of the functional walk test compared with normative values could be due to amputation and pain-related fatigue.

Measurement properties of the L Test with fast walking speed in patients after lower limb amputation in initial prosthetic training phase

The L Test is a clinical mobility test used in patients after lower limb amputation. To assess dynamic balance, it should be performed with fast walking speed. Its measurement properties in the initial prosthetic training phase are not known yet. The objective of the study was to establish intra- and interrater reliability, concurrent and discriminant validity, minimal detectable change, effect size between the rehabilitation time points and ceiling effect of the L Test with fast walking speed in patients after lower limb amputation in initial prosthetic training phase. The study included 36 inpatients aged 19-86 years who were provided with a prosthesis for the first time. They were assessed repeatedly with the L Test, Ten-meter Walk Test and 6-min Walk Test. The intra- (ICC3, k = 0.94) and interrater reliability (ICC2, k = 0.96) of the L Test were excellent. Correlations with the walking tests were very good (r = 0.75-0.86). Regression analysis with respect to the level of lower limb amputation showed a linear relationship with other variables (R2 = 0.55). Influences of age, cause of lower limb amputation and walking aid were statistically significant. The L Test was responsive to change after two weeks of prosthetic training (Cohen's d = 1.21). No ceiling effect was identified. The L Test with fast walking speed is a feasible, reliable, valid, and responsive measure of basic mobility skills in patients after lower limb amputation in the initial prosthetic training phase.

Feasibility of Implementing a Tai Chi Program in an Assisted Living Facility: Reducing Fall Risks and Improving Quality of Life

One in four American older adults fall every year, resulting in injuries, death, and significant financial burden. Although fall etiology is multifactorial, the medical problems and aging factors that lead to unsteady gait and imbalance represent one of the major fall risks among older adults. A growing number of research studies support the health benefits of regular Tai Chi (TC) practice including improved physical, cognitive, and psychological function. The purpose of this quality improvement project was to assess the feasibility of establishing a 12-week (45 min per session) Tai Chi (TC) program (Sun Style Tai Chi) in a 75 bed assisted living facility as well as to evaluate the potential of the TC program to improve the fear of falling and functional mobility (as proxy for fall risk) and quality of life (QoL). A nurse who was a certified TC instructor taught the program. Twenty-three participants, 96% female and 96% white, mean (SD) age 83 (±7) years, attended one or more TC classes. Class attendance, self-reported questionnaires (e.g., fear of falling, QoL), and objective measure Timed Up and Go (TUG) were used to collect data. Nine participants (39%) completed 9 out of 12 sessions. Eleven participants (48%) completed both pre- and post-intervention measurements and twelve (52%) provided feedback on a post-intervention satisfaction survey. Participants showed 20% improvement in fear of falling (mean relative change) and 21% decrease (mean relative change) in TUG test (p = 0.001) with no clinically important changes in QoL. This quality improvement project suggested that TC is a feasible exercise that might have the potential to reduce risk of falls in older adults, and the program was well accepted with no serious or other adverse events reported. Further research studies are needed to examine the potential effects of TC programs with an appropriately powered RCT and longer intervention period.

Ankle motor strategy use in older and younger adults as assessed by a two-dimensional kinematic analysis smart device application

Background/aims

Motor strategies change with age, resulting in balance deficits. Clinical options for objectively measuring motor strategies are limited. The use of two-dimensional kinematic analysis through smart devices and applications may provide a cost-effective portable solution for measuring differences in motor strategy use between older and younger adults. The aims of this study were to investigate the concurrent validity of a two-dimensional software and two-dimensional application and to determine whether the application could capture the difference in ankle motor strategy use by older and younger adults (construct validity).

Methods

Video clips captured by Sony and iPad Air cameras were used to assess concurrent validity between the two-dimensional software and application. A total of 30 older (72.6 ± 4.0 years) and 30 younger (26.5±4.5 years) adults performed forward and backward stepping. A two-dimensional applicationmeasured the ankle position in degrees and time taken in seconds to initiate and complete a compensatory step.

Results

The two-dimensional software and app demonstrated excellent reliability (ICC2,1 ≥0.994). The ankle forward stop angle differed significantly between older and younger adults (P=0.012). No differences were observed in time taken to initiate and complete a compensatory step.

Conclusions

The two-dimensional application appears to be a valid alternative to two-dimensional software for measuring ankle motor strategies. Further investigation for clinical use is warranted.

Impact of Psychological Distress and Sleep Quality on Balance Confidence, Muscle Strength, and Functional Balance in Community-Dwelling Middle-Aged and Older People

The objective was to evaluate the associations of psychological distress and sleep quality with balance confidence, muscle strength, and functional balance among community-dwelling middle-aged and older people. An analytical cross-sectional study was conducted (n = 304). Balance confidence (Activities-specific Balance Confidence scale, ABC), muscle strength (hand grip dynamometer), and functional balance (Timed Up-and-Go test) were assessed. Psychological distress and sleep quality were evaluated by the Hospital Anxiety and Depression Scale and the Pittsburgh Sleep Quality Index, respectively. Age, sex, physical activity level, nutritional status, and fatigue were included as possible confounders. Multivariate linear and logistic regressions were performed. Higher values of anxiety (OR = 1.10), fatigue (OR = 1.04), and older age (OR = 1.08) were associated with an increased risk of falling (ABC < 67%). Greater muscle strength was associated with male sex and improved nutritional status (adjusted R² = 0.39). On the other hand, being older and using sleeping medication were linked to poorer functional balance (adjusted R² = 0.115). In conclusion, greater anxiety levels and the use of sleep medication were linked to a high risk of falling and poorer functional balance, respectively. No associations were found between muscle strength and sleep quality, anxiety, or depression.

Selecting, Administering, and Interpreting Outcome Measures among Adults with Lower-Limb Loss: An Update for Clinicians

Purpose of review

To summarize outcome measurement research among adults with lower-limb loss (LLL) for clinicians.

Recent findings

Houghton Scale, Prosthetic Evaluation Questionnaire-mobility subscale (PEQ-m), Prosthetic Limb Users Survey of Mobility (PLUS-M™), Activities-Specific Balance Confidence Scale (ABC), Amputee Mobility Predictor (AMP), Comprehensive High-Level Activity Mobility Predictor, Four Square Step Test (FSST), Narrowing Beam Walking Test (NBWT), L Test, 10 Meter Walk Test (10MWT), and 6 Minute Walk Test (6MWT) are appropriate for evaluating individual patient changes post-LLL. Post-LLL, Socket Comfort Score, Patient-Specific Functional Scale, Patient-Reported Outcomes Measurement Information System 29-Item Profile, Timed Up and Go, and 2 Minute Walk Test may be more appropriate for evaluating groups. Minimal detectable change is available for 15/20 reviewed measures. Many measures differ between mobility levels.

Summary

Quick, reliable measures for evaluating patient functional change include ABC, PEQ-m, PLUS-M™, FSST, and L Test; when resources allow, NBWT, 10MWT, 6WMT and AMP may be considered.

Impact of Balance Confidence on Daily Living Activities of Older People with Knee Osteoarthritis with Regard to Balance, Physical Function, Pain, and Quality of Life - A Preliminary Report

OBJECTIVES

The objective of this study was to explore the impact of balance confidence on different activities of daily living (ADL) in older people with knee osteoarthritis (OA).

METHODS

Forty-seven consecutive participants with knee OA were included in this cross-sectional study. They were divided according to the results of the Activities-specific Balance Confidence (ABC) Scale into a group with a low level of confidence in physical functioning (ABC < 50, n = 22) and a group with moderate and high levels of confidence (ABC ≥ 50, n = 25).

RESULTS

In the ABC < 50 group, the effect of pain on ADL, the physician's global assessment of the disease, and the Western Ontario and McMaster Universities Osteoarthritis Index scores were significantly higher, while quality of life (Short form-36) was lower compared to the ABC ≥ 50 group. No significant difference was found between the two groups regarding the static and dynamic balance measurements.

CONCLUSIONS

Older people with knee OA who were less confident in their daily physical activities had more physical difficulties and a greater effect of pain on ADL, lower quality of life, and a higher physician's global assessment, but no differences were obtained in balance tests.

CLINICAL IMPLICATIONS

In people with knee OA, decreased balance confidence is associated with more physical difficulties, an increased effect of pain on ADL, and lower quality of life. An improved awareness of decreased balance confidence may lead to more effective management of older people with knee OA by improving their mobility and QOL through rehabilitation. Furthermore, future research in that direction is warranted.

Balance performance in older adults and its relationship with falling

BACKGROUND AND AIMS

A normal consequence of aging is a general deterioration in a number of musculoskeletal and sensory systems that affect postural control and balance. The aim of this study was to evaluate history of falls among active older individuals in Iran, and estimate the risk factors for falls among this population.

METHODS

A total of 448 active older subjects from rural region of Rasht city, Iran, were included. They were divided into three groups depending on their age: young-old (n = 266); middle-old (n = 154) and oldest-old (n = 28). We assessed balance performance by One-Leg Balance (OLB), Functional Reach (FR), Timed Up and Go (TUG) and Romberg tests.

RESULTS

The fall rate (>2 in the last year) was 27.0 %. The cut-off point 13.75 s for TUG test showed 84.7 % sensitivity and 56 % specificity. Also the best cut-off point for OLB test was 12.7 s (63 % sensitivity and 83.5 % specificity). Logistic regression analysis revealed that age, BMI, diabetes, and failure in OLB, FR, and Romberg tests predicted fall risk. The decision tree classification of older individuals showed three categorical variables, which in their order of importance included diabetes, Romberg test, and OLB test.

CONCLUSIONS

This study revealed the value of history taking about diabetes as a predictor for existing falling. Decision tree technique showed that Romberg and OLB tests help in identifying older adults with balance problems. Given the incidence and consequences of falls among older adults, large-scale prospective studies on older individuals to identify those prone to falls are warranted.