The aim of this study was to test the inter- and intraobserver reliability of the Physician Rating Scale (PRS) and the Edinburgh Visual Gait Analysis Interval Testing (GAIT) scale for use in children with cerebral palsy (CP). Both assessment scales are quantitative observational scales, evaluating gait. The study involved 24 patients ages 3 to 10 years (mean age 6.7 years) with an abnormal gait caused by CP. They were all able to walk independently with or without walking aids. Of the children 15 had spastic diplegia and 9 had spastic hemiplegia. With a minimum time interval of 6 weeks, video recordings of the gait of these 24 patients were scored twice by three independent observers using the PRS and the GAIT scale. The study showed that both the GAIT scale and the PRS had excellent intraobserver reliability but poor interobserver reliability for children with CP. In the total scores of the GAIT scale and the PRS, the three observers showed systematic differences. Consequently, the authors recommend that longitudinal assessments of a patient should be done by one observer only.
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BackgroundGait analysis has been used for decades to quantify knee function in patients with knee osteoarthritis; however, it is unknown whether and to what extent inter-laboratory differences affect the comparison of gait data between studies. Therefore, the aim of this study was to perform an inter-laboratory comparison of knee biomechanics and muscle activation patterns during gait of patients with knee osteoarthritis.MethodsKnee biomechanics and muscle activation patterns from patients with knee osteoarthritis were analyzed, previously collected at Dalhousie University (DAL: n = 55) and Amsterdam UMC, VU medical center (VUmc: n = 39), using their in-house protocols. Additionally, one healthy male was measured at both locations. Both direct comparisons and after harmonization of components of the protocols were made. Inter-laboratory comparisons were quantified using statistical parametric mapping analysis and discrete gait parameters.ResultsThe inter-laboratory comparison showed offsets in the sagittal plane angles, moments and frontal plane angles, and phase shifts in the muscle activation patterns. Filter characteristics, initial contact identification and thigh anatomical frame definitions were harmonized between the laboratories. After this first step in protocol harmonization, the offsets in knee angles and sagittal plane moments remained, but the inter-laboratory comparison of the muscle activation patterns improved.ConclusionsInter-laboratory differences obstruct valid comparisons of gait datasets from patients with knee osteoarthritis between gait laboratories. A first step in harmonization of gait analysis protocols improved the inter-laboratory comparison. Further protocol harmonization is recommended to enable valid comparisons between labs, data-sharing and multicenter trials to investigate knee function in patients with knee osteoarthritis.
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Background Objective gait analysis that fully captures the multi-segmental foot movement of a clubfoot may help in early identification of a relapse clubfoot. Unfortunately, this type of objective measure is still lacking in a clinical setting and it is unknown how it relates to clinical assessment. Research question The aim of this study was to identify differences in total gait and foot deviations between clubfoot patients with and without a relapse clubfoot and to evaluate their relationship with clinical status. Methods In this study, Ponseti-treated idiopathic clubfoot patients were included and divided into clubfoot patients with and without a relapse. Objective gait analysis was done resulting in total gait and foot scores and clinical assessment was performed using the Clubfoot Assessment Protocol (CAP). Additionally, a new clubfoot specific foot score, the clubFoot Deviation Index (cFDI*), was calculated to better capture foot kinematics of clubfoot patients. Results Clubfoot patients with a relapse show lower total gait quality (GDI*) and lower clinical status defined by the CAP than clubfoot patients without a relapse. Abnormal cFDI* was found in relapse patients, reflected by differences in corresponding variable scores. Moderate relationships were found for the subdomains of the CAP and total gait and foot quality in all clubfoot patients. Significance A new total foot score was introduced in this study, which was more relevant for the clubfoot population. The use of this new foot score (cFDI*) besides the GDI*, is recommended to identify gait and foot motion deviations. Along with clinical assessment, this will give an overview of the overall status of the complex, multi-segmental aspects of a (relapsed) clubfoot. The relationships found in this study suggest that clinical assessment might be indicative of a deviation in total gait and foot pattern, therefore hinting towards personalised screening for better treatment decision making.
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Background: A significant part of neurological rehabilitation focuses on facilitating the learning of motor skills. Training can adopt either (more) explicit or (more) implicit forms of motor learning. Gait is one of the most practiced motor skills within rehabilitation in people after stroke because it is an important criterion for discharge and requirement for functioning at home. Objective: The aim of this study was to describe the design of a randomized controlled study assessing the effects of implicit motor learning compared with the explicit motor learning in gait rehabilitation of people suffering from stroke. Methods: The study adopts a randomized, controlled, single-blinded study design. People after stroke will be eligible for participation when they are in the chronic stage of recovery (>6 months after stroke), would like to improve walking performance, have a slow walking speed (<1 m/s), can communicate in Dutch, and complete a 3-stage command. People will be excluded if they cannot walk a minimum of 10 m or have other additional impairments that (severely) influence gait. Participants will receive 9 gait-training sessions over a 3-week period and will be randomly allocated to an implicit or explicit group. Therapists are aware of the intervention they provide, and the assessors are blind to the intervention participants receive. Outcome will be assessed at baseline (T0), directly after the intervention (T1), and after 1 month (T2). The primary outcome parameter is walking velocity. Walking performance will be assessed with the 10-meter walking test, Dynamic Gait Index, and while performing a secondary task (dual task). Self-reported measures are the Movement Specific Reinvestment Scale, verbal protocol, Stroke and Aphasia Quality of Life Scale, and the Global Perceived Effect scale. A process evaluation will take place to identify how the therapy was perceived and identify factors that may have influenced the effectiveness of the intervention. Repeated measures analyses will be conducted to determine significant and clinical relevant differences between groups and over time. Results: Data collection is currently ongoing and results are expected in 2019. Conclusions: The relevance of the study as well as the advantages and disadvantages of several aspects of the chosen design are discussed, for example, the personalized approach and choice of measurements.
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In order to achieve a level of community involvement and physical independence, being able to walk is the primary aim of many stroke survivors. It is therefore one of the most important goals during rehabilitation. Falls are common in all stages after stroke. Reported fall rates in the chronic stage after stroke range from 43 to 70% during one year follow up. Moreover, stroke survivors are more likely to become repeated fallers as compared to healthy older adults. Considering the devastating effects of falls in stroke survivors, adequate fall risk assessment is of paramount importance, as it is a first step in targeted fall prevention. As the majority of all falls occur during dynamic activities such as walking, fall risk could be assessed using gait analysis. It is only recent that technology enables us to monitor gait over several consecutive days, thereby allowing us to assess quality of gait in daily life. This thesis studies a variety of gait assessments with respect to their ability to assess fall risk in ambulatory chronic stroke survivors, and explores whether stroke survivors can improve their gait stability through PBT.
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BackgroundExercise-induced fatigue is a common consequence of physical activities. Particularly in older adults, it can affect gait performance. Due to a wide variety in fatiguing protocols and gait parameters used in experimental settings, pooled effects are not yet clear. Furthermore, specific elements of fatiguing protocols (i.e., intensity, duration, and type of activity) might lead to different changes in gait parameters. We aimed to systematically quantify to what extent exercise-induced fatigue alters gait in community-dwelling older adults, and whether specific elements of fatiguing protocols could be identified.MethodsThis systematic review and meta-analysis was conducted in accordance with the PRISMA guidelines. In April 2023, PubMed, Web of Science, Scopus, Cochrane and CINAHL databases were searched. Two independent researchers screened and assessed articles using ASReview, Rayyan, and ROBINS-I. The extracted data related to spatio-temporal, stability, and variability gait parameters of healthy older adults (55 +) before and after a fatiguing protocol or prolonged physical exercise. Random-effects meta-analyses were performed on both absolute and non-absolute effect sizes in RStudio. Moderator analyses were performed on six clusters of gait parameters (Dynamic Balance, Lower Limb Kinematics, Regularity, Spatio-temporal Parameters, Symmetry, Velocity).ResultsWe included 573 effect sizes on gait parameters from 31 studies. The included studies reflected a total population of 761 older adults (57% female), with a mean age of 71 (SD 3) years. Meta-analysis indicated that exercise-induced fatigue affected gait with a standardized mean change of 0.31 (p < .001). Further analyses showed no statistical differences between the different clusters, and within clusters, the effects were non-uniform, resulting in an (indistinguishable from) zero overall effect within all clusters. Elements of fatiguing protocols like duration, (perceived) intensity, or type of activity did not moderate effects.DiscussionDue to the (mainly) low GRADE certainty ratings as a result of the heterogeneity between studies, and possible different strategies to cope with fatigue between participants, the only conclusion that can be drawn is that older adults, therapist, and researchers should be aware of the small to moderate changes in gait parameters as a result of exercise-induced fatigue.
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Background The gait modification strategies Trunk Lean and Medial Thrust have been shown to reduce the external knee adduction moment (EKAM) in patients with knee osteoarthritis which could contribute to reduced progression of the disease. Which strategy is most optimal differs between individuals, but the underlying mechanism that causes this remains unknown. Research question Which gait parameters determine the optimal gait modification strategy for individual patients with knee osteoarthritis? Methods Forty-seven participants with symptomatic medial knee osteoarthritis underwent 3-dimensional motion analysis during comfortable gait and with two gait modification strategies: Medial Thrust and Trunk Lean. Kinematic and kinetic variables were calculated. Participants were then categorized into one of the two subgroups, based on the modification strategy that reduced the EKAM the most for them. Multiple logistic regression analysis with backward elimination was used to investigate the predictive nature of dynamic parameters obtained during comfortable walking on the optimal modification gait strategy. Results For 68.1 % of the participants, Trunk Lean was the optimal strategy in reducing the EKAM. Baseline characteristics, kinematics and kinetics did not differ significantly between subgroups during comfortable walking. Changes to frontal trunk and tibia angles correlated significantly with EKAM reduction during the Trunk Lean and Medial Thrust strategies, respectively. Regression analysis showed that MT is likely optimal when the frontal tibia angle range of motion and peak knee flexion angle in early stance during comfortable walking are high (R2Nagelkerke = 0.12). Significance Our regression model based solely on kinematic parameters from comfortable walking contained characteristics of the frontal tibia angle and knee flexion angle. As the model explains only 12.3 % of variance, clinical application does not seem feasible. Direct assessment of kinetics seems to be the most optimal strategy for selecting the most optimal gait modification strategy for individual patients with knee osteoarthritis.
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Background: Improved preferred gait speed in older adults is associated with increased survival rates. There are inconsistent findings in clinical trials regarding effects of exercise on preferred gait speed, and heterogeneity in interventions in the current reviews and meta-analyses. Objective: to determine the meta-effects of different types or combinations of exercise interventions from randomized controlled trials on improvement in preferred gait speed. Methods: Data sources: A literature search was performed; the following databases were searched for studies from 1990 up to 9 December 2013: PubMed, EMBASE, EBSCO (AMED, CINAHL, ERIC, Medline, PsycInfo, and SocINDEX), and the Cochrane Library. Study eligibility criteria: Randomized controlled trials of exercise interventions for older adults ≥ 65 years, that provided quantitative data (mean/SD) on preferred gait speed at baseline and post-intervention, as a primary or secondary outcome measure in the published article were included. Studies were excluded when the PEDro score was ≤4, or if participants were selected for a specific neurological or neurodegenerative disease, Chronic Obstructive Pulmonary Disease, cardiovascular disease, recent lower limb fractures, lower limb joint replacements, or severe cognitive impairments. The meta-effect is presented in Forest plots with 95 % confidence Study appraisal and synthesis methods: intervals and random weights assigned to each trial. Homogeneity and risk of publication bias were assessed. Results: Twenty-five studies were analysed in this meta-analysis. Data from six types or combinations of exercise interventions were pooled into sub-analyses. First, there is a significant positive meta-effect of resistance training progressed to 70-80 % of 1RM on preferred gait speed of 0.13 [CI 95 % 0.09-0.16] m/s. The difference between intervention- and control groups shows a substantial meaningful change (>0.1 m/s). Secondly, a significant positive meta-effect of interventions with a rhythmic component on preferred gait speed of 0.07 [CI 95 % 0.03-0.10] m/s was found. Thirdly, there is a small significant positive meta-effect of progressive resistance training, combined with balance-, and endurance training of 0.05 [CI 95 % 0.00-0.09] m/s. The other sub-analyses show non-significant small positive meta-affects. Conclusions: Progressive resistance training with high intensities, is the most effective exercise modality for improving preferred gait speed. Sufficient muscle strength seems an important condition for improving preferred gait speed. The addition of balance-, and/or endurance training does not contribute to the significant positive effects of progressive resistance training. A promising component is exercise with a rhythmic component. Keeping time to music or rhythm possibly trains higher cognitive functions that are important for gait. Limitations: The focus of the present meta-analysis was at avoiding as much heterogeneity in exercise interventions. However heterogeneity in the research populations could not be completely avoided, there are probably differences in health status within different studies.
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PURPOSE: To compare the responses in knee joint muscle activation patterns to different perturbations during gait in healthy subjects.SCOPE: Nine healthy participants were subjected to perturbed walking on a split-belt treadmill. Four perturbation types were applied, each at five intensities. The activations of seven muscles surrounding the knee were measured using surface EMG. The responses in muscle activation were expressed by calculating mean, peak, co-contraction (CCI) and perturbation responses (PR) values. PR captures the responses relative to unperturbed gait. Statistical parametric mapping analysis was used to compare the muscle activation patterns between conditions.RESULTS: Perturbations evoked only small responses in muscle activation, though higher perturbation intensities yielded a higher mean activation in five muscles, as well as higher PR. Different types of perturbation led to different responses in the rectus femoris, medial gastrocnemius and lateral gastrocnemius. The participants had lower CCI just before perturbation compared to the same phase of unperturbed gait.CONCLUSIONS: Healthy participants respond to different perturbations during gait with small adaptations in their knee joint muscle activation patterns. This study provides insights in how the muscles are activated to stabilize the knee when challenged. Furthermore it could guide future studies in determining aberrant muscle activation in patients with knee disorders.
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Knee joint instability is frequently reported by patients with knee osteoarthritis (KOA). Objective metrics to assess knee joint instability are lacking, making it difficult to target therapies aiming to improve stability. Therefore, the aim of this study was to compare responses in neuromechanics to perturbations during gait in patients with self-reported knee joint instability (KOA-I) versus patients reporting stable knees (KOA-S) and healthy control subjects.Forty patients (20 KOA-I and 20 KOA-S) and 20 healthy controls were measured during perturbed treadmill walking. Knee joint angles and muscle activation patterns were compared using statistical parametric mapping and discrete gait parameters. Furthermore, subgroups (moderate versus severe KOA) based on Kellgren and Lawrence classification were evaluated.Patients with KOA-I generally had greater knee flexion angles compared to controls during terminal stance and during swing of perturbed gait. In response to deceleration perturbations the patients with moderate KOA-I increased their knee flexion angles during terminal stance and pre-swing. Knee muscle activation patterns were overall similar between the groups. In response to sway medial perturbations the patients with severe KOA-I increased the co-contraction of the quadriceps versus hamstrings muscles during terminal stance.Patients with KOA-I respond to different gait perturbations by increasing knee flexion angles, co-contraction of muscles or both during terminal stance. These alterations in neuromechanics could assist in the assessment of knee joint instability in patients, to provide treatment options accordingly. Furthermore, longitudinal studies are needed to investigate the consequences of altered neuromechanics due to knee joint instability on the development of KOA.
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