Fatigue induced changes to kinematic and kinetic gait parameters following six minutes of walking in people with Multiple Sclerosis

This is an Accepted Manuscript of an article published by Taylor & Francis in Disability and Rehabilitation on 20 May 2015, available online: http://www.tandfonline.com/doi/abs/10.3109/09638288.2015.1047969Purpose: The aim of this study was to examine the effect of 6 min of walking on fatigue, exertion and spatiotemporal, kinematic and kinetic gait parameters in people with multiple sclerosis (MS). Methods: Thirty-four people with MS with moderate levels of disability completed measures of fatigue, exertion and instrumented gait analysis before and after 6-min trials of rest and walking (using a modified 6-min walk test, m6MWT). Ten age- and gender-matched healthy controls completed analysis before and after the m6MWT. Results: The MS group had a significant increase in self-reported fatigue following the m6MWT; however, there was no effect on spatiotemporal gait parameters. During stance on the more affected side ankle dorsiflexion at initial contact decreased, while knee and hip flexor moments and hip power absorption increased. On the less affected side ankle and knee power absorption, and hip extensor moment all increased. Healthy controls showed increases in joint kinetics likely due to increased walking speeds following m6MWT. Conclusion: For people with MS, ankle dorsiflexion angle reduces at initial contact following walking induced fatigue, while increased power absorption at the hip, knee and ankle indicate gait inefficiencies that may contribute to higher levels of fatigue and exertion. Implications for Rehabilitation The modified 6-min walk test (m6MWT) leads to significant increases in self-reported fatigue and exertion in people with MS. Following the m6MWT, there is significantly reduced ankle dorsiflexion angle at initial contact in the more affected leg in people with MS. This reveals an important walking-induced kinematic change that should be the target of future orthotic and strengthening interventions. In people with MS, increased power absorption primarily during the stance phase of gait following the m6MWT reveals important walking-induced muscle weakness that should also be monitored in future strengthening and gait retraining interventions

Tai Chi for osteopenic women: design and rationale of a pragmatic randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Post-menopausal osteopenic women are at increased risk for skeletal fractures. Current osteopenia treatment guidelines include exercise, however, optimal exercise regimens for attenuating bone mineral density (BMD) loss, or for addressing other fracture-related risk factors (e.g. poor balance, decreased muscle strength) are not well-defined. Tai Chi is an increasingly popular weight bearing mind-body exercise that has been reported to positively impact BMD dynamics and improve postural control, however, current evidence is inconclusive. This study will determine the effectiveness of Tai Chi in reducing rates of bone turnover in post-menopausal osteopenic women, compared with standard care, and will preliminarily explore biomechanical processes that might inform how Tai Chi impacts BMD and associated fracture risks.</p> <p>Methods/Design</p> <p>A total of 86 post-menopausal women, aged 45-70y, T-score of the hip and/or spine -1.0 and -2.5, have been recruited from primary care clinics of a large healthcare system based in Boston. They have been randomized to a group-based 9-month Tai Chi program plus standard care or to standard care only. A unique aspect of this trial is its pragmatic design, which allows participants randomized to Tai Chi to choose from a pre-screened list of community-based Tai Chi programs. Interviewers masked to participants' treatment group assess outcomes at baseline and 3 and 9 months after randomization. Primary outcomes are serum markers of bone resorption (C-terminal cross linking telopeptide of type I collagen), bone formation (osteocalcin), and BMD of the lumbar spine and proximal femur (dual-energy X-ray absorptiometry). Secondary outcomes include health-related quality-of-life, exercise behavior, and psychological well-being. In addition, kinetic and kinematic characterization of gait, standing, and rising from a chair are assessed in subset of participants (n = 16) to explore the feasibility of modeling skeletal mechanical loads and postural control as mediators of fracture risk.</p> <p>Discussion</p> <p>Results of this study will provide preliminary evidence regarding the value of Tai Chi as an intervention for decreasing fracture risk in osteopenic women. They will also inform the feasibility, value and potential limitations related to the use of pragmatic designs for the study of Tai Chi and related mind-body exercise. If the results are positive, this will help focus future, more in-depth, research on the most promising potential mechanisms of action identified by this study.</p> <p>Trial registration</p> <p>This trial is registered in Clinical Trials.gov, with the ID number of NCT01039012.</p

Orthotic and therapeutic effect of functional electrical stimulation on fatigue induced gait patterns in people with multiple sclerosis

Author version made available following 12 month embargo from date of publication (26 March 2016) in accordance with publisher copyright policy. The Version of Record of this manuscript has been published and is available in Disability and Rehabilitation:Assistive Technology http://www.tandfonline.com/10.3109/17483107.2015.1136702.’ABSTRACT Purpose: To assess the orthotic and therapeutic effects of prolonged use of functional electrical stimulation (FES) on fatigue induced gait patterns in people with Multiple Sclerosis (MS). Method: Thirteen people with MS completed 3D gait analysis with FES off and on, before and after a fatiguing 6-minute walk, at baseline and after 8 weeks of use of FES. Results: Eleven participants completed all testing. An orthotic effect on gait was not evident on first use of FES. However, therapeutic effects on gait after 8 weeks use were generally positive, including increases in walking speed due to improved neuromuscular control and power generated at the hip and ankle of the more affected limb. The action of FES alone was not sufficient to overcome all fatigue related deficits in gait but there was evidence 8 weeks use of FES can ameliorate some fatigue effects on lower limb kinetics, including benefits to ankle mechanics involved in generating power around push-off during stance. Conclusions: Eightweeks of FES can benefit the gait pattern of people with MS under non-fatigued and fatigued conditions. -IMPLICATIONS FOR REHABILITATION - In some people with MS prolonged use of FES may be necessary before observing positive orthotic effects. - Improvements in the neuromuscular control of the more affected lower limb may develop with prolonged use of FES in people with MS. - Only some therapeutic benefits of FES are maintained during fatigued walking in people with MS. - FES may be considered as a gait retraining device as well as an orthotic intervention for people with MS

A. Stacoff) 68 REFERENCES De Clercq

INTRODUCTION Perception of the severity of repeated lower limb impacts is important in adapting to loading conditions and minimising overloading of the musculo-skeletal system. The ability to discriminate the severity of typical impact loads experienced during locomotion was evaluated using an established psychophysical protocol. Lower limb impacts were administered under controlled initial conditions across a range of impact severities manipulated using a range of soft and hard EVA materials. REVIEW AND THEORY There is evidence for distinct differences in absolute sensitivity of the footsole in a normal population as characterised by sensory thresholds of tactile and vibration stimuli (Nurse et al., 1998). Transients of lower limb impact loads are highly related to perceived impact severity, while transients of initial contact are also important in the ability to discriminate object softness in tactile tasks PROCEDURES A group of 20 male subjects (mean mass = 75.2 kg) free of lower extremity injury experienced controlled impacts of 1.05 m s -1 to the bare right heel using a human pendulum apparatus. Impact severity was manipulated using a range of sixteen 24mm mats of EVA materials of increasing hardness (shore A20-A68) comprising both homogenous and composite materials. A range of 9 sheets was selected from both the low severity (shore A20-A40) and high severity (shore A35-A68) end of the range. Mechanical impact severity was quantified by the external impact force recorded by a wall mounted Kistler (9218B) force platform, and shock to the shank recorded by a surface mounted Entran uni-axial accelerometer (EGAX-25). Signals were sampled at 2000 Hz and peaks and transient rates of the signals characterised the severity of impacts. The method of constant stimuli was used to determine the discrimination threshold (DL) of impact severity for the low and high impact ranges. A two alternative forced choice paradigm was used by subjects to rate the perceived severity of the 9 experimental conditions, in terms of greater or lesser severity, relative to a central standard condition. All subjects were exposed to 20 impacts per condition. The order of the conditions was counterbalanced about the standard and presented in a randomised order. Probit analysis (Finney, 1971) was used to fit normal distribution curves to the psychometric functions of each subject for the low and high ranges. Group and subject DL&apos;s for each mechanical input was calculated as half the difference between the 25 th and 75 th percentiles ( RESULTS AND DISCUSSION Across the low and high ranges of impact severity subjects experienced mean peak impact forces of 2.14 -2.36 BW and 2.20 -2.84 BW, and peak shank shocks of 6.68 -9.55 g and 8.65 -16.83 g, respectively. This range represents loads typically experienced during jogging and running. A highly significant difference between low and high DL&apos;s was present for the group (F [8, 12] = 64.53, P &lt; 0.0005) as illustrated i

The role of augmented feedback in pediatric roboticassisted gait training: A case series

Abstract. Recent work has examined the feasibility of roboticassisted gait training in pediatric patients, including children with cerebral palsy (CP). Herein we present a case series describing clinical outcomes in four children diagnosed with spastic diplegia due to CP who underwent gait training using a robotic driven gait orthosis (DGO) (Pediatric Lokoma c ). The children were paired based on functional abilities and observed gait characteristics. Two children were classified as Gross Motor Function Classification System (GMFCS) level II and displayed a crouch gait pattern. The other two children were classified as GMFCS level III and exhibited a toewalking gait pattern. Each child participated in a 6week intervention of roboticassisted gait training that involved three 30minute sessions per week. One child of each GMFCS level underwent training using the augmented feedback module of the Pediatric Lokomat c system, while the other child of each pair underwent training without using the augmented feedback module. Pretraining, posttraining, and 3month followup evaluations were performed including clinical tests of standing and walking function (Gross Motor Function Measure, GMFM, sections D and E, respectively), walking speed, and walking endurance. Clinical gait analysis was also performed during each evaluation using a motion capture system to assess changes in gait biomechanics. All children showed an improvement in gait speed. For the lower functioning children (i.e.GMFCS level III), this may be mediated by improved trunk control suggested by concomitantly large increases in standing function (i.e. GMFM section D). Conversely, for the higher functioning children (i.e. GMFCS level II), large changes were observed in walking function assessed by the GMFM section E. The use of augmented feedback was associated with larger improvements in walking function (i.e. GMFM section E) and in walking speed. Furthermore, subjects who received roboticassisted gait training in combination with augmented feedback showed a large increase in endurance while subjects who received roboticassisted gait training without augmented feedback showed limited or no improvements in endurance. Overall, these results suggest that the use of an augmented feedback module in combination with roboticassisted gait training leads to better outcomes than roboticassisted gait training without augmented feedback

Enhancing robotic gait training via augmented feedback.

Recent work has examined the feasibility of robotic-assisted gait training in pediatric patients, including children with cerebral palsy (CP). Herein we present a case series describing clinical outcomes in four children with CP who underwent gait training using a robotic driven gait orthosis (DGO) (Pediatric Lokomat©). Children had a diagnosis of spastic diplegia due to CP. They were paired based on functional abilities and observed gait characteristics. Two children had a GMFCS of III and showed excessive ankle plantarflexion during stance. The other two children had a GMFCS of II and displayed a crouch gait pattern. Each subject participated in a 6-week intervention of robotic-assisted gait training that involved three 30-minute sessions per week. Pre-and post-training evaluations were performed including clinical tests of standing and walking function, walking speed, and walking endurance. Clinical gait analysis was also performed using a motion capture system to assess changes in gait mechanics. All subjects showed an improvement in locomotor function. For lower functioning children, this may be mediated by improved trunk control. The use of augmented feedback was associated with larger. However, these results have to be considered with caution because of the limited sample size of the stud

Clinical application of rehabilitation technologies in children undergoing neurorehabilitation

The application of rehabilitation technologies in children with neurological impairments appears promising as these systems can induce repetitive goal-directed movements to complement conventional treatments. Characteristics of robotic-supported and computer-assisted training are in line with principles of motor learning and include high numbers of repetitions, prolonged training durations, and online feedback about the patient’s active participation. When experienced therapists apply these technologies, they can be considered a rather safe and in combination with virtual realities a motivating supplementary approach. Therapists might have to take into account that there might be some factors that are different when applying such technologies to children with congenital versus acquired neurological lesions. Currently, clinical guidelines on how to apply such technologies are missing, and clinical evidence considering the effectiveness of such technologies has just started to commence in pediatric neurorehabilitation. Experienced therapists formulated recommendations that might be useful to those with less experience on how to apply some of these systems to train the lower and upper extremity intensively and playfully. Finally, suggestions are made on how these technologies could be integrated into the clinical path