Effects of Handrail and Cane Support on Energy Cost of Walking in People With Different Levels and Causes of Lower Limb Amputation

Objective: The energy cost of walking with a lower limb prosthesis is higher than able-bodied walking and depends on both cause and level of amputation. This increase might partly be related to problems with balance control. In this study we investigated to what extent energy cost can be reduced by providing support through a handrail or cane and how this depends on level and cause of amputation. Design: Quasi-experimental study. Setting: Rehabilitation gait laboratory. Participants: Twenty-six people with a lower limb amputation were included: 9 with vascular and 17 with nonvascular causes, 16 at transtibial, and 10 at transfemoral or knee disarticulation level (N=26). Interventions: Participants walked on a treadmill with and without handrail support and overground with and without a cane. Main Outcome Measures: Energy cost was assessed using respirometry. Results: On the treadmill, handrail support resulted in a 6% reduction in energy cost on average. This effect was attributed to an 11% reduction in those with an amputation attributable to vascular causes, whereas the nonvascular group did not show a significant difference. No interaction with level of amputation was found. Overground, no main effect of cane support was found, although an interaction effect with cause of amputation demonstrated a small nonsignificant decrease in energy cost (3%) in the vascular group and a significant increase (6%) in the nonvascular group when walking with a cane. The effect of support was positively correlated with self-selected walking speed. Conclusions: This study demonstrates that providing external support can contribute to a reduction in energy cost in people with an amputation due to vascular causes with reduced walking ability while walking in the more challenging condition of the treadmill. Although it is speculated that this effect might be related to problems with balance control, this will need further investigation

Cardiorespiratory Fitness in Individuals Post-stroke:Reference Values and Determinants

Objective: To provide reference values of cardiorespiratory fitness for individuals post-stroke in clinical rehabilitation and to gain insight in characteristics related to cardiorespiratory fitness post stroke. Design: A retrospective cohort study. Reference equations of cardiopulmonary fitness corrected for age and sex for the fifth, 25th, 50th, 75th, and 95th percentile were constructed with quantile regression analysis. The relation between patient characteristics and cardiorespiratory fitness was determined by linear regression analyses adjusted for sex and age. Multivariate regression models of cardiorespiratory fitness were constructed. Setting: Clinical rehabilitation center. Participants: Individuals post-stroke who performed a cardiopulmonary exercise test as part of clinical rehabilitation between July 2015 and May 2021 (N=405). Main Outcome Measures: Cardiorespiratory fitness in terms of peak oxygen uptake (V˙O2peak) and oxygen uptake at ventilatory threshold (V˙O2-VT). Results: References equations for cardiorespiratory fitness stratified by sex and age were provided based on 405 individuals post-stroke. Median V˙O2peak was 17.8[range 8.4-39.6] mL/kg/min and median V˙O2-VT was 9.7[range 5.9-26.6] mL/kg/min. Cardiorespiratory fitness was lower in individuals who were older, women, using beta-blocker medication, and in individuals with a higher body mass index and lower motor ability. Conclusions: Population specific reference values of cardiorespiratory fitness for individuals post-stroke corrected for age and sex were presented. These can give individuals post-stroke and health care providers insight in their cardiorespiratory fitness compared with their peers. Furthermore, they can be used to determine the potential necessity for cardiorespiratory fitness training as part of the rehabilitation program for an individual post-stroke to enhance their fitness, functioning and health. Especially, individuals post-stroke with more mobility limitations and beta-blocker use are at a higher risk of low cardiorespiratory fitness.</p

Relative Aerobic Load of Daily Activities After Stroke

Objective: Individuals after stroke are less active, experience more fatigue, and perform activities at a slower pace than peers with no impairments. These problems might be caused by an increased aerobic energy expenditure during daily tasks and a decreased aerobic capacity after stroke. The aim of this study was to quantify relative aerobic load (ie, the ratio between aerobic energy expenditure and aerobic capacity) during daily-life activities after stroke. Methods: Seventy-nine individuals after stroke (14 in Functional Ambulation Category [FAC] 3, 25 in FAC 4, and 40 in FAC 5) and 22 peers matched for age, sex, and body mass index performed a maximal exercise test and 5 daily-life activities at a preferred pace for 5 minutes. Aerobic energy expenditure (mL O2/kg/min) and economy (mL O2/kg/unit of distance) were derived from oxygen uptake (V˙O2). Relative aerobic load was defined as aerobic energy expenditure divided by peak aerobic capacity (%V˙O2peak) and by V˙O2 at the ventilatory threshold (%V˙O2-VT) and compared in individuals after stroke and individuals with no impairments. Results: Individuals after stroke performed activities at a significantly higher relative aerobic load (39%-82% V˙O2peak) than peers with no impairments (38%-66% V˙O2peak), despite moving at a significantly slower pace. Aerobic capacity in individuals after stroke was significantly lower than that in peers with no impairments. Movement was less economical in individuals after stroke than in peers with no impairments. Conclusion: Individuals after stroke experience a high relative aerobic load during cyclic daily-life activities, despite adopting a slower movement pace than peers with no impairments. Perhaps individuals after stroke limit their movement pace to operate at sustainable relative aerobic load levels at the expense of pace and economy. Impact: Improving aerobic capacity through structured aerobic training in a rehabilitation program should be further investigated as a potential intervention to improve mobility and functioning after stroke.</p

Use of antenatal services and delivery care among women in rural western Kenya: a community based survey

BACKGROUND: Improving maternal health is one of the UN Millennium Development Goals. We assessed provision and use of antenatal services and delivery care among women in rural Kenya to determine whether women were receiving appropriate care. METHODS: Population-based cross-sectional survey among women who had recently delivered. RESULTS: Of 635 participants, 90% visited the antenatal clinic (ANC) at least once during their last pregnancy (median number of visits 4). Most women (64%) first visited the ANC in the third trimester; a perceived lack of quality in the ANC was associated with a late first ANC visit (Odds ratio [OR] 1.5, 95% confidence interval [CI] 1.0–2.4). Women who did not visit an ANC were more likely to have < 8 years of education (adjusted OR [AOR] 3.0, 95% CI 1.5–6.0), and a low socio-economic status (SES) (AOR 2.8, 95% CI 1.5–5.3). The ANC provision of abdominal palpation, tetanus vaccination and weight measurement were high (>90%), but provision of other services was low, e.g. malaria prevention (21%), iron (53%) and folate (44%) supplementation, syphilis testing (19.4%) and health talks (14.4%). Eighty percent of women delivered outside a health facility; among these, traditional birth attendants assisted 42%, laypersons assisted 36%, while 22% received no assistance. Factors significantly associated with giving birth outside a health facility included: age ≥ 30 years, parity ≥ 5, low SES, < 8 years of education, and > 1 hour walking distance from the health facility. Women who delivered unassisted were more likely to be of parity ≥ 5 (AOR 5.7, 95% CI 2.8–11.6). CONCLUSION: In this rural area, usage of the ANC was high, but this opportunity to deliver important health services was not fully utilized. Use of professional delivery services was low, and almost 1 out of 5 women delivered unassisted. There is an urgent need to improve this dangerous situation

Estimation of Metabolic Energy Expenditure during Short Walking Bouts

Assessment of metabolic energy expenditure from indirect calorimetry is currently limited to sustained (>4 min) cyclic activities, because of steady-state requirements. This is problematic for patient populations who are unable to perform such sustained activities. Therefore, this study explores validity and reliability of a method estimating metabolic energy expenditure based on oxygen consumption (V˙O 2) during short walking bouts. Twelve able-bodied adults twice performed six treadmill walking trials (1, 2 and 6 min at 4 and 5 km/h), while V˙O 2was measured. Total V˙O 2was calculated by integrating net V˙O 2over walking and recovery. Concurrent validity with steady-state V˙O 2was assessed with Pearson's correlations. Test-retest reliability was assessed using intra-class correlation coefficients (ICC) and Bland-Altman analyses. Total V˙O 2was strongly correlated with steady-state V˙O 2(r=0.91-0.99), but consistently higher. Test-retest reliability of total V˙O 2(ICC=0.65-0.92) was lower than or comparable to steady-state V˙O 2(ICC=0.83-0.92), with lower reliability for shorter trials. Total V˙O 2discriminated between gait speeds. Total oxygen uptake provides a useful measure to estimate metabolic load of short activities from oxygen consumption. Although estimates are less reliable than steady-state measurements, they can provide insight in the yet unknown metabolic demands of daily activities for patient populations unable to perform sustained activities