How to improve walking, balance and social participation following stroke: a comparison of the long term effects of two walking aids--canes and an orthosis TheraTogs--on the recovery of gait following acute stroke. A study protocol for a multi-centre, single blind, randomised control trial

<p>Abstract</p> <p>Background</p> <p>Annually, some 9000 people in Switzerland suffer a first time stroke. Of these 60% are left with moderate to severe walking disability. Evidence shows that rehabilitation techniques which emphasise activity of the hemiplegic side increase ipsilesional cortical plasticity and improve functional outcomes. Canes are commonly used in gait rehabilitation although they significantly reduce hemiplegic muscle activity. We have shown that an orthosis "TheraTogs" (a corset with elasticated strapping) significantly increases hemiplegic muscle activity during gait. The aim of the present study is to investigate the long term effects on the recovery of gait, balance and social participation of gait rehabilitation with TheraTogs compared to gait rehabilitation with a cane following first time acute stroke.</p> <p>Methods/Design</p> <p>Multi-centre, single blind, randomised trial with 120 patients after first stroke. When subjects have reached Functional Ambulation Category 3 they will be randomly allocated into TheraTogs or cane group. TheraTogs will be applied to support hip extensor and abductor musculature according to a standardised procedure. Cane walking held at the level of the radial styloid of the sound wrist. Subjects will walk throughout the day with only the assigned walking aid. Standard therapy treatments and usual care will remain unchanged and documented. The intervention will continue for five weeks or until patients have reached Functional Ambulation category 5. Outcome measures will be assessed the day before begin of intervention, the day after completion, 3 months, 6 months and 2 years. Primary outcome: Timed "up and go" test, secondary outcomes: peak surface EMG of gluteus maximus and gluteus medius, activation patterns of hemiplegic leg musculature, temporo-spatial gait parameters, hemiplegic hip kinematics in the frontal and sagittal planes, dynamic balance, daily activity measured by accelerometry, Stroke Impact Scale. Significance levels will be 5% with 95% CI's. IntentionToTreat analyses will be performed. Descriptive statistics will be presented.</p> <p>Discussion</p> <p>This study could have significant implications for the clinical practice of gait rehabilitation after stroke, particularly the effect and appropriate use of walking aids.</p> <p>The results could be important for the development of clinical guidelines and for the socio-economic costs of post-stroke care</p> <p>Trial registration number</p> <p>ClinicalTrials.gov <a href="http://www.clinicaltrials.gov/ct2/show/NCT01366729">NCT01366729</a>.</p

Intraindividual double burden of overweight or obesity and micronutrient deficiencies or anemia among women of reproductive age in 17 population-based surveys

Background: Rising prevalence of overweight/obesity (OWOB) alongside persistent micronutrient deficiencies suggests many women face concomitant OWOB and undernutrition. Objectives: We aimed to 1) describe the prevalence of the double burden of malnutrition (DBM) among nonpregnant women of reproductive age, defined as intraindividual OWOB and either ≥1 micronutrient deficiency [micronutrient deficiency index (MDI) \u3e 0; DBM-MDI] or anemia (DBM-anemia); 2) test whether the components of the DBM were independent; and 3) identify factors associated with DBM-MDI and DBM-anemia. Methods: With data from 17 national surveys spanning low- and middle-income countries (LMICs) and high-income countries from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project (n = 419 to n = 9029), we tested independence of over- and undernutrition using the Rao–Scott chi-square test and examined predictors of the DBM and its components using logistic regression for each survey. Results: Median DBM-MDI was 21.9% (range: 1.6%–39.2%); median DBM-anemia was 8.6% (range: 1.0%–18.6%). OWOB and micronutrient deficiencies or anemia were independent in most surveys. Where associations existed, OWOB was negatively associated with micronutrient deficiencies and anemia in LMICs. In 1 high-income country, OWOB women were more likely to experience micronutrient deficiencies and anemia. Age was consistently positively associated with OWOB and the DBM, whereas the associations with other sociodemographic characteristics varied. Higher socioeconomic status tended to be positively associated with OWOB and the DBM in LMICs, whereas in higher-income countries the association was reversed. Conclusions: The independence of OWOB and micronutrient deficiencies or anemia within individuals suggests that these forms of over- and undernutrition may have unique etiologies. Decision-makers should still consider the prevalence, consequences, and etiology of the individual components of the DBM as programs move towards double-duty interventions aimed at addressing OWOB and undernutrition simultaneously

Bewertung des funktionellen Status von Patienten mit Kardiorespiratorischen Erkrankungen mittels Tele-Akzelerometrie

This work illustrates two different approaches of using tele-accelerometry to measure functional exercise capacity in patients with chronic diseases. In the first approach we demonstrated that it is possible to remotely conduct a standardized exercise test in patients with chronic heart failure using tele- accelerometry. The association of 6-minute walk test step frequency is interchangeable with 6-minute walk distance. The second approach shows daily physical activity to be a solid indicator of functional exercise capacity in patients with CHF and COPD. Daily walking time and intensity can be used to predict the probability of poor prognosis (NYHA IV, BODE index > 6). In particular walking intensity proved to be a key indicator of disease status in this patient population. Continuous monitoring of daily activity enables patient screening and improves long-term chronic disease management. Moreover, our findings emphasize an independent and significant association between accelerometer based functional exercise capacity and health related quality of life in patients with COPD. The amount of daily walking activity is indicative of patients’ functional status and directly linked to disease severity. Using tele-accelerometry to monitor quality of life can be useful to guide therapeutic interventions. Our data also illustrates that daily walking activity is significantly and independently associated with prognostic biomarkers of cardiac distress in patients with COPD, in particular MRproADM. Employing activity monitors in stable COPD patients not only enables continuous patient monitoring in a real life setting, but can also reduce the risk for exacerbation in COPD.In dieser Arbeit werden zwei unterschiedliche Methoden demonstriert, um die funktionelle körperliche Leistungsfähigkeit bei chronisch kranken Patienten zu messen. Die erste Methode zeigt, das es möglich ist den 6- Minuten Gehtest in ein Telemedizinkonzept zu integrieren. Die Patienten absolvieren diesen regelmäßig einmal im Monat via Akzelerometer in ihrer häuslichen Umgebung, und die Daten werden nach Abschluss direkt an das Telemedizinzentrum geschickt. Es zeigt sich, dass die Schrittfrequenz und die Gehintensität ebenso aussagekräftig hinsichtlich des Gesundheitszustands ist wie die Gehdistanz in Patienten mit Chronischer Herzinsuffizienz. Die zweite Methode untersucht die Aussagekraft der Alltagsaktivität in Patienten mit Chronischer Herzinsuffizienz (CHF) und Chonisch Obstruktiver Bronchitis (COPD). Auch hier wurde die Aktivität mittels Akzelerometer gemessen. Unsere Untersuchungen konnten nachweisen, dass auch die Alltagsaktivität stark mit der Prognose der Patienten zusammenhängt und der Schweregrad der Erkrankung somit erkennbar ist. Des weiteren zeigte sich eine signifikante Korrelation zwischen der Alltagsaktivität und wichtigen klinischen Parametern die mit einer hohen prognostischen Aussagekraft in diesen Patientengruppen einhergehen, wie z.B. die kardialen Biomarker NTproBNP, MRproADM und MRproANP, sowie auch die mittels Fragebogen erhobene Lebensqualität der Patienten.Schlussfolgernd kann man sagen, dass die telemetrische Überwachung der Patienten mittels Akzelerometrie, die sogenannte Tele-Akzelerometrie, eine starke klinische Relevanz in diesem Patientengut aufweist, egal ob mittels der Schrittfrequenz im 6-Minuten Gehtest oder mittels der Alltagsaktivität

Associations of daily walking activity with biomarkers related to cardiac distress in patients with chronic obstructive pulmonary disease

The prevalence of cardiovascular mortality is high in Chronic Obstructive Pulmonary Disease (COPD) and the identification of clinical parameters to improve risk stratification is of great interest.; This study aims to assess the predictive strength of daily walking activity on expression of cardiac biomarkers in patients with COPD.; One hundred and five patients with COPD (66.1 ± 8.7 years of age) were prospectively analyzed. Daily walking activity was measured by means of accelerometry. Stepwise multivariate regression analyses were employed with either midregional proatrial natriuretic peptide (MRproANP) or plasma proadrenomedullin (MRproADM) as dependent variables, and age, age-adjusted Charlson score, Modified Medical Research Council Dyspnea Scale (MMRC), Saint Georges Respiratory Questionnaire total score and either total walk, steps per day or fast walk as covariates.; Independent predictors of MRproANP included age (p = 0.015) and either total walk or steps per day (both p > 0.0001). Total walk or steps per day were the only independent predictors of MRproADM (p > 0.0001). There was a significant negative correlation between fast walk and MMRC (R = -0.70; p > 0.001) and fast walk was only independently predictive of MRproANP but not MRproADM once MMRC was excluded from the list of covariates (p = 0.023 and p = 0.057, respectively).; Daily walking activity independently predicts levels of circulating MRproANP and MRproADM in stable COPD patients, two prognostic biomarkers of cardiac distress associated with long-term survival upon exacerbation of COPD. Employing activity monitors in the stable state might simplify risk stratification in daily living

Multivariable analysis of heart rate recovery after cycle ergometry in heart failure: exercise in heart failure

The purpose of this study was to investigate the association between impairment in heart rate recovery (HR(rec)) after cycle ergometry and prognostic markers in patients with heart failure (HF) compared with healthy controls.; Fifty patients with chronic HF (systolic HF, N = 30; diastolic HF, N = 20; mean age = 62 ± 12 years) and 50 healthy controls (N = 50; mean age = 66 ± 13 years) underwent 2-dimensional and M-mode echocardiography followed by cardiopulmonary exercise testing. Independent predictors of HR(rec) at 1 and 2 minutes after exercise were analyzed by univariable and multivariable regression analyses, and receiver operating characteristics were performed to obtain area under the curve.; In HF, left ventricular end-diastolic diameter (millimeters), left ventricular ejection fraction (%), N-terminal pro-brain natriuretic peptide (picograms/milliliter), peak oxygen uptake (VO(2)peak [milliliters/kilogram/min]), and peak heart rate (HR(peak)) showed a significant association with HR(rec) (beats/min) in univariate regression analyses (P &lt; .001), but only VO(2)peak remained independently predictive of both HR(rec)1 (P = .034) and HR(rec)2 (P = .008) in the multivariable regression analyses. In controls, VO(2)peak (P = .035) and HR(peak) (P = .032) were significantly associated with HR(rec)2 in univariate analyses only. Optimal cutoff values for discriminating HF versus non-HF based on HR(rec) were 17.5 beats/min (sensitivity 92%; specificity 74%) for HR(rec)1 and 31.5 beats/min (sensitivity 94%; specificity 86%) for HR(rec)2. Optimal cutoff values for discriminating systolic HF versus diastolic HF were 12.5 beats/min (sensitivity 78%; specificity 80%) for HR(rec)1 and 24.5 beats/min (sensitivity 82%; specificity 90%) for HR(rec)2.; Impairment in after exercise HR(rec) is significantly and independently associated with VO2peak in HF and thus might constitute a useful tool for assessing the degree of functional status during exercise rehabilitation

Association of physical activity and prognostic parameters in elderly patients with heart failure

Assessment of habitual physical activity (PA) in patients with heart failure.; This study included 50 patients with heart failure (61.9 ± 4.0 yr). Seven days of PA were assessed by questionnaire (AQ), pedometer, and accelerometer and correlated with prognostic markers including VO(2peak), percent left-ventricular ejection fraction, N-terminal pro-B-type natriuretic peptide, and New York Heart Association (NYHA) functional class.; Accelerometry showed a stronger correlation with VO(2peak) and NYHA class (R = .73 and R = -.68; p &lt; .001) than AQ (R = .58 and R = -.65; p &lt; .001) or pedometer (R = .52 and R = -.50; p &lt; .001). In the multivariable regression model accelerometry was the only consistent independent predictor of VO(2peak) (p = .002). Moreover, when its accuracy of prediction was tested, 59% of NYHA I and 95% of NYHA III patients were correctly classified into their assigned NYHA classes based on their accelerometer activity.; PA assessed by accelerometer is significantly associated with exercise capacity in patients with heart failure and is predictive of disease severity. The data suggests that PA monitoring can aid in evaluating clinical status

The 6-min walk test in heart failure : is it a max or sub-maximum exercise test?

The aim of the study is to compare the cardiorespiratory response during the 6-min walk test (6MWT) with a symptom-limited cardiopulmonary exercise test (CPET) in patients with varying degrees of heart failure. Thirty-seven patients with heart failure (New York Heart Association I-III) were asked to complete a 6MWT and a CPET on a cycle ergometer. Respiratory gases were measured during both the tests and patients were grouped into tertiles according to their VO(2peak) reached during the CPET prior to performing statistical analysis of all other respiratory parameters. Patients were grouped into the following tertiles: Group 1 (VO(2peak) or =17.5 ml/kg per min). Despite the good overall correlation between 6MWT VO(2) and CPET VO(2peak) (r = 0.72, P > 0.001), significant differences were seen within Groups 1 and 3 (P > 0.05). In Group 1, 6MWT VO(2) was significantly lower compared with CPET VO(2peak), whereas Group 3 showed significantly higher 6MWT VO(2) compared with CPET VO(2peak). In conclusion, the use of the 6MWT to evaluate exercise capacity in patients with heart failure is highly dependent on the degree of functional impairment. In patients with advanced heart failure, the 6MWT elicits a maximum exercise response, whereas it only constitutes a sub-maximal exercise test in patients with mild heart failure and no functional limitations. This must be taken into consideration when using the 6MWT in large epidemiological studies to evaluate therapy outcome and clinical prognosis in patients with varying degrees of clinical disabilities