Visual biofeedback training reduces quantitative drugs index scores associated with fall risk.
ABSTRACT: OBJECTIVE:Drugs increase fall risk and decrease performance on balance and mobility tests. Conversely, whether biofeedback training to reduce fall risk also decreases scores on a published drug-based fall risk index has not been documented. Forty-eight community-dwelling older adults underwent either treadmill gait training plus visual feedback (+VFB), or walked on a treadmill without feedback. The Quantitative Drug Index (QDI) was derived from each participant's drug list and is based upon all cause drug-associated fall risk. Analysis of covariance assessed changes in the QDI during the study, and data is presented as mean?±?standard error of the mean. RESULTS:The QDI scores decreased significantly (p?=?0.031) for participants receiving treadmill gait training +VFB (-?0.259?±?0.207), compared to participants who walked on the treadmill without VFB (0.463?±?0.246). Changes in participants QDI scores were dependent in part upon their age, which was a significant covariate (p?=?0.007). These preliminary results demonstrate that rehabilitation to reduce fall risk may also decrease use of drugs associated with falls. Determination of which drugs or drug classes that contribute to the reduction in QDI scores for participants receiving treadmill gait training +VFB, compared to treadmill walking only, will require a larger participant investigation. Trial Registration ISRNCT01690611, ClinicalTrials.gov #366151-1, initial 9/24/2012, completed 4/21/2016.
Project description:BACKGROUND:The European population is rapidly ageing. There is an urgent need for innovative solutions to reduce fall risk in older adults. Perturbation-based gait training is a promising new method to improve reactive balance responses. Whereas positive effects on task-specific dynamic balance recovery during gait have been shown in clinical or laboratory settings, translation of these effects to daily life gait function and fall risk is limited. We aim to evaluate the effect of a 4-week perturbation-based treadmill training on daily-life dynamic gait stability, assessed with inertial sensor data. Secondary outcomes are balance recovery performance, clinical balance and gait assessment scores, the amount of physical activity in daily life and falls incidence during 6?months follow-up. METHODS:The study is a monocenter assessor-blinded randomized controlled trial. The target study sample consists of 70 older adults of 65?years and older, living in the community and with an elevated risk of falling. A block-randomization to avoid seasonal effects will be used to allocate the participants into two groups. The experimental group receives a 4-week, two times per week perturbation-based gait training programme on a treadmill, with simulated slips and trips, in combination with cognitive dual tasks. The control group receives a 4-week, two times per week treadmill training programme under cognitive dual-task conditions without perturbations. Participants will be assessed at baseline and after the 4-weeks intervention period on their daily-life gait stability by wearing an inertial sensor on the lower back for seven consecutive days. In addition, clinical balance and gait assessments as well as questionnaires on falls- and gait-efficacy will be taken. Daily life falls will be followed up over 6 months by a fall calendar. DISCUSSION:Whereas perturbation-based training has shown positive effects in improving balance recovery strategies and in reducing laboratory falls, this study will contribute to investigate the translation of perturbation-based treadmill training effects in a clinical setting towards improving daily life gait stability and reducing fall risk and falls. TRIAL REGISTRATION:NTR7703 / NL66322.028.18, Registered: January 8, 2019; Enrolment of the first participant April 8, 2019.
Project description:Most falls occur after a loss of balance following an unexpected perturbation such as a slip or a trip. Greater understanding of how humans control and maintain stability during perturbed walking may help to develop appropriate fall prevention programs. The aim of this study was to examine changes in spatiotemporal gait and stability parameters in response to sudden mechanical perturbations in medio-lateral (ML) and anterior-posterior (AP) direction during treadmill walking. Moreover, we aimed to evaluate which parameters are most representative to quantify postural recovery responses. Ten healthy adults (mean = 26.4, SD = 4.1 years) walked on a treadmill that provided unexpected discrete ML and AP surface horizontal perturbations. Participants walked under no perturbation (normal walking), and under left, right, forward, and backward sudden mechanical perturbation conditions. Gait parameters were computed including stride length (SL), step width (SW), and cadence, as well as dynamic stability in AP- (MoS-AP) and ML- (MoS-ML) directions. Gait and stability parameters were quantified by means, variability, and extreme values. Overall, participants walked with a shorter stride length, a wider step width, and a higher cadence during perturbed walking, but despite this, the effect of perturbations on means of SW and MoS-ML was not statistically significant. These effects were found to be significantly greater when the perturbations were applied toward the ML-direction. Variabilities, as well as extremes of gait-related parameters, showed strong responses to the perturbations. The higher variability as a response to perturbations might be an indicator of instability and fall risk, on the same note, an adaptation strategy and beneficial to recover balance. Parameters identified in this study may represent useful indicators of locomotor adaptation to successfully compensate sudden mechanical perturbation during walking. The potential association of the extracted parameters with fall risk needs to be determined in fall-prone populations.
Project description:BACKGROUND:Virtual reality and augmented feedback have become more prevalent as training methods to improve balance. Few reports exist on the benefits of providing trunk motion visual feedback (VFB) during treadmill walking, and most of those reports only describe within session changes. RESEARCH QUESTION:To determine whether trunk motion VFB treadmill walking would improve over-ground balance for older adults with self-reported balance problems. METHODS:40 adults (75.8 years (SD 6.5)) with self-reported balance difficulties or a history of falling were randomized to a control or experimental group. Everyone walked on a treadmill at a comfortable speed 3×/week for 4 weeks in 2?min bouts separated by a seated rest. The control group was instructed to look at a stationary bulls-eye target while the experimental group also saw a moving cursor superimposed on the stationary bulls-eye that represented VFB of their walking trunk motion. The experimental group was instructed to keep the cursor in the center of the bulls-eye. Somatosensory (monofilaments and joint position testing) and vestibular function (canal specific clinical head impulses) was evaluated prior to intervention. Balance and mobility were tested before and after the intervention using Berg Balance Test, BESTest, mini-BESTest, and Six Minute Walk. RESULTS:There were no significant differences between groups before the intervention. The experimental group significantly improved on the BESTest (p?=?0.031) and the mini-BEST (p?=?0.019). The control group did not improve significantly on any measure. Individuals with more profound sensory impairments had a larger improvement on dynamic balance subtests of the BESTest. SIGNIFICANCE:Older adults with self-reported balance problems improve their dynamic balance after training using trunk motion VFB treadmill walking. Individuals with worse sensory function may benefit more from trunk motion VFB during walking than individuals with intact sensory function.
Project description:<h4>Background</h4>Walking requires gait adjustments in order to walk safely in continually changing environments. Gait adaptability is reduced in older adults, and (near) falls, fall-related hip fractures and fear of falling are common in this population. Most falls occur due to inaccurate foot placement relative to environmental hazards, such as obstacles. The C-Mill is an innovative, instrumented treadmill on which visual context (e.g., obstacles) is projected. The C-Mill is well suited to train foot positioning relative to environmental properties while concurrently utilizing the high-intensity practice benefits associated with conventional treadmill training. The present protocol was designed to examine the efficacy of C-Mill gait adaptability treadmill training for improving walking ability and reducing fall incidence and fear of falling relative to conventional treadmill training and usual care. We hypothesize that C-Mill gait adaptability treadmill training and conventional treadmill training result in better walking ability than usual care due to the enhanced training intensity, with superior effects for C-Mill gait adaptability treadmill training on gait adaptability aspects of walking given the concurrent focus on practicing step adjustments.<h4>Methods/design</h4>The protocol describes a parallel group, single-blind, superiority randomized controlled trial with pre-tests, post-tests, retention-tests and follow-up. Hundred-twenty-six older adults with a recent fall-related hip fracture will be recruited from inpatient rehabilitation care and allocated to six weeks of C-Mill gait adaptability treadmill training (high-intensity, adaptive stepping), conventional treadmill training (high-intensity, repetitive stepping) or usual care physical therapy using block randomization, with allocation concealment by opaque sequentially numbered envelopes. Only data collectors are blind to group allocation. Study parameters related to walking ability will be assessed as primary outcome pre-training, post-training, after 4 weeks retention and 12 months follow-up. Secondary study parameters are measures related to fall incidence, fear of falling and general health.<h4>Discussion</h4>The study will shed light on the relative importance of adaptive versus repetitive stepping and practice intensity for effective intervention programs directed at improving walking ability and reducing fall risk and fear of falling in older adults with a recent fall-related hip fracture, which may help reduce future fall-related health-care costs.
Project description:Stride sequences of healthy gait are characterized by persistent long-range correlations, which become anti-persistent in the presence of an isochronous metronome. The latter phenomenon is of particular interest because auditory cueing is generally considered to reduce stride variability and may hence be beneficial for stabilizing gait. Complex systems tend to match their correlation structure when synchronizing. In gait training, can one capitalize on this tendency by using a fractal metronome rather than an isochronous one? We examined whether auditory cues with fractal variations in inter-beat intervals yield similar fractal inter-stride interval variability as isochronous auditory cueing in two complementary experiments. In Experiment 1, participants walked on a treadmill while being paced by either an isochronous or a fractal metronome with different variation strengths between beats in order to test whether participants managed to synchronize with a fractal metronome and to determine the necessary amount of variability for participants to switch from anti-persistent to persistent inter-stride intervals. Participants did synchronize with the metronome despite its fractal randomness. The corresponding coefficient of variation of inter-beat intervals was fixed in Experiment 2, in which participants walked on a treadmill while being paced by non-isochronous metronomes with different scaling exponents. As expected, inter-stride intervals showed persistent correlations similar to self-paced walking only when cueing contained persistent correlations. Our results open up a new window to optimize rhythmic auditory cueing for gait stabilization by integrating fractal fluctuations in the inter-beat intervals.
Project description:CONTEXT:Neither supervised treadmill exercise nor strength training for patients with peripheral arterial disease (PAD) without intermittent claudication have been established as beneficial. OBJECTIVE:To determine whether supervised treadmill exercise or lower extremity resistance training improve functional performance of patients with PAD with or without claudication. DESIGN, SETTING, AND PARTICIPANTS:Randomized controlled clinical trial performed at an urban academic medical center between April 1, 2004, and August 8, 2008, involving 156 patients with PAD who were randomly assigned to supervised treadmill exercise, to lower extremity resistance training, or to a control group. MAIN OUTCOME MEASURES:Six-minute walk performance and the short physical performance battery. Secondary outcomes were brachial artery flow-mediated dilation, treadmill walking performance, the Walking Impairment Questionnaire, and the 36-Item Short Form Health Survey physical functioning (SF-36 PF) score. RESULTS:For the 6-minute walk, those in the supervised treadmill exercise group increased their distance walked by 35.9 m (95% confidence interval [CI], 15.3-56.5 m; P < .001) compared with the control group, whereas those in the resistance training group increased their distance walked by 12.4 m (95% CI, -8.42 to 33.3 m; P = .24) compared with the control group. Neither exercise group improved its short physical performance battery scores. For brachial artery flow-mediated dilation, those in the treadmill group had a mean improvement of 1.53% (95% CI, 0.35%-2.70%; P = .02) compared with the control group. The treadmill group had greater increases in maximal treadmill walking time (3.44 minutes; 95% CI, 2.05-4.84 minutes; P < .001); walking impairment distance score (10.7; 95% CI, 1.56-19.9; P = .02); and SF-36 PF score (7.5; 95% CI, 0.00-15.0; P = .02) than the control group. The resistance training group had greater increases in maximal treadmill walking time (1.90 minutes; 95% CI, 0.49-3.31 minutes; P = .009); walking impairment scores for distance (6.92; 95% CI, 1.07-12.8; P = .02) and stair climbing (10.4; 95% CI, 0.00-20.8; P = .03); and SF-36 PF score (7.5; 95% CI, 0.0-15.0; P = .04) than the control group. CONCLUSIONS:Supervised treadmill training improved 6-minute walk performance, treadmill walking performance, brachial artery flow-mediated dilation, and quality of life but did not improve the short physical performance battery scores of PAD participants with and without intermittent claudication. Lower extremity resistance training improved functional performance measured by treadmill walking, quality of life, and stair climbing ability. TRIAL REGISTRATION:clinicaltrials.gov Identifier: NCT00106327.
Project description:Recent work has demonstrated that fall risk can be attributed to cognitive as well as motor deficits. Indeed, everyday walking in complex environments utilizes executive function, dual tasking, planning and scanning, all while walking forward. Pilot studies suggest that a multi-modal intervention that combines treadmill training to target motor function and a virtual reality obstacle course to address the cognitive components of fall risk may be used to successfully address the motor-cognitive interactions that are fundamental for fall risk reduction. The proposed randomized controlled trial will evaluate the effects of treadmill training augmented with virtual reality on fall risk.Three hundred older adults with a history of falls will be recruited to participate in this study. This will include older adults (n=100), patients with mild cognitive impairment (n=100), and patients with Parkinson's disease (n=100). These three sub-groups will be recruited in order to evaluate the effects of the intervention in people with a range of motor and cognitive deficits. Subjects will be randomly assigned to the intervention group (treadmill training with virtual reality) or to the active-control group (treadmill training without virtual reality). Each person will participate in a training program set in an outpatient setting 3 times per week for 6 weeks. Assessments will take place before, after, and 1 month and 6 months after the completion of the training. A falls calendar will be kept by each participant for 6 months after completing the training to assess fall incidence (i.e., the number of falls, multiple falls and falls rate). In addition, we will measure gait under usual and dual task conditions, balance, community mobility, health related quality of life, user satisfaction and cognitive function.This randomized controlled trial will demonstrate the extent to which an intervention that combines treadmill training augmented by virtual reality reduces fall risk, improves mobility and enhances cognitive function in a diverse group of older adults. In addition, the comparison to an active control group that undergoes treadmill training without virtual reality will provide evidence as to the added value of addressing motor cognitive interactions as an integrated unit.(NIH)-NCT01732653.
Project description:An unsettled question in the use of robotics for post-stroke gait rehabilitation is whether task-specific locomotor training is more effective than targeting individual joint impairments to improve walking function. The paretic ankle is implicated in gait instability and fall risk, but is difficult to therapeutically isolate and refractory to recovery. We hypothesize that in chronic stroke, treadmill-integrated ankle robotics training is more effective to improve gait function than robotics focused on paretic ankle impairments.Participants with chronic hemiparetic gait were randomized to either six weeks of treadmill-integrated ankle robotics (n?=?14) or dose-matched seated ankle robotics (n?=?12) videogame training. Selected gait measures were collected at baseline, post-training, and six-week retention. Friedman, and Wilcoxon Sign Rank and Fisher's exact tests evaluated within and between group differences across time, respectively. Six weeks post-training, treadmill robotics proved more effective than seated robotics to increase walking velocity, paretic single support, paretic push-off impulse, and active dorsiflexion range of motion. Treadmill robotics durably improved gait dorsiflexion swing angle leading 6/7 initially requiring ankle braces to self-discarded them, while their unassisted paretic heel-first contacts increased from 44 % to 99.6 %, versus no change in assistive device usage (0/9) following seated robotics.Treadmill-integrated, but not seated ankle robotics training, durably improves gait biomechanics, reversing foot drop, restoring walking propulsion, and establishing safer foot landing in chronic stroke that may reduce reliance on assistive devices. These findings support a task-specific approach integrating adaptive ankle robotics with locomotor training to optimize mobility recovery.NCT01337960. https://clinicaltrials.gov/ct2/show/NCT01337960?term=NCT01337960&rank=1.
Project description:<h4>Background</h4>Robot-assisted gait training (RAGT) was developed to restore gait function by promoting neuroplasticity through repetitive locomotor training and has been utilized in gait training. However, contradictory outcomes of RAGT have been reported for patients with Parkinson's disease (PD). In addition, the mechanism of the RAGT treatment effect is still unknown. This study aims to investigate the effects of RAGT on gait velocity in patients with PD and to unveil the mechanisms of these effects.<h4>Methods</h4>This is a prospective, single-blind, single-center, randomized controlled trial. Eligible participants will be randomly allocated to: 1) a Walkbot-S™ RAGT group or 2) a treadmill training group. The participants will receive three 45-min sessions of each intervention per week for 4?weeks. Gait speed during RAGT will be targeted to the maximal speed depending on the participant's height; the same principle will be applied to the treadmill training group to match the training intensity. The primary outcome measure is gait speed measured by the 10-Meter Walk Test at a comfortable pace under single-task conditions. Secondary outcomes include dual-task interference, the Berg Balance Scale, Timed Up and Go test, the Korean version of the Falls Efficacy Scale-International, New Freezing of Gait Questionnaire, Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale, and functional connectivity measured by resting-state functional magnetic resonance imaging. Baseline assessments (T0) will be conducted to acquire clinical characteristics and outcome measure values before the intervention. Postintervention assessments (T1) will compare immediate efficacies within 3 days after the intervention. Follow-up assessments (T2) will be conducted 1 month after the intervention. Considering an alpha of 0.05 and a power of 80%, the total number of participants to be recruited is 44.<h4>Discussion</h4>This study will reveal the effect of RAGT using an exoskeletal robot, not only on gait speed, but also on gait automaticity, balance function, fall risk, quality of life, and disease severity. In addition, the study will shed new light on the mechanism of the RAGT effect by evaluating changes in gait automaticity and brain functional networks.<h4>Trial registration</h4>ClinicalTrials.gov, NCT03490578 . Registered on 21 March 2018.
Project description:Impairments in walking speed, capacity, and endurance are commonly seen after stroke. Treadmill training improves endurance and gait speed. However, the lack of variable training speed and automated speed progression increases the risk of backward displacement and falling. An automated, speed-sensing treadmill prototype with partial body weight support, the Variable Automated Speed and Sensing Treadmill II (VASST II), was tested in an outpatient rehabilitation setting. Eleven subacute or chronic hemiplegics who could ambulate at > 0.2 m/s for >50 m participated in the study. All subjects underwent physiotherapist-supervised training on VASST II for 60 min daily, 3 times per week, for 5 weeks (total 15 h). Outcome measures at Week 3 (mid-VASST II training), Week 6 (post-VASST II training), Week 12 (first follow-up), and Week 24 (second follow-up) included the 6 minute walk test (6 MWT), 10 meter walk test (10 MWT), Berg Balance Scale (BBS) score, and Functional Ambulation category (FAC) score. User acceptability of VASST II for both study subjects and physiotherapists were also assessed. All subjects [median (IQR) age: 53.0 (22) years; median (IQR) duration post-stroke: 524 (811) days] completed VASST II training. At baseline, mean ± SD 6 MWT was 114 ± 50.9 m; mean ± SD 10 MWT was 0.37 ± 0.18 m/s; mean ± SD BBS score was 40 ± 10; and, mean ± SD FAC score was 4 ± 1. At Week 6, there were significant improvements in the 6 MWT [158.91 ± 88.69 m; P = 0.003], 10 MWT [0.49 ± 0.30 m/s; P = 0.016], and BBS score [42 ± 10; P = 0.003]. Improvements in 6 MWT and BBS scores were sustained at Week 24, but not in the 10 MWT. No VASST II-training related falls were reported. All subjects rated their VASST II training positively and indicated that it improved their current walking ability. VASST II training was effective, feasible, and safe in patients with subacute or chronic post-stroke hemiparetic gait, with sustained gains in distance walked (6 MWT) and functional balance (BBS score) up to 19 weeks post-intervention.