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Current research is unclear with respect to whether pole walking (PW) reduces lower limb loading when compared to regular walking (RW). Contradictory findings in the literature may be related to the relative timing between pole and foot contact events, which were examined in the current study among naïve pole walkers. Fourteen young (4 F; 25.3 ± 5.4 years) and 8 older adults (4 F; 68.5 ± 3.2 years) performed PW and RW trials along a force plate embedded walkway at two different visits. The time difference between pole and foot contact during both the onset of ground contact and the peak force application was calculated. Several kinetic measures were calculated for the lower limbs and poles. A significant decrease during PW, compared to RW, was found for foot impulse (2.1%; p < 0.01 ), peak vertical ground reaction force (vGRF) (3.4%; p < 0.01 ), rate of loading (5.2%; p = 0.02 ), and peak push-off vGRF (2.1%; p = 0.01 ). No difference in pole loading was found between age groups and visits. No significant correlations were found between the relative timing and foot loading measures. Significant low-to-moderate negative correlations were found between peak foot and pole vGRFs ( p = 0.04 ), peak foot vGRF and pole strike impulse ( p = 0.01 ), peak foot vGRF and pole impulse ( p = 0.02 ), and peak foot push-off vGRF and pole impulse ( p = 0.01 ), suggesting that as pole loading increased, foot loading decreased. Findings suggest timing between pole and heel contact may not be related to unloading the lower limbs but may be related to other aspects of pole use since PW reduced lower limb loading.

This study investigated the physical and psychological issues of sexuality for men after spinal cord injury and identified areas of top concern. Using the Delphi Method, a panel of expert judges (twenty men with spinal cord injury [SCI], C3-T12, age 26–59) completed a series of three questionnaires in an attempt to reach a consensus on previously identified issues. It was agreed that SCI affects physical and psychosocial aspects of sexuality and that sexual support is limited for exploring sexuality post-SCI. Additionally, insight into the social constructs of masculinity, gender roles, body image and disability and their influence on the sexual experiences of this population is provided. Enhancing patient, healthcare provider and societal awareness of sexuality for men after spinal cord injury should be an immediate area of focus to improve sexual and overall quality of life for this population.

Descriptive phenomenological approach. This study explored the lived experience of sexuality for men after spinal cord injury (SCI) and described the current state of tools and resources available to assist with sexual adjustment from the perspective of men living with SCI. Men living in the community in Ontario, Canada. Six men (age 24–49 years) with complete or incomplete SCI (C4-T12

Variability in the timing of walking patterns has a complex mathematical structure (fractality). Fractality of gait can reflect health,so practicing walking with specific temporal coordination could be helpful for various groups at high risk of falls. However, the degreeto which gait fractalitycan be‘prescribed’using differentauditory stimuli is yet to be elucidated. This study evaluated the use of several fluctuating timing imperatives on the consistency of ‘prescribing’gait complexity in healthy individuals. 14healthy young adults cuedtimingof heel contactto anfractal auditory stimuliacross four conditions(uncued, white noise, pinknoise, and red noise)administered across three sessions(session 1, session 2, and session 3), with each experimentaltrial repeated twice within each session.Fractality differed based on the walking condition while no effect of sessionwas revealed. The results of this study suggest gait fractality adapts to various fractalstimuliand thatfractalitycan beconsistentlyprescribed in a desired direction withina group of healthy young individuals.

The type of balance recovery, feet-in-place or stepping, is predicated on the perturbation intensity, often defined by the combination of applied force and displacement. Few studies examined the relationship between characteristics required to produce a stepping response with one of the postural perturbation methods. The purpose of this study was to investigate the relationship between perturbation characteristics (applied force and displacement) required to elicit a forward stepping response with platform-translation and shoulder-pull methods, and to establish whether a common set of perturbation characteristics existed across both perturbation methods. Fourteen young healthy males participated. Temporally unexpected platform translations and shoulder pulls were induced by release of free weights, which fell a controlled height exerting a pull on the platform or on the participant via a shoulder harness. Participants responded with either feet-in-place or stepping responses. The force and displacement were varied to investigate the range of force-displacement combinations required to elicit stepping responses. Force-displacement combinations that elicited stepping responses were recorded and normalized to the participant’s body weight (BW) and the base of support (BOS; participant’s foot length). The lowest force and associated displacement that elicited stepping responses showed an inverse linear relationship during both platform-translation and shoulder-pull trials. The lowest force-displacement combination common to both perturbation methods was found to be 8.75%BW and 105%BOS, which, in the future work, could enable a direct comparison of the neuromuscular and biomechanical responses to different perturbation methods in a manner that attempts to equilibrate the perturbation stimulus across the methods.

Wearable point-of-care testing (PoCTs) technologies offer great potential to advance healthcare by providing high-quality continuous biometric data to inform clinical care decisions. Driven by the success of consumer-grade devices and rapid technical advances, exciting new developments suggest the potential for chemical sensor data alongside mature movement and electrophysiology capabilities even when facing indirect or noisy measurements. Emerging trends suggest a promising role for wearable PoCT as an early detection and diagnosis tool through longitudinal monitoring of identified biomarkers facilitating proactive, preventative care. However, translating the promise of wearable PoCT to clinical practice remains slow. We argue that a lack of clinical validation research examining the role of wearable PoCT in clinical care pathways is a major bottleneck to adoption. To address these gaps, we recommend fostering a transdisciplinary approach by integrating technical, clinical, institutional, and patient roles in research and development teams.

Negative age-stereotypes can have widespread effects on older adult functionality; however, no research has explored psychophysical aspects of stair navigation after exposure to stereotype priming. The present study examined self-efficacy and biomechanics related to stair navigation in older adults ( N = 90). Between-groups analyses revealed positively primed older adults ascended and descended the stairs significantly faster with greater velocity in the medio-lateral plane than older adults who received a negative prime or controls ( p < .017). Moreover, negatively primed older adults rated their stair self-efficacy significantly lower compared with the control and positively primed groups ( p < .017). These results suggest positively primed older adults can navigate stairs with more confidence, quickness, and efficiency. With implications for interventions aimed at maintaining older adult functionality, the present study highlights the potential benefits of positive age-stereotypes, especially related to challenging physical tasks.

Identifying the optimal approach for motivating faculty to adopt teaching innovation is important, given that broad-scale initiatives can utilize an inordinate amount of time and resources. Using a quantitative approach, we evaluate policy actions that are most strongly associated with the adoption of either e-learning or community-focused experiential learning, over a five-year period in a single institution. Comparisons between adopters and non-adopters affirm the relevance of previously documented facilitators and barriers. However, a logistic regression analysis demonstrates that actions that promote a supportive institutional culture (such as, an institutional plan, committee involvement, professional development and logistical support) as well as faculty perceptions and beliefs (i.e., “using new methods is not risky for student learning”; confidence and self-efficacy with respect to implementation), is strongly associated with the adoption of either e-learning (n = 118) or community-focused experiential learning (n = 97). In contrast, funding and professional dimensions (i.e., workload, historical precedence, and the institutional promotion of the innovation with respect to academic freedom) is weakly associated with adoption. The results not only provide a fine-grained analysis of current assumptions regarding the necessary conditions for implementing organizational change in the university context, but also suggest an approach that reinforces and sustains the adoption of teaching innovation over the long term. Theoretical and practical implications are discussed in reference to models of organizational change, faculty motivation and approaches to institutionalizing teaching innovation., Innovation adoption, organizational change, experiential learning, e-learning, faculty motivation, self-efficacy, institutionalization

Descriptive phenomenological approach.This study explored the lived experience of sexuality for men after spinal cord injury (SCI) and described the current state of tools and resources available to assist with sexual adjustment from the perspective of men living with SCI.Men living in the community in Ontario, Canada.Six men (age 24-49 years) with complete or incomplete SCI (C4-T12;1-29 years post injury) participated in one individual, in-depth, standardized, open-ended interview (68-101 min). Analysis was conducted using Giorgi's method, and involved within case analysis followed by cross-case analysis.All participants reported that resources available to support sexual adjustment after SCI were inadequate, and the majority of men felt their healthcare providers lacked knowledge regarding, and comfort discussing sexuality after SCI. Men reported sexuality was not a priority of the rehabilitation centers and felt that healthcare providers did not understand the importance of addressing sexuality. Existing resources were described as too clinical and not necessarily relevant given changes in sensation and mobility post injury. Participants provided recommendations for the effective delivery of relevant sexual education information.To improve quality of life for men after SCI, suitable resources must be available to support sexual rehabilitation post injury. Future research should focus on developing strategies to facilitate discussions about sexuality between individuals with SCI and healthcare providers, and on developing resources that are effective and relevant for these men.

While physical activity is increasingly promoted for older adults, there is a paucity of sport promotion, which has distinct benefits from exercise and remains stereotypically associated with younger age. Curling is a moderately intense and safe sport that continues to gain popularity; however, no research has investigated psychophysical benefits of curling for older adults. The present study compares high-experience (20+ years; n = 63) and low-experience (20 years; n = 53) curlers (aged 60+ years) with older adult noncurlers (n = 44) on measures of daily functionality, balance confidence, and perceptions of the aging process. While no significant differences were found between high- and low-experience curlers, any level of experience reported significantly better functionality, physical confidence, and aging attitudes compared to noncurlers (p ≤ .05). Although further research is necessary, the results suggest that any level of curling experience can enhance older adult psychophysical well-being, and warrants consideration for physical activity promotion and falls prevention programs.

National joint replacement registries have reported a substantial growth in younger knee osteoarthritic patients (55years old) undergoing total knee replacement, however this younger population is generally understudied. Importantly, studies examining experimentally controlled perturbation have shown age-related differences between younger and older healthy adults, whether similar age-related differences exist among total knee replacement patients is unknown.A total of 59 participants, including 29 unilateral total knee replacement patients (six-months post-surgery) made up the four experimental groups: 1) younger patient (54.3 (SD 7.9) years), 2) younger control (55.2 (SD 4.0) years), 3) older patient (76.9 (SD 4.7) years), and 4) older control (77.7 (SD 4.1) years). Using a tether-release method to perturb balance and simulate a forward fall, center of mass and stepping characteristics were analyzed.Younger patients recovered following the perturbation with a significantly smaller center of mass displacement compared to the older patients (14.85 (SD 0.01) v. 18.13 (SD 0.02) %ht, p=0.02); utilizing a longer (0.43 (SD 0.02) v. 0.39 (SD 0.03) m, p0.001) and higher velocity (2.01 (SD 0.2) v. 1.59 (SD 0.2) m/s, p=0.001) recovery step. Importantly, younger patients did not differ significantly from the younger controls in center of mass displacement or recovery step characteristics (p0.05).The younger patients demonstrated superior center of mass control in response to a forward perturbation, suggesting that younger patients would be at a reduced risk of falling when recovering from a forward-directed postural perturbation compared to older patients.

Background Experts of the Krav Maga (KM) self-defense system propose that KM techniques are based on simple body movements which are suggested to be learned rapidly and retained. This study investigated the acquisition, retention, and further improvement with additional training of two KM strike techniques among novice female practitioners: straight punch and defensive kick. Methods Sixteen healthy females (age: 23 ± 3.7 years) without any previous martial arts/self-defense experience volunteered to participate. All participants received an initial 30-min instruction session (AQ), taught by a certified KM instructor, where each technique was deconstructed into three checkpoints (defined as a component of the entire movement) for learning. Participants were divided into two groups, one of which received additional training. Several kinematic and kinetic measures were recorded at four timepoints: immediately before AQ, immediately after AQ, 5 days after AQ, and 12 days after AQ. Results Results suggest that both techniques were learned rapidly, as checkpoint performance was significantly improved after AQ. Kick velocity and impact force also increased significantly after AQ; however, these measures did not change after AQ for the punch technique. Additional training did not improve either punch or kick performance beyond that learned during AQ. Conclusion The findings from this study suggest that a single training session may be sufficient to learn and retain KM strike techniques relatively permanently; and the acquisition of the kick technique may lead to concomitant improvements in kick velocity and impact force.

Gait asymmetry is observed after total knee replacement, often leading to excessive forces at the contralateral limb. The number of total knee replacement procedures has increased substantially over the past 2 decades, particularly among younger patients. Relatively little is known regarding these younger patients (65 y), specifically, with respect to gait asymmetry. The purpose of this study was to investigate if age affects gait asymmetry after unilateral total knee replacement. Three-dimensional analysis of 10 walking trials was collected from the following 4 groups: younger patient (age: 54.3 [7.9] y), younger control (age: 55.2 [4.0] y), older patient (age: 76.9 [4.7] y), and older control (age: 77.7 [4.1] y). The older patients, but not any of the other groups, demonstrated a significantly larger heel strike transient and peak knee adduction moment at the nonsurgical compared with the surgical limb. The observed gait pattern of the younger patients resembled that of the younger controls, rather than the older patients. The greater loading of the nonsurgical limb for the older patients could contribute to the initiation or further progression of osteoarthritic degeneration in the contralateral knee; these asymmetries were not observed for the younger patients.

Complaints and their management are an important indicator of the quality of care. Therefore, effective management of complaints is central to improve services and prioritise an open, honest and transparent health service. However, there is scope for NHS organisations to improve their response to complaints. This article outlines the NHS complaints procedure, focusing on how nurses can develop essential skills to help them to improve their management of any complaints that arise in their clinical area. It provides a structured framework, identifying useful communication skills, and explores how managing complaints relates to a nurse's statutory duty of candour.

The understanding of reactive balance control mechanisms in humans emanates from studies utilizing a variety of perturbation methods, instructions, and sensory conditions. The use of different perturbation methods may produce method-specific balance-correcting responses. This study evaluated balance-correcting responses induced with platform-translation and shoulder-pull methods with equilibrated perturbation intensities, and whether the absence of vision affects balance-correcting responses differently between perturbation methods. Fifteen healthy young males participated. Unexpected forward and backward platform-translation and shoulder-pull perturbations were induced with eyes-open and eyes-closed. Participants were asked to behave naturally. Forward stepping trials were analyzed. Margin of stability (MOS) was calculated from the position data of reflective markers placed strategically around the body. MOS was reported at step onset and at foot contact. MOS was smaller at step onset (0.01 ± 0.01 m) and at foot contact (0.09 ± 0.01 m) during platform-translation trials and at both time points during shoulder-pull trials (0.04 ± 0.01 m and 0.17 ± 0.01 m, respectively). The absence of vision did not affect MOS at step onset. At foot contact during platform-translation with eyes-closed MOS was larger (0.11 ± 0.01 m) than with eyes-open (0.08 ± 0.01 m), but not different between eyes-open (0.17 ± 0.01 m) and eyes-closed (0.18 ± 0.01 m) during shoulder-pull. Participants required a second step to recover balance in 14% of the platform-translation and 3% of the shoulder-pull trials. During platform-translation trials participants demonstrated smaller MOS which placed them in a less favorable circumstance for balance recovery. Platform-translation appears to be more challenging than shoulder-pull perturbation in terms of balance recovery. This study underscores that caution is required when interpreting results of studies utilizing different perturbation paradigms.

The Imperial College Healthcare National Health Service Trust, a large health care provider in London, together with an academic research unit, used a learning health systems cycle of interventions. The goals were to improve patient safety incident reporting and learning and shape a more just organizational safety culture. Following a phase of feedback gathering from front-line staff, seven evidence-based interventions were implemented and evaluated from October 2016 to August 2018. Indicators of safety culture, incident reporting rates, and reported rates of harm to patients and "never events" (events that should not happen in medical practice) were continuously monitored. In this article we report on this initiative, including its early results. We observed improvement on some measures of safety culture and incident reporting rates. Staff members' perceptions of six of the seven interventions were positive. The intervention exercise demonstrated the importance of health care policies in supporting local ownership of safety culture and encouraging the application of rigorous research standards.

This article discusses the prevention and management of pressure ulcers in intensive care. It outlines a service improvement project conducted in the intensive care units at Imperial College Healthcare NHS Trust with the aim of reducing the incidence of hospital-acquired pressure ulcers. The project introduced a set of 'essential standards' and an audit tool to monitor compliance. Implementation of the essential standards resulted in a reduction in the total number of pressure ulcers acquired in the four intensive care units, with an absence of any category 3 or 4 pressure ulcers (the most severe categories of pressure ulcer). The article describes the measures taken to ensure the sustainability and spread of the initiative within the NHS trust.

Force plate targeting has been referenced as a confounding factor in gait research, but the literature is sparse. Asking participants to target force plates is a convenient strategy to increase the number of acceptable trials, but may inadvertently alter the motor control of gait and limit external validity. This study aimed to investigate the effect of visual targeting on spatiotemporal, kinematic, and kinetic measures of gait and their variability. Young healthy participants were asked to traverse a walkway with three embedded hidden force plates. Starting from a participant-specific initial position and leading with the same foot each time, participants performed series of natural walking trials (no targeting and unaware of the hidden force plates), followed by targeting walking trials. For the targeting trials, participants were asked to step completely within the bounds of a tape outline (∼50cm×45cm), which coincided with the position of the last hidden force plate. The results demonstrated evidence of targeting during targeting trials; compared to natural walking trials, mean heel-target distance variability for targeting trials decreased progressively for the steps approaching the targeting step, reaching significance (p

Background The path to recovery of muscle strength and mobility following discharge from the intensive care unit (ICU) has not been well described. Objective The study objective was to quantify muscle function, gait, and postural control at 3 and 6 months after discharge in people who were recovering from critical illness and who were ventilated for 7 days or more. Design This was a nested longitudinal study with continuous inclusion of individuals over a 2-year period and with age- and sex-matched controls. Methods Twenty-four people were tested at 3 months after ICU discharge; 16 of them (67%) were reevaluated at 6 months (post-ICU group). Healthy controls (n = 12) were tested at a single time point. Muscle function of the knee extensors (KEs), plantar flexors (PFs), and dorsiflexors (DFs) was assessed on a dynamometer. Gait was measured using an electronic walkway, and postural control was measured with 2 portable force plates. Results Muscle weakness was observed across all muscle groups at 3 months, with the greatest strength reductions in the ankle PFs (45%) and DFs (30%). Muscle power was reduced in the PFs and DFs but was not reduced in the KEs. Gait in the post-ICU group was characterized by a narrower step, longer stride, and longer double-support time than in the controls. Improvements were found in KE strength and in stride time and double-support time during gait at 6 months. Leg muscle strength and power had moderate associations with gait velocity, step width, and stride length (r = .44–.65). Limitations The small heterogeneous sample of people with a high level of function was a limitation of this study. Conclusions Muscle strength and power were impaired at 6 months after ICU discharge and were associated with gait parameters. Future studies are needed to examine the role of muscle strength and power training in post-ICU rehabilitation programs to improve mobility.

This study focused on differences between the rapidly growing younger (65 years old) and older (65 years old) total knee replacement (TKR) patients for measures of balance confidence, movement reinvestment, and functional mobility. Fifty-nine participants, including twenty-nine primary unilateral TKR patients (six months post-TKR) formed the four experimental groups: 1) Younger TKR Patient (YP), 2) Younger Control (YC), 3) Older TKR Patient (OP), and 4) Older Control (OC). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Oxford Knee Score (OKS), Activities-specific Balance Confidence scale (ABC), the Movement-Specific Reinvestment Scale (MSRS), and the Timed Up and Go (TUG) test were measured. The YP group reported a significantly lower WOMAC score (p 0.001), and higher perceived knee joint function (p = 0.001), compared to the OP group. The YP group also reported significantly higher balance confidence (p 0.001) and less movement reinvestment (p = 0.001) than the OP group. TUG durations revealed that the YP group had significantly higher functional mobility compared to the OP group (p = 0.001). The YP group did not differ from the YC group across any of these measures (p 0.05). These results identify a clear distinction between younger and older TKR patients for fall risk and TKR outcome, which argues that age should be a factor clinicians take into account when addressing the management and care of individuals recovering from TKR.

Background Mechanical loading during exercise has been shown to promote tissue remodeling. Safe and accessible exercise may be beneficial to populations at risk of diminished bone and joint health. We examined the effect of drop height and instruction on knee loading during a drop-landing task and proposed a task that makes use of drop heights that may be appropriate for rehabilitation purposes and functional in daily life to examine transient knee joint loads. Methods Twenty males (22.0 ± 2.8 years) performed drop landings from 22 cm (low) and 44 cm (high) heights, each under three instructions: “land naturally” (natural), “softly” (soft), and “stiffly” (stiff). Knee compression force and external flexion moment were estimated using three-dimensional inverse dynamics and normalized to body mass. Results Peak knee compression force was larger (p

Background. Balance impairments, falls, and spasticity are common after stroke, but the effect of spasticity on balance control after stroke is not well understood.Methods. In this cross-sectional study, twenty-seven participants with stroke were divided into two groups, based on ankle plantar flexor spasticity level. Fifteen individuals with high spasticity (Modified Ashworth Scale (MAS) score of ≥2) and 12 individuals with low spasticity (MAS score Results. The high spasticity group demonstrated greater ML COP velocity, trunk roll velocity, trunk roll velocity frequency amplitude at 3.7 Hz, and trunk roll velocity frequency amplitude at 4.9 Hz, particularly in the eyes closed condition (spasticitybyvisioninteraction). ML COP MPF was greater in the high spasticity group.Conclusion. Individuals with high spasticity after stroke demonstrated greater impairment of balance control in the frontal plane, which was exacerbated when vision was removed.

While assisting with balance is a primary reason for rollator use, few studies have examined how the upper limbs are used for balance. This study examines upper limb contributions to balance control during rollator-assisted walking. We hypothesized that there would be an increased upper limb contribution, measured by mean vertical loading (Fz) and variation in frontal plane center-of-pressure (COPhigh), when walking balance is challenged/impaired. Experiment 1 compared straight-line and beam-walking in young adults (n = 11). As hypothesized, Fz and COPhighincreased in beam-walking compared to baseline (mean Fz: 13.7 vs. 9.1% body weight (BW), p < 0.001, RMS COPhigh: 1.35 vs. 1.07 cm, p < 0.001). Experiment 2 compared older adults who regularly use rollators (RU, n = 10) to older adult controls (CTL, n = 10). The predicted higher upper limb contribution in the RU group was not supported. However, when individuals were grouped by balance impairment, those with the lowest Berg Balance scores (< 45) demonstrated greater speed-adjusted COPhigh than those with higher scores (p = 0.013). Furthermore, greater COPhigh and Fz were correlated to greater reduction in step width, supporting the role of upper limb contributions to frontal plane balance. This work will guide studies assessing reliance on rollators by providing a basis for measurement of upper limb balance contributions.

The current study quantified lumbar loading while carrying an anterior load mass and navigating an obstacle. Eight healthy male participants walked down a walkway and crossed an obstacle under three randomised LOAD conditions; empty-box (2 KG), five kilogram (5 KG) and ten kilogram (10 KG). Each walk was assessed at two events: left foot mid-stance (LMS) and right toe-crossing (TC) to characterise any changes from approach to crossing. Measures of interest included: trunk pitch, L4/L5 joint moment, compression, joint anterior-posterior shear and erector spinae activation. Findings demonstrate that obstacle crossing extended posture by 50, 41, 44%, respectively for each carried load magnitude. Further, these results indicate that shear rather than compressive loading may be an important consideration during crossing due to increase by 8, 9, 22% from LMS to TC for each load magnitude tested. These results provide insight into sagittal lumbar loading when navigating an obstacle while carrying a load. Practitioner Summary: The risk of carrying while navigating obstacles on the lumbar spine is not completely understood. The forces at the lumbar spine while simultaneously carrying and obstacle crossing were analysed. Data indicate that carrying and obstacle crossing influence lumbar shear loads, thereby moderately increasing the relative risk at lumbar spine.

Problem Falling is a leading cause of serious injury, loss of independence, and nursing-home admission in older adults. Impaired balance control is a major contributing factor. Methods Results from our balance-control studies have been applied in the development of new and improved interventions and assessment tools. Initiatives to facilitate knowledge-translation of this work include setting up a new network of balance clinics, a research-user network and a research-user advisory board. Results Our findings support the efficacy of the developed balance-training methods, balance-enhancing footwear, neuro-prosthesis, walker design, handrail-cueing system, and handrail-design recommendations in improving specific aspects of balance control. Impact on Knowledge Users A new balance-assessment tool has been implemented in the first new balance clinic, a new balance-enhancing insole is available through pharmacies and other commercial outlets, and handrail design recommendations have been incorporated into 10 Canadian and American building codes. Work in progress is expected to have further impact.

Despite widespread acceptance of clinical benefits, empirical evidence to evaluate the advantages and limitations of ambulation aids for balance control is limited. The current study investigates the upper limb biomechanical contributions to the control of frontal plane stability while using a 4-wheeled walker in quiet standing. We hypothesized that: (1) upper limb stabilizing moments would be significant, and (2) would increase under conditions of increased stability demand. Factors influencing upper limb moment generation were also examined. Specifically, the contributions of upper limb center-of-pressure ( COP hands ), vertical and horizontal loads applied to the assistive device were assessed. The results support a significant mechanical role for the upper limbs, generating 27.1% and 58.8% of overall stabilizing moments under baseline and challenged stability demand conditions, respectively. The increased moment was achieved primarily through the preferential use of phasic upper limb control, reflected by increased COP hands (baseline vs. challenged conditions: 0.29 vs. 0.72 cm). Vertical, but not horizontal, was the primary force direction contributing to stabilizing moments in quiet standing. The key finding that the upper limbs play an important role in effecting frontal plane balance control has important implications for ambulation aid users (e.g., elderly, stroke, and traumatic brain injury).

Background. There is little information about the quality of gait in the years following stroke. Long-term changes in mobility, using global indices of function, suggest a decline well after initial rehabilitation. However, global indices of mobility do not reveal more specific changes in walking competency or underlying gait-specific impairment. Objectives. The authors used a cross-sectional design with gait-specific measures (velocity and symmetry) to investigate whether deterioration in gait occurs over the long term poststroke. Methods. Data were abstracted from a standardized database containing clinical assessments and spatiotemporal gait analyses for 171 individuals with stroke. Velocity and 3 expressions of symmetry ratios (swing time, stance time, and step length) were calculated for each individual; they were then assigned to 1 of the 5 following groups: 0 to 3, 3 to 12, 12 to 24, 24 to 48, and >48 months poststroke. Results. Swing time, stance time, and step length symmetry demonstrated a systematic linear trend toward greater asymmetry in groups in the later stages poststroke, whereas velocity, neurological deficit, and lower-extremity (LE) motor impairment did not. Conclusions. The quality of gait, as measured by spatial and temporal symmetry, appears to worsen in later years. These results suggest a dissociation between quantitative measures of gait, such as velocity versus symmetry, and that these parameters may measure independent features. A longitudinal study is needed to confirm the presence and to interpret the clinical meaning of a long-term decline in specific parameters of poststroke gait.

Total knee arthroplasty (TKA) is associated with altered sensory and motor functions of the knee which may impair balance control when standing and walking. This study examined the organization of electromyographic and kinematic postural responses to frontal plane support surface rotations, after TKA. Eight TKA patients and nine control participants volunteered. Patients demonstrated changes in onset latency of rectus femoris and gluteus medius, and in amplitude of muscle activity in tibialis anterior, gastrocnemius, rectus femoris, and gluteus medius, for both perturbation directions, and for both the surgical and sound limbs. Peak knee joint angular velocity was reduced among the patients for both perturbation directions and both the surgical and sound limbs, and patients demonstrated greater peak center of mass displacement. The CNS appears to alter the response to postural perturbation of both lower limbs, based on the reduced capacities of the surgical limb. Impaired detection of the valgus-varus loading of the knee joints may lead to the changes in muscle activity and resultant kinematics. Clinically, these findings are relevant in understanding that fully recovered TKA patients may continue to demonstrate balance impairments, and that balance training during physical rehabilitation may be advantageous to these patients.

To determine the potential differences in control underlying compensatory and voluntary reach-to-grasp movements the current study compared the kinematic and electromyographic profiles associated with upper limb movement. Postural perturbations were delivered to evoke compensatory reach-to-grasp in ten healthy young adult volunteers while seated on a chair that tilted as an inverted pendulum in the frontal plane. Participants reached to grasp a laterally positioned stable handhold and pulled (or pushed) to return the chair to vertical. The distinguishing characteristic between the two behaviors was the onset latency and speed of movement. Consistent with compensatory balance reactions, the perturbation-evoked reach response was initiated very rapidly (137 vs. 239 ms for voluntary). As well the movement time was shorter, and peak velocity was greater for PERT movements. In spite of the profound differences in timing, the sequence of muscle activity onsets and the order of specific kinematic events were not different between maximum velocity voluntary (VOL) and perturbation-evoked (PERT) reach-to-grasp movements. Peak velocity and grasp aperture occurred prior to hand contact with the target for PERT and VOL movements, and wrist trajectory was influenced by the direction of perturbation relative to the target. To achieve such target specific control for responses initiated within 100 ms of the perturbation, and when characteristics of body movement were unpredictable, the perturbation-evoked movements would need to incorporate sensory cues associated with body movement relative to the target into the earliest aspects of the movement. This suggests reliance on an internal spatial map constructed prior to the onset of perturbation. Parallels in electromyographic and kinematic profiles between compensatory and voluntary reach-to-grasp movements, in spite of temporal differences, lead to the view they are controlled by common neural mechanisms.

OBJECTIVE To develop a video-based system, mounted on a rollator to quantify the step width values of rollator users in the community. SUBJECTS A total of 5 able-bodied young adults, age range 24-28 years. METHODS A digital video camera system was mounted on the rollator frame to capture the position of the participant's feet during overground walking. A method of estimating step width from the video data was developed and evaluated against the output from a concurrently recording Vicon MX motion capture system. RESULTS Mean step widths of the rollator and motion capture systems were 14.40 cm (standard deviation (SD) 4.64) and 14.37 cm (SD 4.34), respectively, revealing a strong level of agreement; intra-class correlation coefficient 0.999 (95% confidence interval (95% CI) 0.987-1.000; and root-mean-square difference 0.70 cm. CONCLUSION The video-based system mounted on a rollator to collect foot placement data enabled accurate measurement of step width during rollator use. The ability to record foot placement measurements outside the laboratory setting, characterizing foot placement patterns occurring in the community, will enable research into how these assistive devices influence mobility during everyday use.

Background. The purpose of this study was to determine if the prioritization of postural control over secondary task performance is altered in younger and older adults under different conditions of postural threat. Methods. Fifteen healthy older adults (mean age = 69.53 +/- 5.78) and 15 younger adults (mean age = 22.00 +/- 2.17) performed Brooks' Spatial Letter Task (BST) while standing in four conditions of postural threat. Galvanic skin conductance (GSC) was collected to measure changes in physiological arousal. BST task duration was used to measure changes in cognitive performance, and center of pressure (COP) area was used to determine changes in postural stability across each of the testing conditions. A prioritization index was calculated based on the relative change in BST and COP across testing conditions. This measure was used to quantify changes in the relationship between postural control and secondary task performance under conditions of postural threat. Results. Measures of GSC increased in younger and older adults in response to conditions of increased postural threat. Prioritization index scores revealed that a greater number of older adults than younger adults prioritized postural control over secondary task performance under conditions of increased postural threat. Conclusions. Environmental contexts that alter postural threat may lead to modifications in the prioritization between postural control and secondary task performance among older adults. This relationship may have implications for postural control under situations that do not afford deterioration in secondary task performance.

Objective. The purpose of this study was to determine how bilateral lower limb joint function is altered by the combined effects of osteoarthritis and its treatment by total knee arthroplasty. Design. Lower limb joint work of age-matched healthy, control participants was compared to surgical and non-surgical limb work in individuals who had undergone total knee arthroplasty. Background. Research investigating outcomes following total knee arthroplasty has focussed primarily on the surgical knee, identifying deficits in surgical knee function. The existence of additional lower limb deficits and adjustments made by unaffected joints to complement these deficits, has yet to be examined. Methods. Joint moments, power and work were calculated using bilateral lower limb force and kinematic data collected during a step-up to heights of 11.25 and 20 cm. Results. Fifty percent of patients were unable to step onto the 20 cm step. At both step heights, when the surgical limb led the step-up, surgical knee work was less than controls. When the non-surgical limb led, deficits in non-surgical lead knee work were observed. In both cases, lead hip work increased. Conclusions. Work done by both surgical and non-surgical knees in a step-up task was lower than that done by healthy controls. This deficit was balanced by increased lead hip extensor work. Relevance These findings highlight the importance of including exercises that optimize bilateral knee and hip function in rehabilitation programs used following knee replacement. Clinicians working with this population can use this information to assist in the design of evidenced based treatment programs.

Although falls, balance impairment, and spasticity are common post-stroke, their interrelationship remains unclear. We review the literature for a) a relationship between spasticity and balance and b) the effect of botulinum toxin injections on balance. Electronic databases were searched based on two criteria: a) studies assessing balance in subjects with spasticity and b) studies examining the effect of botulinum toxin on balance. The primary findings were a) balance is impaired in subjects with spasticity, but only one study assessed relationship between spasticity and balance; and b) four studies reported that balance improves following botulinum treatment for limb spasticity. Persons with spasticity demonstrate impaired balance, but the correlation between spasticity and balance has not been adequately assessed in the literature. Evidence for balance changes following botulinum toxin is weak because of lack of randomization, control group comparison, objective balance assessment measures, and standard clinical scales.

Good nursing handover is central to the delivery of high-quality care. However, there are no national tools available to audit and benchmark practice standards in this area. Following a review of the literature, evidence-based best practice standards were identified and used by the author to audit nursing handover in one acute NHS trust in the UK. Results of the audit were used to assure quality of care and identify areas for improvement.

Background The purpose of this study was to describe professional soccer players’ perceptions towards injuries, physical recovery and the effect of surface related factors on injury resulting from soccer participation on 3rd generation artificial turf (FT) compared to natural grass (NG). Methods Information was collected through a questionnaire that was completed by 99 professional soccer players from 6 teams competing in Major League Soccer (MLS) during the 2011 season. Results The majority (93% and 95%) of the players reported that playing surface type and quality influenced the risk of sustaining an injury. Players believed that playing and training on FT increased the risk of sustaining a non-contact injury as opposed to a contact injury. The players identified three surface related risk factors on FT, which they related to injuries and greater recovery times: 1) Greater surface stiffness 2) Greater surface friction 3) Larger metabolic cost to playing on artificial grounds. Overall, 94% of the players chose FT as the surface most likely to increase the risk of sustaining an injury. Conclusions Players believe that the risk of injury differs according to surface type, and that FT is associated with an increased risk of non-contact injury. Future studies should be designed prospectively to systematically track the perceptions of groups of professional players training and competing on FT and NG.

Retrospective chart review.To evaluate and compare the relationship between patients' age and the change in Oxford Knee Score from preoperative to postoperative assessments, and to investigate whether there is a relationship between preoperative Oxford Knee Score results and the indication for total knee replacement surgery, and if age affects this relationship.An increasing number of younger patients receive knee joint replacements, yet it is unknown how this cohort functions after surgery. This warrants investigation into the potential age-related differences in joint function following surgery. The Oxford Knee Score has been validated as a clinical tool but has yet to be accepted in the decision-making process regarding the need for, or appropriateness of, total knee replacement.In a retrospective chart review, 240 patients completed the Oxford Knee Score questionnaire to evaluate chronic pain and/or dysfunction associated with the knee.The largest improvement with joint replacement was observed to occur in the youngest patient group (50-59 years old). Moreover, the Oxford Knee Score was shown to be the strongest predictor (odds ratio = 0.61) for the indicated intervention when compared to other predictors. The youngest patient group reported a significantly (P.03) higher Oxford Knee Score result when indicated for surgery, compared to the oldest patient group (80-89 years old).The results provide insight into how age influences self-perceived joint function before and after joint replacement surgery, and into the clinical decision to provide the surgical option to younger patients. Moreover, the observed relationship between the Oxford Knee Score and the indicated treatment supports the use of the questionnaire as a preoperative tool in considering treatment options for patients with knee osteoarthritis.Prognosis, level 2b.

This article discusses the role of service improvement methodology in changing the quality of care delivered. It outlines the six-stage framework for quality improvement recommended by the NHS Institute for Innovation and Improvement. The reader is encouraged to complete a series of activities to plan and deliver a service improvement project. Potential challenges to the successful delivery of a service improvement project are also considered. The article concludes with an example of the use of the six-stage framework to improve the quality of urinary catheter care in one acute NHS trust.

Despite the importance of regaining independent ambulation after stroke, the amount of daily walking completed during in-patient rehabilitation is low. The purpose of this study is to determine if (1) walking-related heart rate responses reached the minimum intensity necessary for therapeutic aerobic exercise (40%–60% heart rate reserve) or (2) heart rate responses during bouts of walking revealed excessive workload that may limit walking (>80% heart rate reserve). Eight individuals with subacute stroke attending in-patient rehabilitation were recruited. Participants wore heart rate monitors and accelerometers during a typical rehabilitation day. Walking-related changes in heart rate and walking bout duration were determined. Patients did not meet the minimum cumulative requirements of walking intensity (>40% heart rate reserve) and duration (>10 minutes continuously) necessary for cardiorespiratory benefit. Only one patient exceeded 80% heart rate reserve. The absence of significant increases in heart rate associated with walking reveals that patients chose to walk at speeds well below a level that has meaningful cardiorespiratory health benefits. Additionally, cardiorespiratory workload is unlikely to limit participation in walking. Measurement of heart rate and walking during in-patient rehabilitation may be a useful approach to encourage patients to increase the overall physical activity and to help facilitate recovery.

The objective of this study was to investigate the relationship between medio-lateral foot placement characteristics and environmental context when individuals with Multiple Sclerosis (MS) walk with a rollator (four-wheeled walker).Ten women diagnosed with MS, who used rollators regularly, participated in this study. First, a rollator-based technique of calculating step width (SW) was validated in this patient population by comparing the output of an instrumented rollator (iWalker) to a laboratory-based Vicon Motion Capture System. Secondly, the iWalker-based technique was used to calculate the participants' SW and SW variability as they used the iWalker in four common outdoor community environments.There was a strong level of agreement between the iWalker and Vicon SW calculations, with an intra-class correlation coefficient of 0.993 and a root-mean-square difference of 0.71 cm. Furthermore, SW variability (P = 0.002), but not SW (P = 0.288), was influenced by the walking environment (i.e. between the in-lab vs. up-ramp and up-ramp vs. down-ramp conditions).Foot placement variability appears to be influenced by the walking environment of MS patients. Therefore, an enhanced understanding of walker-user interactions in relation to the environment must be established in order to improve mobility.

The external knee adduction moment is an accurate estimation of the load distribution of the knee and is a valid predictor for the presence, severity and progression rate of medial compartment knee osteoarthritis. Gait modification strategies have been shown to be an effective means of reducing the external adduction moment. The purpose of this study was to test narrow gait as a mechanism to reduce the external adduction moment and investigate if limb dominance affects this pattern. Fifteen healthy male participants (mean age: 23.8 (SD=3.1) years, mean height: 1.8 (SD=0.1) m, and mean body mass: 82.9 (SD=16.1 kg) took part in this study. Five walking trials were performed for each of the three different gait conditions: normal gait, toe-out gait, and narrow gait. Adoption of the narrow gait strategy significantly reduced the early stance phase external knee adduction moment compared to normal and toe-out gait (p