Cementation of proximal femoral nails of the very elderly subject in per-trochanteric fractures

The management of pertrochanteric fractures (PTF) in the very elderly relies on early verticalisation to limit complications of the decubitus and this requires stable osteosynthesis allowing immediate full support without risk of mechanical failure. The aim of the study was to analyse the value of cementing the cervicocephalic blade during osteosynthesis with a proximal femoral nail. A prospective bicentric comparative study was con- ducted. Patients over 90 years of age with PTF were included. Centre A used a PFNA (Proximal Femoral Nail Antirotation) nail without blade cementing and Centre B used the same nail with blade cementing. The primary endpoint was the occurrence of disassembly of the osteosynthesis requiring revision surgery. Secondary endpoints were functional out- come (resumption of walking), postoperative pain and duration of surgery. Sixty-four patients were included in Centre A and 23 patients were included in Centre B. Mean age, gender, functional abilities before fracture, fracture type and tip-apex distance were comparable between the groups. Postoperative pain and duration of surgery did not show significant differences between the groups. Four patients operated on with an uncemented PFNA (6.25%) and one patient operated on with a cemented PFNA nail (4.35%) showed early dismantling. The rate of patients returning to walking was significantly higher in the cemented group (p=0.00005). No significant differences in the rate of dismantling were observed between the two groups. However, the group operated on with a cemented PFNA showed better functional recovery with a significantly higher rate of walking recovery.

Using a simple rope-pulley system that mechanically couples the arms, legs, and treadmill reduces the metabolic cost of walking

Background Emphasizing the active use of the arms and coordinating them with the stepping motion of the legs may promote walking recovery in patients with impaired lower limb function. Yet, most approaches use seated devices to allow coupled arm and leg movements. To provide an option during treadmill walking, we designed a rope-pulley system that physically links the arms and legs. This arm-leg pulley system was grounded to the floor and made of commercially available slotted square tubing, solid strut channels, and low-friction pulleys that allowed us to use a rope to connect the subject’s wrist to the ipsilateral foot. This set-up was based on our idea that during walking the arm could generate an assistive force during arm swing retraction and, therefore, aid in leg swing. Methods To test this idea, we compared the mechanical, muscular, and metabolic effects between normal walking and walking with the arm-leg pulley system. We measured rope and ground reaction forces, electromyographic signals of key arm and leg muscles, and rates of metabolic energy consumption while healthy, young subjects walked at 1.25 m/s on a dual-belt instrumented treadmill (n = 8). Results With our arm-leg pulley system, we found that an assistive force could be generated, reaching peak values of 7% body weight on average. Contrary to our expectation, the force mainly coincided with the propulsive phase of walking and not leg swing. Our findings suggest that subjects actively used their arms to harness the energy from the moving treadmill belt, which helped to propel the whole body via the arm-leg rope linkage. This effectively decreased the muscular and mechanical demands placed on the legs, reducing the propulsive impulse by 43% (p < 0.001), which led to a 17% net reduction in the metabolic power required for walking (p = 0.001). Conclusions These findings provide the biomechanical and energetic basis for how we might reimagine the use of the arms in gait rehabilitation, opening the opportunity to explore if such a method could help patients regain their walking ability. Trial registration: Study registered on 09/29/2018 in ClinicalTrials.gov (ID—NCT03689647).

Factors associated with time to independent walking recovery post-stroke

BackgroundPast studies have inconsistently identified factors associated with independent walking post-stroke. We investigated the relationship between pre-stroke factors and factors collected acutely after stroke and number of days to walking 50 m unassisted using data from A Very Early Rehabilitation Trial (AVERT).MethodsThe outcome was recovery of 50 m independent walking, tested from 24 hours to 3 months post-stroke. A set of a priori defined factors (participant demographics: age, sex, handedness; pre-stroke: hypertension, ischaemic heart disease, hypercholesterolaemia, diabetes mellitus, atrial fibrillation; stroke-related: stroke severity, stroke type, ischaemic stroke location, stroke hemisphere, thrombolysis) were investigated for association with independent walking using a cause-specific competing risk Cox proportional hazards model. Respective effect sizes are reported as cause-specific adjusted HR (caHR) adjusted for age, stroke severity and AVERT intervention.ResultsA total of 2100 participants (median age 73 years, National Institutes of Health Stroke Scale 7, <1% missing data) with stroke were included. The median time to walking 50 m unassisted was 6 days (IQR 2–63) and 75% achieved independent walking by 3 months. Adjusted Cox regression indicated that slower return to independent walking was associated with older age (caHR 0.651, 95% CI 0.569 to 0.746), diabetes (caHR 0.836, 95% CI 0.740 to 0.945), severe stroke (caHR 0.094, 95% CI 0.072 to 0.122), haemorrhagic stroke (caHR 0.790, 95% CI 0.675 to 0.925) and right hemisphere stroke (caHR 0.796, 95% CI 0.714 to 0.887).ConclusionOur analysis provides robust evidence for important factors associated with independent walking recovery. These findings highlight the need for tailored mobilisation programmes that target subgroups, in particular people with haemorrhagic and severe stroke.

Ratings of Perceived Exertion during Walking: Predicting Major Mobility Disability and Effect of Structured Physical Activity in Mobility-Limited Older Adults

Background This study evaluated the association between ratings of perceived exertion (RPE) of walking and major mobility disability (MMD), as well as their transitions in response to a physical activity (PA) compared to a health education (HE) program. Methods Older adults (n=1633) at risk for mobility impairment were randomized to structured PA or HE programs. During a 400m walk, participants rated exertion as “light” or “hard”. An MMD event was defined as the inability to walk 400m. MMD events and RPE values were assessed every 6-months for an average of 2.6 years. Results Participants rating their exertion as “hard” had a nearly 3-fold higher risk of MMD compared with those rating their exertion as “light” (HR: 2.61, 95%CI: 2.19-3.11). The association held after adjusting for disease conditions, depression, cognitive function and walking speed (HR: 2.24, 95%CI: 1.87-2.69). The PA group was 25% more likely to transition from “light” to “hard” RPE than the HE group (1.25, 1.05-1.49). Additionally, the PA group was 27% (0.73, 0.55 – 0.97) less likely to transition from a “hard” RPE to inability to walk 400m and was more likely to recover their ability to walk 400m by transitioning to a “hard” RPE (2.10, 1.39-3.17) than the HE group. Conclusions Older adults rating “hard” effort during a standardized walk test were at increased risk of subsequent MMD. A structured PA program enabled walking recovery, but was more likely to increase transition from "light" to "hard" effort, which may reflect greater capacity to perform the test.

The Effect of Frailty on Walking Recovery After Hip Fracture: A Secondary Analysis of the Community Ambulation Project

Background The impact of frailty on walking recovery after hip fracture has not been reported. We describe the prevalence of frailty approximately 3 months after hip fracture, and identify the impact of baseline frailty on ambulation recovery. Methods Data from the Community Ambulation Project, that examined the effects of 2 multicomponent home exercise programs on 6-minute walk test in participants post hip fracture, were used to reconstruct the 5-item frailty phenotype. We detailed the prevalence of frailty by subgroup and assessed the comparability between frailty groups for the categorical variable of achieving 300 m in 6-minute walk test (community ambulation threshold), and the continuous variable of total distance in 6-minute walk test before and after 16 weeks of intervention. Results Of the 210 participants, 9% were nonfrail, 59% were prefrail, and 32% were frail. The odds of a nonfrail participant achieving the 300-m threshold were 14.4 (95% CI: 2.4–87.6) times the odds of a frail participant, while a prefrail participant’s odds were 6.1 (95% CI: 1.3–28.4) times after controlling for treatment group and baseline walking distance. The nonfrail participants had an increase of 92.1 m from baseline to 16 weeks, the prefrail had a 50.8 m increase, and the frail group had the smallest increase of 36.6 m (p &lt; .001 for all). Conclusions Prefrailty and frailty were highly prevalent in this sample of community-dwelling survivors of a recent hip fracture. Gains in walking distance and attaining a level of community ambulation were affected significantly by the level of baseline frailty.

Brain activity during real-time walking and with walking interventions after stroke: a systematic review

Investigations of real-time brain activations during walking have become increasingly important to aid in recovery of walking after a stroke. Individual brain activation patterns can be a valuable biomarker of neuroplasticity during the rehabilitation process and can result in improved personalized medicine for rehabilitation. The purpose of this systematic review is to explore the brain activation characteristics during walking post-stroke by determining: (1) if different components of gait (i.e., initiation/acceleration, steady-state, complex) result in different brain activations, (2) whether brain activations differ from healthy individuals. Six databases were searched resulting in 22 studies. Initiation/acceleration showed bilateral activation in frontal areas; steady-state and complex walking showed broad activations with the majority exploring and finding increases in frontal regions and some studies also showing increases in parietal activation. Asymmetrical activations were often related to performance asymmetry and were more common in studies with slower gait speed. Hyperactivations and asymmetrical activations commonly decreased with walking interventions and as walking performance improved. Hyperactivations often persisted in individuals who had experienced severe strokes. Only a third of the studies included comparisons to a healthy group: individuals post-stroke employed greater brain activation compared to young adults, while comparisons to older adults were less clear and limited. Current literature suggests some indicators of walking recovery however future studies investigating more brain regions and comparisons with healthy age-matched adults are needed to further understand the effect of stroke on walking-related brain activation.

Higher Doses Improve Walking Recovery During Stroke Inpatient Rehabilitation

Background and Purpose: We investigated the effect of higher therapeutic exercise doses on walking during inpatient rehabilitation, typically commencing 1 to 4 weeks poststroke. Methods: This phase II, blinded-assessor, randomized controlled trial recruited from 6 Canadian inpatient rehabilitation units, between 2014 and 2018. Subjects (n=75; 25/group) were randomized into: control (usual care) physical therapy: typically, 1 hour, 5 days/week; Determining Optimal Post-Stroke Exercise (DOSE1): 1 hour, 5 days/week, more than double the intensity of Control (based on aerobic minutes and walking steps); and DOSE2: 2 hours, 5 days/week, more than quadruple the intensity of Control, each for 4 weeks duration. The primary outcome, walking endurance at completion of the 4-week intervention (post-evaluation), was compared across these groups using linear regression. Secondary outcomes at post-evaluation, and longitudinal outcomes at 6 and 12-month evaluations, were also analyzed. Results: Both DOSE1 (mean change 61 m [95% CI, 9–113], P =0.02) and DOSE2 (mean change 58 m, 6–110, P =0.03) demonstrated greater walking endurance compared with Control at the post-evaluation. Significant improvements were also observed with DOSE2 in gait speed (5-m walk), and both DOSE groups in quality of life (EQ-5D-5 L) compared with Control. Longitudinal analyses revealed that improvements in walking endurance from the DOSE intervention were retained during the 1-year follow-up period over usual care. Conclusions: This study provides the first preliminary evidence that patients with stroke can improve their walking recovery and quality of life with higher doses of aerobic and stepping activity within a critical time period for neurological recovery. Furthermore, walking endurance benefits achieved from a 4-week intervention are retained over the first-year poststroke. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01915368.