Serious Fall Injuries Before and After Initiation of Hemodialysis Among Older ESRD Patients in the United States: A Retrospective Cohort Study

BACKGROUND

Because initiation of dialysis therapy often occurs in the setting of acute illness and may signal worsening health and functional decline, we examined whether rates of serious fall injuries among older hemodialysis patients differ before and after dialysis therapy initiation.

STUDY DESIGN

Retrospective cohort study of claims data from the 2 years spanning dialysis therapy initiation among patients initiating dialysis therapy in 2010 to 2012.

SETTING & PARTICIPANTS

Claims from 81,653 Medicare end-stage renal disease beneficiaries aged 67 to 100 years.

PREDICTOR

Post- versus pre-dialysis therapy initiation periods, defined as on or after versus before dialysis therapy initiation.

OUTCOMES

Serious fall injuries were defined using diagnostic codes for falls in combination with fractures, brain injuries, or joint dislocation. Incidence rate ratios (overall and stratified) for post- versus pre-dialysis therapy initiation periods were estimated using generalized estimating equation models with a negative binomial link.

RESULTS

Overall, 12,757 serious fall injuries occurred in the pre- and post-dialysis therapy initiation periods. Annual rates of serious fall injuries were 64.4 (95% CI, 62.7-66.2) and 107.8 (95% CI, 105.4-110.3) per 1,000 patient-years, respectively, in the pre- and post-dialysis therapy initiation periods (incidence rate ratio, 1.62; 95% CI, 1.56-1.67). Relative rates of serious fall injuries in the post- vs pre-dialysis initiation periods were of greater magnitude among patients who were younger (<75 years), had pre-end-stage renal disease nephrology care, had albumin levels > 3g/dL, were able to walk and transfer, did not need assistance with activities of daily living, and were not institutionalized compared with relative rates among their counterparts.

LIMITATIONS

Potential misclassification due to the use of claims data and survival bias among those initiating hemodialysis therapy.

CONCLUSIONS

Among older Medicare beneficiaries receiving hemodialysis, serious fall injuries are common, the post-dialysis initiation period is a high-risk time for falls, and dialysis therapy initiation may be an important time to screen for fall risk factors and implement multifactorial fall prevention strategies.

Validation of Predictors of Fall Events in Hospitalized Patients With Cancer

BACKGROUND

A seven-item cancer-specific fall risk tool (Cleveland Clinic Capone-Albert [CC-CA] Fall Risk Score) was shown to have a strong concordance index for predicting falls; however, validation of the model is needed.

OBJECTIVES

The aims of this study were to validate that the CC-CA Fall Risk Score, made up of six factors, predicts falls in patients with cancer and to determine if the CC-CA Fall Risk Score performs better than the Morse Fall Tool.

METHODS

Using a prospective, comparative methodology, data were collected from electronic health records of patients hospitalized for cancer care in four hospitals. Risk factors from each tool were recorded, when applicable. Multivariable models were created to predict the probability of a fall. A concordance index for each fall tool was calculated.

FINDINGS

The CC-CA Fall Risk Score provided higher discrimination than the Morse Fall Tool in predicting fall events in patients hospitalized for cancer management.

Clinical assessment tools identify functional deficits in fragility fracture patients

Purpose

To identify inexpensive, noninvasive, portable, clinical assessment tools that can be used to assess functional performance measures that may put older patients at risk for falls such as balance, handgrip strength, and lumbopelvic control.

Patients and methods

Twenty fragility fracture patients and 21 healthy control subjects were evaluated using clinical assessment tools (Nintendo Wii Balance Board [WBB], a handheld dynamometer, and an application for the Apple iPod Touch, the Level Belt) that measure functional performance during activity of daily living tasks. The main outcome measurements were balance (WBB), handgrip strength (handheld dynamometer), and lumbopelvic control (iPod Touch Level Belt), which were compared between fragility fracture patients and healthy controls.

Results

Fragility fracture patients had lower scores on the vertical component of the WBB Torso Twist task (P=0.042) and greater medial–lateral lumbopelvic sway during a 40 m walk (P=0.026) when compared to healthy controls. Unexpectedly, the fracture patients had significantly higher scores on the left leg (P=0.020) and total components (P=0.010) of the WBB Single Leg Stand task as well as less faults during the left Single Leg Stand task (P=0.003).

Conclusion

The clinical assessment tools utilized in this study are relatively inexpensive and portable tools of performance measures capable of detecting differences in postural sway between fragility fracture patients and controls.

Depressive symptomology management and falls among middle aged and older adults

OBJECTIVES

This study aims to examine the relationship between middle-aged and older adults' depressive symptomology and anti-depressant use and the frequency of falls within the previous 12 months, controlling for sociodemographic variables, health indicators, and health behaviors.

METHOD

From the 2010 National Social Life, Health, and Aging Project, 2338 cases were examined. Falls were categorized into a binary variable, comparing zero falls with one or more falls. An unadjusted model was run to examine the relationship between independent and dependent variables. Potential covariates were added into the model, and backward elimination was used among independent variables with a univariate P < 0.05 to identify the covariates with the strongest association with falls. This final adjusted binary logistic regression model was then used to examine the relationship between falls and the independent variables.

RESULTS

In the adjusted model, anti-depressant use was positively associated with falls (P = 0.001), as was being female (P < 0.001), having diabetes (P = 0.018), and having increased limitations in daily activities (P < 0.001). The relationship between depressive symptomology and anti-depressant prescription was also significantly associated with falls (P = 0.006).

CONCLUSION

While findings confirm that a relationship between depressive symptomology and anti-depressant use are associated with falls among middle-aged and older adults, additional studies are needed that simultaneously examine the influence of these two risk factors.

Seniors' self-preservation by maintaining established self and defying deterioration - A grounded theory

The purpose of this classic grounded theory study was to understand how seniors who are living independently resolve issues influenced by visual impairment and high fall risk. We interviewed and observed 13 seniors with visual impairment in their homes. We also interviewed six visual instructors with experience from many hundreds of relevant incidents from the same group of seniors. We found that the seniors are resolving their main concern of “remaining themselves as who they used to be” by self-preservation. Within this category, the strategies maintaining the established self and defying deterioration emerged as the most prominent in our data. The theme maintaining the established self is mostly guided by change inertia and includes living the past (retaining past activities, reminiscing, and keeping the home intact) and facading (hiding impairment, leading to avoidance of becoming a burden and to risk juggling). Defying deterioration is a proactive scheme and involves moving (by exercising, adapting activities, using walking aids, driving), adapting (by finding new ways), and networking by sustaining old support networks or finding new networks. Self-preservation is generic human behavior and modifying this theory to other fields may therefore be worthwhile. In addition, health care providers may have use for the theory in fall preventive planning.

High serum adiponectin levels predict incident falls among middle-aged and older adults: a prospective cohort study

BACKGROUND AND OBJECTIVE

adiponectin is an adipocyte-derived hormone with anti-obesity and anti-diabetic properties. However, higher circulating adiponectin levels are related to poor muscle function and physical disability, which suggests a potential link between adiponectin and risk of falls. Nevertheless, no direct association between circulating adiponectin levels and incident fall risk has been reported. Therefore, this study aimed to investigate the relationship between serum adiponectin levels and incident falls in a population of middle-aged and older adults.

DESIGN

a prospective cohort study.

SETTING

Oroshisho Center in Sendai City, Japan.

SUBJECTS

Japanese adults who were ≥45 years old (n = 430).

MEASUREMENTS

serum adiponectin levels were measured at baseline, and the subjects were divided into sex-specific tertiles. Data regarding a history of falls were collected via participant recall using a self-reported questionnaire. Incident falls were defined as falls that were experienced by people without a history of falls at baseline.

RESULTS

during the 2-year follow-up, 15.6% (67/430) of the subjects experienced an incident fall. In the univariate logistic regression analysis, incident falls were significantly more frequent across the increasing sex-specific serum adiponectin tertiles (P for trend = 0.008). Adjusted odds ratios (95% confidence interval) for incident falls were 2.31 (1.07-4.98) in the middle tertile and 3.61 (1.63-7.99) in the highest tertile; this risk was significantly higher than that for the lowest adiponectin tertile (P for trend = 0.002).

CONCLUSIONS

the findings of this prospective cohort study indicate that higher serum adiponectin levels may be a predictor of incident falls.

Cortical Modulation of Motor Control Biofeedback among the Elderly with High Fall Risk during a Posture Perturbation Task with Augmented Reality

The cerebral cortex provides sensorimotor integration and coordination during motor control of daily functional activities. Power spectrum density based on electroencephalography (EEG) has been employed as an approach that allows an investigation of the spatial–temporal characteristics of neuromuscular modulation; however, the biofeedback mechanism associated with cortical activation during motor control remains unclear among elderly individuals. Thirty one community-dwelling elderly participants were divided into low fall-risk potential (LF) and high fall-risk potential (HF) groups based upon the results obtained from a receiver operating characteristic analysis of the ellipse area of the center of pressure. Electroencephalography (EEG) was performed while the participants stood on a 6-degree-of-freedom Stewart platform, which generated continuous perturbations and done either with or without the virtual reality scene. The present study showed that when there was visual stimulation and poor somatosensory coordination, a higher level of cortical response was activated in order to keep postural balance. The elderly participants in the LF group demonstrated a significant and strong correlation between postural-related cortical regions; however, the elderly individuals in the HF group did not show such a relationship. Moreover, we were able to clarify the roles of various brainwave bands functioning in motor control. Specifically, the gamma and beta bands in the parietal–occipital region facilitate the high-level cortical modulation and sensorimotor integration, whereas the theta band in the frontal–central region is responsible for mediating error detection during perceptual motor tasks. Finally, the alpha band is associated with processing visual challenges in the occipital lobe.With a variety of motor control demands, increment in brainwave band coordination is required to maintain postural stability. These investigations shed light on the cortical modulation of motor control among elderly participants with varying fall-risk potentials. The results suggest that, although elderly adults may be without neurological deficits, inefficient central modulation during challenging postural conditions could be an internal factor that contributes to the risk of fall. Furthermore, training that helps to improve coordinated sensorimotor integration may be a useful approach to reduce the risk of fall among elderly populations or when patients suffer from neurological deficits.

Preoperative and postoperative serial assessments of postural balance and fall risk in patients with arthroscopic anterior cruciate ligament reconstruction

BACKGROUND

Impaired postural balance due to somatosensory data loss with mechanical instability has been shown in patients with ACL deficiency.

OBJECTIVE

To assess postural balance in patients with ACL insufficiency prior to surgery and following reconstruction with serial evaluations.

METHODS

Thirty patients (mean age of 27.7 ± 6.7 years) who underwent arthroscopic reconstruction of ACL with bone-patellar tendon-bone autograft were examined for clinical and functional variables at preoperative day and postoperative 12th week. Posturographic analysis were performed by using Tetrax Interactive Balance System (Sunlight Medical Ltd, Israel) at preoperative day, at 4th, 8th, and 12th weeks following reconstruction. Data computed by posturographic software by the considerations of the oscillation velocities of body sways is fall risk as a numeric value (0-100, lower values indicate better condition).

RESULTS

All of the patients (mean age of 27.7 ± 6.7 years) had significant improvements for clinical, functional evaluations and fall risk (p< 0.05). Mean fall risk was within high-risk category (59.9 ± 22.8) preoperatively. The highest fall risk was detected at postoperative 4th week. Patients had high fall risk at 8th week similar to preoperative value. Mean fall risk decreased to low level risk at 12th week. Preoperative symptom duration had relationships with preoperative fall risk and postoperative improvement of fall risk (p= 0.001, r= -0.632, p= 0.001, r= -0.870, respectively). The improvement of fall risk was higher in patients with symptoms shorter than 6 months (p= 0.001).

CONCLUSIONS

According to these results, mean fall risk of patients with ACL insufficiency was within high risk category preoperatively, and fall risk improves after surgical reconstruction, but as the duration of complaints lengthens especially longer than 6 months, the improvement of fall risk decreases following reconstruction.

The Prognostic Validity of the Timed Up and Go Test With a Dual Task for Predicting the Risk of Falls in the Elderly

Objective: The aim is to examine the prognostic validity of the Timed Up and Go Test with a cognitive and a manual dual task for predicting the risk of falls. Method: A follow-up study was performed. The data were recorded for 120 volunteers in an outpatient physiotherapy center, with a 12-month follow-up. The sample included 120 elderly men and women aged 60 to 87 years (M age = 72.2 years) living at home. The main measurements were as follows: The Timed Up and Go Test (TUG), the TUG with a cognitive dual task (TUGcog), and the TUG with a manual dual task (TUGman) and falls. Results: In the 12-month follow-up, 37 persons (30.8%) had a locomotive fall. The receiver operating characteristic (ROC) curve shows significant results for the TUGcog. The area under the curve is 0.65 (p = .008), with a 95% confidence interval (CI) = [0.55, 0.76]. For the TUGman, the area under the curve is 0.57 with a 95% CI = [0.45, 0.68], which is not significant (p = .256). For the TUG, the area under the curve is 0.58, which is not significant (p = .256), 95% CI = [0.47, 0.69]. Conclusion: The TUGcog is a valid prognostic assessment to predict falls in community-dwelling elderly people.

The impact of time of day on the gait and balance control of Alzheimer's patients

Alzheimer's patients suffer from circadian dysregulation. The aim of this study was to examine the evolution of balance control and gait at different times of the day (11:00, 14:00, 18:00) in order to identify whether Alzheimer's patients were more likely to fall at certain periods of the day. Spatio-temporal parameters of centre of foot pressure displacements were measured with a force platform and spatio-temporal parameters of walking were evaluated with a gait analysis device. The results highlighted that balance control was worse in the evening and the afternoon than in the morning. Furthermore, the walking speed was faster and support duration, swing duration and cycle duration were shorter in the evening than in the morning and afternoon. The combined analysis of balance control and gait parameters revealed that balance control and walking are concomitantly altered in the evening which increases the fall risk in the evening, in comparison with the morning, for Alzheimer's patients.

Training-related improvements in musculoskeletal health and balance: a 13-week pilot study of female cancer survivors

Cancer survivors often experience poor post-treatment musculoskeletal health. This study examined the feasibility of combined aerobic and resistant training (CART) for improving strength, skeletal health and balance. Cancer survivors (n = 24) were identified by convenience sampling in Los Angeles County with 11 survivors consenting to 13 weeks of CART. Pre- and post-intervention assessments of bone mineral density (BMD), strength, flexibility and biomarker analysis were performed. Paired t-test analysis suggested increases in lower and upper body strength. The average T-score for BMD at the femoral neck improved from -1.46 to -1.36 and whole body BMD improved from -1.65 to -1.55. From baseline to follow-up, participants also displayed decreases in sway velocity on the eyes open (7%) and eyes closed (27%) conditions. Improvement in lower body strength was associated with increases in lean body mass (LBM) (r = 0.721) and an inverse association was observed between sway velocity and LBM (r = 0.838). Age and time since last treatment were related with biomarkers of anabolic growth (IGF-1, IGFbp-3) and bone (DPD, BAP). In summary, observed physiological changes were consistent with functional improvements, suggesting that isometric and dynamic exercise prescription may reduce the risk for falls and fall-related fractures among survivors.

Effects of high heeled shoes wearing experience and heel height on human standing balance and functional mobility

This study aimed to examine the effects of high heeled shoes (HHS) wearing experience and heel height on human standing balance and functional mobility. Thirty young and healthy females (ten experienced and twenty inexperienced HHS wearers) participated in a series of balance tests when they wore shoes of four different heel heights: 1 cm (flat), 4 cm (low), 7 cm (medium) and 10 cm (high). Experimental results show that regardless of the wearing experience, the heel elevation induces more effort from lower limb muscles (particularly calf muscles) and results in worse functional mobility starting at 7 cm heel height. While the heel height increased to 10 cm, the standing balance also becomes worse. Experienced HHS wearers do not show significantly better overall performance on standing balance and functional mobility than inexperienced controls, even though they have better directional control (76.8% vs. 74.4%) and larger maximum excursion (93.3% vs. 89.7%). To maintain standing balance, experienced wearers exert less effort on tibialis anterior, vastus lateralis and erector spinae muscles at the cost of more intensive effort from gastrocnemius medialis muscle.

PRACTITIONER SUMMARY

Many women wear high heeled shoes (HHS) to increase female attractiveness. This study shows that HHS induce more muscular effort and worse human standing balance and functional mobility, especially when heel height reaches 10 cm. HHS wearing experience only provides certain advantages to wearers on limits of stability in terms of larger maximum excursion and better directional control.

Sociotechnical probabilistic risk modeling to predict injurious falls in community living centers

The goal of this study was to apply sociotechnical probabilistic risk assessment to prioritize risks and prevention strategies for serious injurious falls of residents in nursing homes. Risk modeling teams consisted of 26 clinical and nonclinical staff from three Department of Veterans Affairs community living centers and one state Veteran's nursing home. Participants met in groups several times to identify and assign probabilities to provider and resident at-risk behaviors and equipment failures. They identified prevention strategies for the failures that accounted for the highest levels of risk. Six scenarios were modeled: (1) transferring from bed to wheelchair, (2) propelling from bedside to bathroom, (3) transferring from wheelchair to toilet, (4) transferring from toilet to wheelchair, (5) propelling from bathroom to bedside, and (6) transferring from wheelchair to bed. The greatest paths of risk were for residents with impaired mobility and high fragility. A 26% reduction in injurious falls could be achieved by (1) reducing the number of unassisted transfers through a modest improvement in response time to alarms, (2) installing automatic brake locks on 90% of wheelchairs, (3) making the wheelchair maintenance process highly reliable, and (4) decreasing improper transfer techniques by 10%.

Active dorsiflexing prostheses may reduce trip-related fall risk in people with transtibial amputation

People with amputation are at increased risk of falling compared with age-matched, nondisabled individuals. This may partly reflect amputation-related changes to minimum toe clearance (MTC) that could increase the incidence of trips and fall risk. This study determined the contribution of an active dorsiflexing prosthesis to MTC. We hypothesized that regardless of speed or incline the active dorsiflexion qualities of the ProprioFoot would significantly increase MTC and decrease the likelihood of tripping. Eight people with transtibial amputation walked on a treadmill with their current foot at two grades and three velocities, then repeated the protocol after 4 wk of accommodation with the ProprioFoot. A mixed-model, repeated-measures analysis of variance was used to compare MTC. Curves representing the likelihood of tripping were derived from the MTC distributions and a multiple regression was used to determine the relative contributions of hip, knee, and ankle angles to MTC. Regardless of condition, MTC was approximately 70% larger with the ProprioFoot (p < 0.001) and the likelihood of tripping was reduced. Regression analysis revealed that MTC with the ProprioFoot was sensitive to all three angles, with sensitivity of hip and ankle being greater. Overall, the ProprioFoot may increase user safety by decreasing the likelihood of tripping and thus the pursuant likelihood of a fall.

A Pilot Study of Gait Function in Farmworkers in Eastern North Carolina

Farmworkers endure many job-related hazards, including fall-related work injuries. Gait analysis may be useful in identifying potential fallers. The goal of this pilot study was to explore differences in gait between farmworkers and non-farmworkers. The sample included 16 farmworkers and 24 non-farmworkers. Gait variables were collected using the portable GAITRite system, a 16-foot computerized walkway. Generalized linear regression models were used to examine group differences. All models were adjusted for two established confounders, age and body mass index. There were no significant differences in stride length, step length, double support time, and base of support; but farmworkers had greater irregularity of stride length (P = .01) and step length (P = .08). Farmworkers performed significantly worse on gait velocity (P = .003) and cadence (P < .001) relative to non-farmworkers. We found differences in gait function between farmworkers and non-farmworkers. These findings suggest that measuring gait with a portable walkway system is feasible and informative in farmworkers and may possibly be of use in assessing fall risk.

A prospective field study for sensor-based identification of fall risk in older people with dementia

OBJECTIVE

Aim of this study was to make a fall prognosis in a cohort of older people with dementia in short-term (2 month), mid-term (4 month) and long-term (8 month) intervals using accelerometry during the subjects' everyday life.

METHODS

The study was designed as a longitudinal cohort study. The subjects were recruited from a nursing home and geriatric assessment tests were conducted at baseline. Each subject underwent four visits and was measured at each visit for one week. Gait episodes were detected and gait parameters were extracted from these episodes. These gait parameters were combined with the falls occurred during the study. A decision tree induction method was used to analyze the data.

RESULTS

Forty subjects participated in the study, whereby 12 drop-outs were registered. The geriatric assessment tests were unable to distinguish between the groups (AUC < 0.6). The evaluation of the models induced with the decision tree classification showed a rate of correctly classified gait episodes of 88.4% for short-term, 74.8% for mid-term, and 88.5 % for long-term monitoring.

DISCUSSION AND CONCLUSIONS

We concluded that it is possible to classify gait episodes of fallers and non-fallers in people with dementia during everyday life using accelerometry.

Comparison of simple vs. performance-based fall prediction models: data from the National Health and Aging Trends Study

Objective: To compare the predictive ability of standard falls prediction models based on physical performance assessments with more parsimonious prediction models based on self-reported data. Design: We developed a series of fall prediction models progressing in complexity and compared area under the receiver operating characteristic curve (AUC) across models. Setting: National Health and Aging Trends Study (NHATS), which surveyed a nationally representative sample of Medicare enrollees (age ≥65) at baseline (Round 1: 2011-2012) and 1-year follow-up (Round 2: 2012-2013). Participants: In all, 6,056 community-dwelling individuals participated in Rounds 1 and 2 of NHATS. Measurements: Primary outcomes were 1-year incidence of “any fall” and “recurrent falls.” Prediction models were compared and validated in development and validation sets, respectively. Results: A prediction model that included demographic information, self-reported problems with balance and coordination, and previous fall history was the most parsimonious model that optimized AUC for both any fall (AUC = 0.69, 95% confidence interval [CI] = [0.67, 0.71]) and recurrent falls (AUC = 0.77, 95% CI = [0.74, 0.79]) in the development set. Physical performance testing provided a marginal additional predictive value. Conclusion: A simple clinical prediction model that does not include physical performance testing could facilitate routine, widespread falls risk screening in the ambulatory care setting.

Shared medical appointments to screen for geriatric syndromes: preliminary data from a quality improvement initiative

Older adults are at greater risk of developing conditions that affect health outcomes, quality of life, and costs of care. Screening for geriatric conditions such as memory loss, fall risk, and depression may contribute to the prevention of adverse physical and mental comorbidities, unnecessary hospitalizations, and premature nursing home admissions. Because screening is not consistently performed in primary care settings, a shared medical appointment (SMA) program was developed to fill this gap in care. The goals of the program were to improve early identification of at-risk individuals and ensure appropriate follow-up for memory loss, fall risk, and depression; facilitate discussion about prevention, diagnosis, and treatment of these conditions; implement strategies to reduce risks for these conditions; and increase access to screening and expand preventive health services for older adults. Between August 2011 and May 2013, 136 individuals aged 60 and older participated in the program. Three case studies highlighting the psychosocial and physiological findings of participation in the program are presented. Preliminary data suggest that SMAs are an effective model of regularly screening at-risk older adults that augments primary care practice by facilitating early detection and referral for syndromes that may otherwise be missed or delayed.

Racial/Ethnic predictors of falls among older adults: the health and retirement study

OBJECTIVE

The objective of this study was to examine racial/ethnic differences in the probability and frequency of falls among adults aged 65 and older.

METHOD

Using data from the Health and Retirement Study (HRS) from 2000 to 2010, the authors conducted random-intercept logistic and Poisson regression analyses to examine whether race/ethnicity predicted the likelihood of a fall event and the frequency of falls.

RESULTS

The analytic sample included 10,484 older adults. Baseline analyses showed no significant racial/ethnic differences in the probability or number of falls. However, in the longitudinal random-intercept models, African Americans had significantly lower odds (0.65) of experiencing at least one fall compared with non-Hispanic Whites. Among fallers, African Americans had significantly fewer falls (24%) than non-Hispanic Whites, controlling for health and sociodemographic covariates (all ps < .05). Latinos did not differ from non-Hispanic Whites in the likelihood or number of falls.

DISCUSSION

African Americans are less likely to experience initial or recurrent falls than non-Hispanic Whites.

Postoperative falls after total knee arthroplasty in patients with a femoral nerve catheter: can we reduce the incidence?

A femoral nerve catheter (FNC) is often used to minimize pain following total knee arthroplasty (TKA), but complications including inpatient falls, may increase as a result, despite fall prevention protocols. We evaluated the rate of falls in 707 primary TKAs performed with an FNC at a major academic center from May 2009 to September 2012. Despite a formalized fall prevention protocol, we found 19 falls (2.7%). Three patients required further operative intervention. At a rate of 2.7%, postoperative fall is one of the most common complications of TKA at our institution. While pain control may be good with the use of FNCs following primary TKA, improvements in fall prevention strategies or the use of alternative postoperative pain control modalities may need to be considered.

Novel balance rehabilitation and training apparatus to improve functional balance

A new balance rehabilitation and training apparatus has been developed to allow a balance-impaired person to cope with his or her fear of falling while safely and independently performing exercises necessary to improve functional balance. The apparatus consists of a stable platform where the user stands and a vertical structure that supports free-floating handles that the user holds with both hands while performing various exercises. The purpose of study 1 was to determine whether this new apparatus significantly alters the biological postural control system, and the purpose of study 2 was to document the benefits of balance training using the apparatus. Study 1 was a randomized repeated-measures design with six healthy adult subjects (mean age = 35.5 yr), and study 2 was a 4 wk intervention case study with a generally healthy 63-yr-old individual. The results suggest that postural sway characteristics and the cortical and proprioceptive feedback were not limited when using the apparatus. We also observed improvements in balance control and postural stability with 4 wk of training with the apparatus. These results support that the apparatus could be an effective tool to help individuals safely and independently perform balance exercises while potentially preventing falls and minimizing fear of falling.

The impact of neurological disorders on the risk for falls in the community dwelling elderly: a case-controlled study

OBJECTIVES

Owing to a lack of data, our aim was to evaluate and compare the impact of various common neurological diseases on the risk for falls in independent community dwelling senior citizens.

DESIGN

Prospective case-controlled study.

SETTING

General hospital.

PARTICIPANTS

Of 298 consecutive patients and 214 controls enrolled, 228 patients (aged 74.5±7.8; 61% women) and 193 controls (aged 71.4±6.8; 63% women) were included. The exclusion criteria were as follows: for patients, severe disability, disabling general condition or severe cognitive impairment; for controls, any history of neurological disorders or disabling medical conditions; and for both, age below 60 years. A matching process led to 171 age-matched and gender-matched pairs of neurological patients and healthy controls.

MAIN OUTCOME MEASURES

A 1-year incidence of falls based on patients' 12-month recall; motor and non-motor function tests to detect additional risk factors.

RESULTS

46% of patients and 16% of controls fell at least once a year. Patients with stroke (89%), Parkinson's disease (77%), dementia (60%) or epilepsy (57%) had a particularly high proportion of fallers, but even subgroups of patients with the least fall-associated neurological diseases like tinnitus (30%) and headache (28%) had a higher proportion of fallers than the control group. Neuropathies, peripheral nerve lesions and Parkinson's disease were predisposing to recurrent falls. A higher number of neurological comorbidities (p<0.001), lower Barthel Index values (p<0.001), lower Activities-Specific Balance Confidence scores (p<0.001) and higher Center of Epidemiological Studies Depression scores (p<0.001) as well as higher age (p<0.001) and female gender (p=0.003) proved to further increase the risk of falls.

CONCLUSIONS

Medical practitioners, allied health professionals and carers should be aware that all elderly neurological patients seen in outpatient settings are potentially at high risk for falls; they should query them routinely about previous falls and fall risks and advise them on preventive strategies.

Effect of balance training on postural balance control and risk of fall in children with diplegic cerebral palsy

PURPOSE

The purpose of this study was to evaluate the effects of balance training on postural control and fall risk in children with diplegic cerebral palsy.

METHODS

Thirty spastic diplegic cerebral palsied children (10-12 years) were included in this study. Children were randomly assigned into two equal-sized groups: control and study groups. Participants in both groups received a traditional physical therapy exercise program. The study group additionally received balance training on the Biodex balance system. Treatment was provided 30 min/d, 3 d/week for 3 successive months. To evaluate the limit of stability and fall risk, participated children received baseline and post-treatment assessments using the Biodex balance system. Overall directional control, total time to complete the test, overall stability index of the fall risk test and total score of the pediatric balance scale were measured.

RESULTS

Children in both groups showed significant improvements in the mean values of all measured variables post-treatment (p < 0.05). The results also showed significantly better improvement in the measured parameters for the study group, as compared to the control group (p < 0.05).

CONCLUSION

Balance training on Biodex system is a useful tool that can be used in improving postural balance control in children with diplegic cerebral palsy.

Non-linear dynamics of human locomotion: effects of rhythmic auditory cueing on local dynamic stability

It has been observed that times series of gait parameters [stride length (SL), stride time (ST), and stride speed (SS)], exhibit long-term persistence and fractal-like properties. Synchronizing steps with rhythmic auditory stimuli modifies the persistent fluctuation pattern to anti-persistence. Another non-linear method estimates the degree of resilience of gait control to small perturbations, i.e., the local dynamic stability (LDS). The method makes use of the maximal Lyapunov exponent, which estimates how fast a non-linear system embedded in a reconstructed state space (attractor) diverges after an infinitesimal perturbation. We propose to use an instrumented treadmill to simultaneously measure basic gait parameters (time series of SL, ST, and SS from which the statistical persistence among consecutive strides can be assessed), and the trajectory of the center of pressure (from which the LDS can be estimated). In 20 healthy participants, the response to rhythmic auditory cueing (RAC) of LDS and of statistical persistence [assessed with detrended fluctuation analysis (DFA)] was compared. By analyzing the divergence curves, we observed that long-term LDS (computed as the reverse of the average logarithmic rate of divergence between the 4th and the 10th strides downstream from nearest neighbors in the reconstructed attractor) was strongly enhanced (relative change +73%). That is likely the indication of a more dampened dynamics. The change in short-term LDS (divergence over one step) was smaller (+3%). DFA results (scaling exponents) confirmed an anti-persistent pattern in ST, SL, and SS. Long-term LDS (but not short-term LDS) and scaling exponents exhibited a significant correlation between them (r = 0.7). Both phenomena probably result from the more conscious/voluntary gait control that is required by RAC. We suggest that LDS and statistical persistence should be used to evaluate the efficiency of cueing therapy in patients with neurological gait disorders.

The Effect of Balance Training by Tetraks Interactive Balance System on Balance and Fall Risk in Parkinson's Patients: A Report of Four Cases

This pilot study aimed to investigate the effect of balance training by Tetraks Interactive Balance System (TIBS) on balance and fall risk in patients with mild to moderate Parkinson's disease. Four patients with Parkinson's disease between the ages of 56 and 70 years (61.25±6.70) were applied balance training for 3 weeks by TIBS. Sociodemographic features and physical properties of the subjects were recorded. Their motor performance was evaluated by the Unified Parkinson's Disease Rating Scale (UPDRS), balance was measured using the Berg Balance Scale (BBS), Functional Reach Test (FRT), Timed Up and Go Test (TUG), and the Standing on One Leg Balance Test (SOL) and, their fall risks were evaluated by TIBS. Evaluations were performed twice, before and after treatment. Following training, Parkinson's patients showed improvements in UPDRS, TUG, BBS, FRT, SOL and fall risk. Balance training by TIBS has positive effects on balance and decreases fall risk in Parkinson's disease patients.