Balance confidence and functional mobility are independently associated with falls in people with Parkinson's disease

Evaluation of Balance Disorders in Parkinson's Disease Using Simple Diagnostic Tests-Not So Simple to Choose

Background: Balance disorders are one of the main symptoms in parkinson's Disease (PD)—patients have a tendency to fall, related traumas and also a significant restriction of mobility. Numerous tools may be used to evaluate the balance, but it is difficult to choose the proper one. The aim of this review was to compare simple diagnostic tools for PD and emphasize those characterized by a high reliability and sensitivity.

Methods: The global literature search was conducted in PubMED, Scopus, Science Direct, Web of Science, Cochrane, and Google Scholar for publications in English and Polish.

Results: According to the literature some scales and functional tests in which clinimetric properties had been assessed in PD population were selected and described.

Conclusion: Basing on current knowledge, psychometric properties, and clinical experience, the authors suggest the BESTest with its shortened versions and the Fullerton Advanced Balance Scale to be used for comprehensive balance assessment of parkinson's disease patients. These tests are easy in administration, not time-consuming and provide a professional diagnosis allowing to plan individual therapy for the patient being examined.

The effects of balance and postural stability exercises on spa based rehabilitation programme in patients with ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) can cause severe functional disorders that lead to loss of balance.

OBJECTIVE

The aim of this study was to investigate the effects of balance and postural stability exercises on spa based rehabilitation programme in AS subjects.

METHODS

Twenty-one participants were randomized to the study (n= 11) and control groups (n= 10). Patients balance and stability were assessed with the Berg Balance Scale (BBS), Timed Up and Go (TUG) Test, Single Leg Stance Test (SLST) and Functional Reach Test (FRT). AS spesicied measures were used for assessing to other parameters. The treatment plan for both groups consisted of conventional transcutaneous electrical nerve stimulation (TENS), spa and land-based exercises 5 days per week for 3 weeks. The study group performed exercises based on postural stability and balance with routine physiotherapy practice in thermal water and in exercise room.

RESULTS

The TUG, SLST and FUT scores were significantly increased in the study group. In both groups, the BASMI, BASFI, BASDAI and ASQoL scores decreased significantly by the end of the treatment period (p< 0.05).

CONCLUSIONS

In AS rehabilitation, performing balance and stability exercises in addition to spa based routine approaches can increase the duration of maintaining balance and can improve the benefits of physiotherapy.

Rasch Analysis of the Activities-Specific Balance Confidence Scale in Older Adults Seeking Outpatient Rehabilitation Services

Background The Activities-specific Balance Confidence (ABC) scale measures confidence in performing various ambulatory activities without falling or experiencing a sense of unsteadiness. Objectives This study (1) examined the ABC scale (0-100) using Rasch analysis, (2) assessed statistically reliable change, and (3) developed a functional staging to guide clinical interpretation of a patient's improvement. Methods The authors examined rating-scale structure, item difficulty hierarchy, item fit, person-item match, separation index, differential item functioning, test precision, and unidimensionality. Additionally, this cross-sectional study of 5012 older patients seeking outpatient rehabilitation therapy in 123 clinics estimated the minimal detectable change and developed a functional staging. Results The item "walk outside on icy sidewalks" was the most difficult item, while the item "reach for a small can off a shelf at eye level" was the easiest item. Overall, average patient ability estimates of 56.2 ± 20.3 were slightly higher than the average item difficulty estimates of 45.9 ± 7.8. With a separation index equal to 3.65, the ABC scale items can differentiate individuals into 5.2 statistically distinct strata. Most ABC scale items were free of differential item functioning. For example, "walk outside on icy sidewalks" was easier for patients who were underweight. Results supported unidimensionality of the ABC scale, with the first factor explaining 77% of the total variance. The estimated minimal detectable change was 15 points. The authors provided an example of functional staging application. Conclusion Results supported sound psychometric properties and clinical usage of the ABC scale for older adults seeking outpatient rehabilitation therapy. J Orthop Sports Phys Ther 2018;48(7):574-583. Epub 30 Mar 2018. doi:10.2519/jospt.2018.8023.

"Staying safe" - a narrative review of falls prevention in people with Parkinson's - "PDSAFE"

Background: Parkinson's disease demonstrates a spectrum of motor and non-motor symptoms. Falling is common and disabling. Current medical management shows minimal impact to reduce falls or fall-related risk factors, such as deficits in gait, strength, and postural instability. Despite evidence supporting rehabilitation in reducing fall risk factors, the most appropriate intervention to reduce overall fall rate remains inconclusive. This article aims to 1) synthesise current evidence and conceptual models of falls rehabilitation in Parkinson's in a narrative review; and based on this evidence, 2) introduce the treatment protocol used in the falls prevention and multi-centre clinical trial "PDSAFE". Method: Search of four bibliographic databases using the terms "Parkinson*" and "Fall*" combined with each of the following; "Rehab*, Balanc*, Strength*, Strateg*and Exercis*" and a framework for narrative review was followed. A total of 3557 papers were identified, 416 were selected for review. The majority report the impact of rehabilitation on isolated fall risk factors. Twelve directly measure the impact on overall fall rate. Discussion: Results were used to construct a narrative review with conceptual discussion based on the "International Classification of Functioning", leading to presentation of the "PDSAFE" intervention protocol. Conclusions: Evidence suggests training single, fall risk factors may not affect overall fall rate. Combining with behavioural and strategy training in a functional, personalised multi-dimensional model, addressing all components of the "International Classification of Functioning" is likely to provide a greater influence on falls reduction. "PDSAFE" is a multi-dimensional, physiotherapist delivered, individually tailored, progressive, home-based programme. It is designed with a strong evidence-based approach and illustrates a model for the clinical delivery of the conceptual theory discussed. Implications for Rehabilitation Parkinson's disease demonstrates a spectrum of motor and non-motor symptoms, where falling is common and disabling. Current medical and surgical management have minimal impact on falls, rehabilitation of falls risk factors has strong evidence but the most appropriate intervention to reduce overall fall rate remains inconclusive. Addressing all components of the International Classification of Function in a multifactorial model when designing falls rehabilitation interventions may be more effective at reducing fall rates in people with Parkinson's than treating isolated risk factors. The clinical model for falls rehabilitation in people with Parkinson's should be multi-dimensional.

Instrumental or Physical-Exercise Rehabilitation of Balance Improves Both Balance and Gait in Parkinson's Disease

We hypothesised that rehabilitation specifically addressing balance in Parkinson's disease patients might improve not only balance but locomotion as well. Two balance-training protocols (standing on a moving platform and traditional balance exercises) were assessed by assigning patients to two groups (Platform, n = 15, and Exercises, n = 17). The platform moved periodically in the anteroposterior, laterolateral, and oblique direction, with and without vision in different trials. Balance exercises were based on the Otago Exercise Program. Both platform and exercise sessions were administered from easy to difficult. Outcome measures were (a) balancing behaviour, assessed by both Index of Stability (IS) on platform and Mini-BESTest, and (b) gait, assessed by both baropodometry and Timed Up and Go (TUG) test. Falls Efficacy Scale-International (FES-I) and Parkinson's Disease Questionnaire (PDQ-8) were administered. Both groups exhibited better balance control, as assessed both by IS and by Mini-BESTest. Gait speed at baropodometry also improved in both groups, while TUG was less sensitive to improvement. Scores of FES-I and PDQ-8 showed a marginal improvement. A four-week treatment featuring no gait training but focused on challenging balance tasks produces considerable gait enhancement in mildly to moderately affected patients. Walking problems in PD depend on postural instability and are successfully relieved by appropriate balance rehabilitation. This trial is registered with ClinicalTrials.gov NCT03314597.

Symptomatic orthostatic hypotension in Parkinson's disease patients: Prevalence, associated factors and its impact on balance confidence

BACKGROUND

Orthostatic hypotension (OH) is a commonly reported sign of the cardiovascular autonomic dysfunctions associated with Parkinson's disease (PD). Patients might suffer from a variety of the clinical symptoms of OH, including dizziness, lightheadedness, or problems with vision and fatigue.

OBJECTIVES

To determine the prevalence of, and factors associated with, symptomatic orthostatic hypotension (OH) in Parkinson's disease (PD) and to identify any relationships between the clinical symptoms of OH and balance confidence in this patient population.

METHODS

Symptomatic OH was defined as a systolic or diastolic BP fall of ≥20 or ≥10mmHg respectively, within 3min of standing and an Orthostatic Hypotension Questionnaire (OHQ) score of more than zero. Factors related to symptomatic OH were identified from a multivariate logistic regression analysis. Pearson's correlation test was used to reveal any relationships between the clinical symptoms of OH and a patient's confidence in their ability to balance, assessed using the Activities-specific Balance Confidence (ABC) scale.

RESULTS

100 Thai PD patients were consecutively recruited into this study. The prevalence of symptomatic OH was 18%, asymptomatic OH was 4%, while 78% were patients without OH. Factors associated with symptomatic OH were age (OR, 95%CI: 1.06, 1.003-1.115, p=0.038) and hypertension (OR, 95%CI: 6.16, 1.171-32.440, p=0.032). A significant and negative correlation (r=-0.229, p=0.022) between OHQ composite scores and item 3 of the ABC scale (picking up slippers from floor), one of the movements in a vertical orientation, was found.

CONCLUSION

Elderly PD patients and with a co-morbidity of essential hypertension should be closely evaluated for the presence of symptomatic OH. In addition, they should be advised to change positions slowly, especially those in a vertical orientation.

High-Speed Cycling Intervention Improves Rate-Dependent Mobility in Older Adults

PURPOSE

The aim was to determine the feasibility of a 6-wk speed-based exercise program that could be used to initiate new exercise behaviors and to improve rapid movement in older adults approaching frailty.

METHODS

The intervention group included 14 older adults (3 males and 11 females; mean ± SD, age = 70 ± 7.6 yr, height = 1.6 ± 0.11 m, mass = 76.8 ± 12.0 kg, body mass index = 27.7 ± 4.7 kg·m). The control group included 12 older adults (6 males and 6 females; mean ± SD, age = 69.2 ± 6.9 yr, height = 1.7 ± 0.09 m, mass = 78.2 ± 10.9 kg, body mass index = 25.3 ± 2.7 kg·m). Subjects included active older adults, including regular exercisers, but none were engaged in sports or exercises with an emphasis on speed (e.g., cycling spin classes or tennis). Stationary recumbent cycling was selected to minimize fall risk, and low pedaling resistance reduced musculoskeletal and cardiovascular load. Two weekly 30-min exercise sessions consisted of interval training in which subjects pedaled at preferred cadence and performed ten 20-s fast cadence intervals separated by 40 s of active recovery at preferred cadence.

RESULTS

Significant group-time interactions (P < 0.05) supported a 2-s improvement in the timed up and go test and a 34% improvement in rapid isometric knee extension contractions in the exercise group but not in controls. Central neural adaptations are suggested because this lower extremity exercise program also elicited significant improvements in the untrained upper extremities of the exercise group (elbow extension rate of force development scaling factor and Nine-Hole Peg Test, P < 0.05).

CONCLUSION

These results demonstrate that a relatively low dose of speed-based exercise can improve neuromuscular function and tests of mobility in older adults. Such a program serves as a sensible precursor to subsequent, more vigorous training or as an adjunct to a program where a velocity emphasis is lacking.

A Cross-sectional Analysis of the Characteristics of Individuals With Parkinson Disease Who Avoid Activities and Participation Due to Fear of Falling

BACKGROUND AND PURPOSE

Avoidance behavior can have deleterious consequences on health and quality of life for persons with Parkinson disease (PD); for this reason, it is important to identify potentially mitigable characteristics. We compared the characteristics of individuals with PD who exhibit fear of falling (FOF) avoidance behavior with those who do not.

METHODS

Fifty-nine participants with PD were classified as avoiders (n = 27) or nonavoiders (n = 32) by using the Fear of Falling Avoidance Behavior Questionnaire and compared across 5 domains: demographic characteristics; PD-specific symptoms (subtype, Movement Disorder Society-Unified Parkinson's Disease Rating Scale [MDS-UPDRS], Hoehn and Yahr Scale, Parkinson's Disease Questionnaire-39 [PDQ-39]); balance and falls (fall history, Berg Balance Scale [BBS], Activities-Specific Balance Confidence [ABC] Scale, Impact of Events Scale, Consequences of Falling Questionnaire [CoFQ]); physical performance (30 Second Sit-to-Stand Test, Timed Up and Go Test, physical activity monitoring); and psychological factors (Zung Anxiety Scale, Beck Depression Inventory [BDI]).

RESULTS

There were no differences between avoiders and nonavoiders for demographic characteristics and fall history (Ps > 0.272). Avoiders had worse MDS-UPDRS (Ps < 0.014) and PDQ-39 scores (Ps < 0.028). Avoiders had poorer balance performance (BBS, P = 0.003), lower balance confidence (ABC, P < 0.001), and more fall catastrophization (CoFQ, P < 0.001). Avoiders reported more depression (P = 0.015) and anxiety (P = 0.028).

DISCUSSION AND CONCLUSIONS

PD FOF avoiders had more involved symptoms and scored lower on balance and physical performance measures. In addition, they reported greater psychological stress. Several potentially mitigable characteristics of those with FOF avoidance behavior were identified.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A153).

Balance training in individuals with Parkinson's disease: Therapist-supervised vs. home-based exercise programme

BACKGROUND

Poor locomotion and balance in Parkinson's disease (PD) often diminishes independence. Accordingly, gait is considered one of the most relevant rehabilitation outcomes, and home-based balance exercises might be a viable mode of exercise delivery for individuals with PD. However, research on PD interventions rarely indicate best practices to deliver exercises. Therefore, this study endeavoured to compare the efficacy of a home-based and therapist-supervised balance programme on gait parameters, dynamic balance, balance confidence and motivation in individuals diagnosed with PD.

METHODS

An experimental study design, including a cluster randomized convenience sample, of 40 participants with idiopathic PD (Hoehn and Yahr stage I-III; age: 65.0±7.7years). Participants were divided into a therapist-supervised (n=24) and home-based group (n=16). Groups received either eight weeks of balance training with an exercise therapist or a DVD. Outcome measures include the instrumented Timed-Up-and-Go, Functional Gait Analysis (FGA), Activity-specific Balance confidence (ABC) scale and Intrinsic Motivation Inventory (IMI).

RESULTS

Both groups improved in stride length (p<0.05). Similar FGA improved by 9% and 16% in the therapist-supervised and home-based group, respectively (p<0.01). Only the therapist-supervised group showed improvements in ABC (p=0.051), stride velocity (p=0.0006) and cadence (p=0.046) over the intervention; the latter two were also better compared to home-based (p<0.05). Furthermore the therapist-supervised group were more motivated (p=002).

CONCLUSION

The home-based balance programme was effective in improving some aspects of gait, albeit the programme supervised by an exercise therapist included somewhat more benefits after the intervention i.e. stride velocity and cadence in individuals with mild to moderate PD.

The coefficient of friction in Parkinson's disease gait

This study aimed to characterize the coefficient of friction (COF) curves of patients with Parkinson's disease (PD) during barefoot gait and to evaluate the relationships between this variable and functional scales. Twenty-two subjects with PD (ON phase of levodopa) and 22 healthy subjects participated in this study. The participants walked barefoot along a pathway that went over two force plates embedded in the floor of the data collection room. The instantaneous COF was calculated as the ratio between the horizontal and vertical components of the ground reaction forces. Two-sample t-tests applied to every 1% of the support phase of the COF curve were used to compare the groups and to identify the phases in which the two groups were different. Specifically, three COF areas were computed: Area 1 (for the loading response phase), Area 2 (for the midstance phase) and Area 3 (for the terminal stance phase). Pearson's tests were applied to assess the associations between the COF curve areas and the clinical scales. The subjects with PD exhibited lower COF values during the loading response and terminal stance phases and higher COF values during the mid-stance phase compared with the control group. A strong positive correlation was observed between Area 1 and the Timed Up and Go Test (90.3%). In conclusion, the patients' COFs exhibited patterns that were different from those of the control group. Moreover, during the loading response phase, these differences were well-correlated with the Timed Up and Go Test scale data; Timed Up and Go Test data can be used to identify the risk of falls among PD patients.

Relationship between Gait Parameters and Postural Stability in Early and Late Parkinson's Disease and Visual Feedback-Based Balance Training Effects

BACKGROUND

Gait disorders or postural instability has been done before. However, lack of reviews has addressed the relation between gait and postural stability in Parkinson's disease (PD).

AIM

The aim was to evaluate the relation between gait parameters and postural stability in early and late stages of PD.

MATERIALS AND METHODS

The forty-one idiopathic PD patients were divided into two groups into a group (A) considered as early PD and group (B) considered as late ambulant PD. They were evaluated for postural stability by computerised dynamic posturography (CDP) device and gait analysis using an 8 m-camera Vicon 612 data capturing system set.

RESULTS

There was a statistically significant improvement of composite equilibrium score, the composite latency of motor response, walking speed and cadence after treatment as compared to before training (p < 0.05) in early PD. However, in the late PD, there was a non-significant change of previous parameters after treatment as compared to before training (p > 0.05). There was a significant correlation between UPDRS motor part score, walking speed and composite equilibrium score after training in early PD (p > 0.05).

CONCLUSIONS

Both gait analysis and CDP are important quantitative assessment tools of gait and posture instability.

Gait and Functional Mobility Deficits in Fragile X-Associated Tremor/Ataxia Syndrome

Fragile X-associated tremor/ataxia syndrome (FXTAS) results from a "premutation" (PM) size CGG repeat expansion in the fragile X mental retardation 1 (FMR1) gene. Cerebellar gait ataxia is the primary feature in some FXTAS patients causing progressive disability. However, no studies have quantitatively characterized gait and mobility deficits in FXTAS. We performed quantitative gait and mobility analysis in seven FMR1 PM carriers with FXTAS and ataxia, six PM carriers without FXTAS, and 18 age-matched controls. We studied four independent gait domains, trunk range of motion (ROM), and movement transitions using an instrumented Timed Up and Go (i-TUG). We correlated these outcome measures with FMR1 molecular variables and clinical severity scales. PM carriers with FXTAS were globally impaired in every gait performance domain except trunk ROM compared to controls. These included total i-TUG duration, stride velocity, gait cycle time, cadence, double-limb support and swing phase times, turn duration, step time before turn, and turn-to-sit duration, and increased gait variability on several measures. Carriers without FXTAS did not differ from controls on any parameters, but double-limb support time was close to significance. Balance and disability scales correlated with multiple gait and movement transition parameters, while the FXTAS Rating Scale did not. This is the first study to quantitatively examine gait and movement transitions in FXTAS patients. Gait characteristics were consistent with those from previous cohorts with cerebellar ataxia. Sensitive measures like the i-TUG may help determine efficacy of interventions, characterize disease progression, and provide early markers of disease in FXTAS.

Curved Walking Rehabilitation with a Rotating Treadmill in Patients with Parkinson's Disease: A Proof of Concept

Training subjects to step-in-place eyes open on a rotating platform while maintaining a fixed body orientation in space [podokinetic stimulation (PKS)] produces a posteffect consisting in inadvertent turning around while stepping-in-place eyes closed [podokinetic after-rotation (PKAR)]. Since the rationale for rehabilitation of curved walking in Parkinson's disease is not fully known, we tested the hypothesis that repeated PKS favors the production of curved walking in these patients, who are uneasy with turning, even when straight walking is little affected. Fifteen patients participated in 10 training sessions distributed in 3 weeks. Both counterclockwise and clockwise PKS were randomly administered in each session. PKS velocity and duration were gradually increased over sessions. The velocity and duration of the following PKAR were assessed. All patients showed PKAR, which increased progressively in peak velocity and duration. In addition, before and at the end of the treatment, all patients walked overground along linear and circular trajectories. Post-training, the velocity of walking bouts increased, more so for the circular than the linear trajectory. Cadence was not affected. This study has shown that parkinsonian patients learn to produce turning while stepping when faced with appropriate training and that this capacity translates into improved overground curved walking.

Use of an Enactive Insole for Reducing the Risk of Falling on Different Types of Soil Using Vibrotactile Cueing for the Elderly

Background

Our daily activities imply displacements on various types of soil. For persons with gait disorder or losing functional autonomy, walking on some types of soil could be challenging because of the risk of falling it represents.

Methods

In this paper, we present, in a first part, the use of an enactive shoe for an automatic differentiation of several types of soil. In a second part, using a second improved prototype (an enactive insole), twelve participants with Parkinson’s disease (PD) and nine age-matched controls have performed the Timed Up and Go (TUG) test on six types of soil with and without cueing. The frequency of the cueing was set at 10% above the cadence computed at the lower risk of falling (walking over the concrete). Depending on the cadence computed at the lower risk, the enactive insole activates a vibrotactile cueing aiming to improve gait and balance control. Finally, a risk index is computed using gait parameters in relation to given type of soil.

Results

The frequency analysis of the heel strike vibration allows the differentiation of various types of soil. The risk computed is associated to an appropriate rhythmic cueing in order to improve balance and gait impairment. The results show that a vibrotactile cueing could help to reduce the risk of falling.

Conclusions

Firstly, this paper demonstrates the feasibility of reducing the risk of falling while walking on different types of soil using vibrotactile cueing. We found a significant difference and a significant decrease in the computed risks of falling for most of types of soil especially for deformable soils which can lead to fall. Secondly, heel strike provides an approximation of the impulse response of the soil that can be analyzed with time and frequency-domain modeling. From these analyses, an index is computed enabling differentiation the types of soil.

Assessing stability in mild and moderate Parkinson's disease: Can clinical measures provide insight?

This cross-sectional study aimed to investigate the relationship between accelerometer-derived measures of movement rhythmicity and clinical measures of mobility, balance confidence and gait difficulty in people with Parkinson's disease (PD). Twenty-nine independently-living PD patients (Hoehn & Yahr Stages 1-3) with no history of significant injury or orthopaedic/deep brain stimulation surgery were recruited from a database of patients who had expressed an interest to participate in research. Participants completed clinical assessments of mobility, postural stability, balance confidence and symptom severity, while head and trunk rhythmicity was evaluated during gait using accelerometers. Following data collection, patients were stratified based on disease stage into either a Mild (Hoehn & Yahr Stage 1) or Moderate (Hoehn & Yahr Stages 2-3) PD group. The results highlighted that the Moderate PD group had poorer quality of life, reduced balance confidence and increased gait and falls difficulty. Furthermore, for these patients, gait disability and the number of previous falls were both negatively correlated with multiple components of head and trunk rhythmicity. For the Mild PD group, six-meter walk time was positively correlated with ML head rhythmicity and linear regression highlighted a significant predictive relationship between these outcomes. For the Mild and Moderate PD groups, balance confidence respectively predicted anterior-posterior trunk rhythmicity and vertical head rhythmicity. While these findings demonstrate that falls history and the Gait and Falls questionnaire provide moderate insight into head and trunk rhythmicity in Moderate PD patients, objective and clinically-feasible measures of postural instability would assist with the management of these symptoms.

Balance self-efficacy in older adults following inpatient rehabilitation

Older adults discharging from inpatient rehabilitation were investigated to determine change in self-efficacy at 1 month after discharge, the relationship with discharge balance performance and physical function, and the influence of diagnosis. A prospective cohort of 101 adults older than 50 years of age, 43% men, average age 75.84 (SD 9.8) years, were recruited at discharge from inpatient rehabilitation. Balance self-efficacy was assessed using Activities-specific Balance Confidence (ABC) scale at discharge and 1 month following discharge. Balance and physical function were measured at discharge using the Functional Independence Measure, Balance Outcome Measure for Elder Rehabilitation, Modified Elderly Mobility Scale and gait speed. At discharge, balance self-efficacy was moderate (ABC score 62, SD 23) and did not change at follow-up. When grouped by discharge self-efficacy (ABC scores: low<50; moderate 51-80; high>80), significant between-group differences were found for balance (P=0.005) and physical function (P=0.035). At the 1-month follow-up, those with low discharge balance self-efficacy showed improvement (mean-change ABC score 12, 95% confidence interval 2-22) and those with high discharge balance self-efficacy had lower scores (mean-change ABC score 18, 95% confidence interval -8 to -28). Differences in ABC change scores were also found between diagnostic groups (F=3.740, P=0.03), with the orthopaedic group improving (ABC mean change=8) and the general frailty group showing a decrease in confidence (ABC mean change=10). The differences in balance self-efficacy change at 1 month following discharge were related to self-efficacy level at discharge and clinical group requiring rehabilitation. Clinicians need to be aware of these changes as patients are prepared for discharge.

Comparison of Self-report and Performance-Based Balance Measures for Predicting Recurrent Falls in People With Parkinson Disease: Cohort Study

BACKGROUND

Balance confidence and fear of falling are factors associated with recurrent falls in people with Parkinson disease (PD). However, the accuracy for predicting falls on the basis of self-report measures has not been widely investigated.

OBJECTIVE

The study objectives were: (1) to compare the accuracy of the Activities-specific Balance Confidence Scale (ABC) and the Falls Efficacy Scale-International (FES-I) with that of the Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Functional Reach Test (FRT), and Timed "Up & Go" Test (TUG) for predicting recurrent falls in people with PD and (2) to explore the ability of combinations of up to 3 tests to predict recurrent falls.

DESIGN

This was a prospective cohort study involving 225 people with PD.

METHODS

Participants were assessed with the ABC, FES-I, BBS, FRT, TUG, and DGI. Participants who reported 2 or more falls in the 12-month follow-up period were classified as recurrent fallers. Areas under the receiver operating characteristic curves were determined, and the Akaike information criterion was used to select the best predictive model.

RESULTS

Eighty-four participants (37.3%) were classified as recurrent fallers. Areas under the receiver operating characteristic curves for the ABC, FES-I, TUG, FRT, DGI, and BBS were 0.73, 0.74, 0.72, 0.74, 0.76, and 0.79, respectively. Two-test models provided additional discriminating ability compared with individual measures and had Akaike information criterion values similar to those of 3-test models, particularly the combination of the BBS with the FES-I.

LIMITATIONS

The lack of an external validation sample was a limitation of this study.

CONCLUSIONS

The ABC and FES-I demonstrated moderate accuracy in predicting recurrent falls and a predictive ability similar to that of performance-based balance measures, especially the FRT and the TUG. Two-test models showed performance similar to that of 3-test models, suggesting that a combination of 2 measures may improve the ability to predict recurrent falls in people with PD. Specifically, the combination of the BBS with the FES-I may be considered.

The effectiveness of physiotherapy treatment on balance dysfunction and postural instability in persons with Parkinson's disease: a systematic review and meta-analysis

Background

Balance dysfunction and postural instability in Parkinson’s disease are among the most relevant determinants of an impaired quality of life. Physiotherapy interventions are essential to reduce the level of disability by treating balance dysfunction and postural instability. The aim of this systematic review with meta-analysis was to test the effectiveness of conventional physiotherapy interventions in the management of balance dysfunction and postural instability in Persons with idiopathic Parkinson’s disease.

Method

A systematic literature search of the Cochrane Library, PubMed/Medline, PEDro, Rehadat, and Rehab Trials were performed by 2 reviewers (AY and AT) independently. Eligible randomised controlled trials published from September 2005 to June 2015 were included. The selected RCTs, which investigated the effects of conventional physiotherapy treatments in the management of postural instability and balance dysfunction in Persons with Parkinson’s disease, were assessed on a methodological quality rating scale. Included studies differed clearly from each other with regard to patient characteristics, intervention protocol, and outcome measures. Important characteristics and outcomes were extracted, summarized and analyzed.

Results

Eight trials with a total of 483 participants were eligible for inclusion of which 5 trials provide data for meta-analysis. Benefits from conventional physiotherapy treatment were reported for all of the outcomes assessed. The pooled estimates of effects showed significantly improved berg balance scale (SMD, 0.23; 95 % CI, 0.10–0.36; P < 0.001) after exercise therapy, in comparison with no exercise or sham treatment. Exercise interventions specifically addressing components of balance dysfunction demonstrated the largest efficacy with moderate effect size (SMD, 5.98; 95 % CI, 2.29–9.66; P < 0.001). Little effects were observed for interventions that specifically targeted Falls efficacy scale. The pooled data indicated that physiotherapy exercises decreased the incidence of falling by 6.73 (95 % CI: −14.00, 0.54, p = 0.07) with the overall effect of Z = 1.81.

Conclusion

Physiotherapy interventions like balance training combined with muscle strengthening, the range of movement and walking training exercise is effective in improving balance in patients with Parkinson’s disease and more effective than balance exercises alone. Highly challenging balance training and incremental speed-dependent treadmill training can also be part of a rehabilitation program for management of balance dysfunction and Postural instability in patients with idiopathic Parkinson’s disease.

Comparison of the Fullerton Advanced Balance Scale, Mini-BESTest, and Berg Balance Scale to Predict Falls in Parkinson Disease

BACKGROUND

The correct identification of patients with Parkinson disease (PD) at risk for falling is important to initiate appropriate treatment early.

OBJECTIVE

This study compared the Fullerton Advanced Balance (FAB) scale with the Mini-Balance Evaluation Systems Test (Mini-BESTest) and Berg Balance Scale (BBS) to identify individuals with PD at risk for falls and to analyze which of the items of the scales best predict future falls.

DESIGN

This was a prospective study to assess predictive criterion-related validity.

SETTING

The study was conducted at a university hospital in an urban community.

PATIENTS

Eighty-five patients with idiopathic PD (Hoehn and Yahr stages: 1-4) participated in the study.

MEASUREMENTS

Measures were number of falls (assessed prospectively over 6 months), FAB scale, Mini-BESTest, BBS, and Unified Parkinson's Disease Rating Scale.

RESULTS

The FAB scale, Mini-BESTest, and BBS showed similar accuracy to predict future falls, with values for area under the curve (AUC) of the receiver operating characteristic (ROC) curve of 0.68, 0.65, and 0.69, respectively. A model combining the items "tandem stance," "rise to toes," "one-leg stance," "compensatory stepping backward," "turning," and "placing alternate foot on stool" had an AUC of 0.84 of the ROC curve.

LIMITATIONS

There was a dropout rate of 19/85 participants.

CONCLUSIONS

The FAB scale, Mini-BESTest, and BBS provide moderate capacity to predict "fallers" (people with one or more falls) from "nonfallers." Only some items of the 3 scales contribute to the detection of future falls. Clinicians should particularly focus on the item "tandem stance" along with the items "one-leg stance," "rise to toes," "compensatory stepping backward," "turning 360°," and "placing foot on stool" when analyzing postural control deficits related to fall risk. Future research should analyze whether balance training including the aforementioned items is effective in reducing fall risk.

The relationship between balance confidence and control in individuals with Parkinson's disease

INTRODUCTION

A broad range of subjective and objective assessments have been used to assess balance confidence and balance control in persons with Parkinson's disease (PD). However, little is known about the relationship between self-perceived balance confidence and actual balance control in PD. The purpose of this investigation was to determine the relationship between self-perceived balance confidence and objectively measured static/dynamic balance control abilities.

METHODS

Forty-four individuals with PD participated in the study. Patients were stratified into 2 groups based on the modified Hoehn and Yahr (H&Y) disability score: early stage, H&Y ≤ 2.0 and moderate stage, H&Y ≥ 2.5. All participants completed the activities-specific balance confidence (ABC) scale and performed standing balance and gait initiation tasks to assess static and dynamic balance control. The center of pressure (COP) sway (CE95%Sway) during static balance and the peak distance between the projections of the COP and the center of mass (COM) in the transverse plane (COPCOM) during gait initiation were calculated. Pearson correlation analyses were conducted relating the ABC score and CE95%Sway and COPCOM.

RESULTS

For early stage PD, there was a moderate correlation between ABC score and CE95%Sway (r = -0.56, R(2) = 0.32, p = 0.002), while no significant correlation was found between ABC score and COPCOM (r = -0.24, R(2) = 0.06, p = 0.227). For moderate stage PD, there was a moderate correlation between ABC score and COPCOM (r = 0.49, R(2) = 0.24, p = 0.044), while no correlation was found between ABC score and CE95%Sway (r = -0.19, R(2) = 0.04, p = 0.478).

CONCLUSION

Individuals with different disease severities showed different relationships between balance confidence and actual static/dynamic balance control.

Predicting Falls in Parkinson Disease: What Is the Value of Instrumented Testing in OFF Medication State?

Background

Falls are a common complication of advancing Parkinson's disease (PD). Although numerous risk factors are known, reliable predictors of future falls are still lacking. The objective of this prospective study was to investigate clinical and instrumented tests of balance and gait in both OFF and ON medication states and to verify their utility in the prediction of future falls in PD patients.

Methods

Forty-five patients with idiopathic PD were examined in defined OFF and ON medication states within one examination day including PD-specific clinical tests, instrumented Timed Up and Go test (iTUG) and computerized dynamic posturography. The same gait and balance tests were performed in 22 control subjects of comparable age and sex. Participants were then followed-up for 6 months using monthly fall diaries and phone calls.

Results

During the follow-up period, 27/45 PD patients and 4/22 control subjects fell one or more times. Previous falls, fear of falling, more severe motor impairment in the OFF state, higher PD stage, more pronounced depressive symptoms, higher daily levodopa dose and stride time variability in the OFF state were significant risk factors for future falls in PD patients. Increased stride time variability in the OFF state in combination with faster walking cadence appears to be the most significant predictor of future falls, superior to clinical predictors.

Conclusion

Incorporating instrumented gait measures into the baseline assessment battery as well as accounting for both OFF and ON medication states might improve future fall prediction in PD patients. However, instrumented testing in the OFF state is not routinely performed in clinical practice and has not been used in the development of fall prevention programs in PD. New assessment methods for daylong monitoring of gait, balance and falls are thus required to more effectively address the risk of falling in PD patients.

Wearable sensor use for assessing standing balance and walking stability in people with Parkinson's disease: a systematic review

Background

Postural instability and gait disability threaten the independence and well-being of people with Parkinson’s disease and increase the risk of falls and fall-related injuries. Prospective research has shown that commonly-used clinical assessments of balance and walking lack the sensitivity to accurately and consistently identify those people with Parkinson’s disease who are at a higher risk of falling. Wearable sensors provide a portable and affordable alternative for researchers and clinicians who are seeking to objectively assess movements and falls risk in the clinical setting. However, no consensus currently exists on the optimal placements for sensors and the best outcome measures to use for assessing standing balance and walking stability in Parkinson’s disease patients. Hence, this systematic review aimed to examine the available literature to establish the best sensor types, locations and outcomes to assess standing balance and walking stability in this population.

Methods

Papers listed in three electronic databases were searched by title and abstract to identify articles measuring standing balance or walking stability with any kind of wearable sensor among adults diagnosed with PD. To be eligible for inclusion, papers were required to be full-text articles published in English between January 1994 and December 2014 that assessed measures of standing balance or walking stability with wearable sensors in people with PD. Articles were excluded if they; i) did not use any form of wearable sensor to measure variables associated with standing balance or walking stability; ii) did not include a control group or control condition; iii) were an abstract and/or included in the proceedings of a conference; or iv) were a review article or case study. The targeted search of the three electronic databases identified 340 articles that were potentially eligible for inclusion, but following title, abstract and full-text review only 26 articles were deemed to meet the inclusion criteria. Included articles were assessed for methodological quality and relevant data from the papers were extracted and synthesized.

Results

Quality assessment of these included articles indicated that 31% were of low methodological quality, while 58% were of moderate methodological quality and 11% were of high methodological quality. All studies adopted a cross-sectional design and used a variety of sensor types and outcome measures to assess standing balance or walking stability in people with Parkinson’s disease. Despite the typically low to moderate methodological quality, 81% of the studies reported differences in sensor-based measures of standing balance or walking stability between different groups of Parkinson’s disease patients and/or healthy controls.

Conclusion

These data support the use of wearable sensors for detecting differences in standing balance and walking stability between people with PD and controls. Further high-quality research is needed to better understand the utility of wearable sensors for the early identification of Parkinson’s disease symptoms and for assessing falls risk in this population.

PROSPERO Registration

CRD42014010838

Recurrent Falls in People with Parkinson's Disease without Cognitive Impairment: Focusing on Modifiable Risk Factors

Falls can be considered a disabling feature in Parkinson's disease. We aimed to identify risk factors for falling, testing simultaneously the ability of disease-specific and balance-related measures. We evaluated 171 patients, collecting demographic and clinical data, including standardized assessments with the Unified Parkinson's Disease Rating Scale (UPDRS), activities of daily living (ADL) and motor sections, modified Hoehn and Yahr Scale, Schwab and England, eight-item Parkinson's Disease Questionnaire, Activities-specific Balance Confidence Scale, Falls Efficacy Scale-International (FES-I), Berg Balance Scale, Dynamic Gait Index, Functional Reach, and Timed Up and Go. ROC curves were constructed to determine the cutoff scores for all measures. Variables with P < 0.1 entered a logistic regression model. The prevalence of recurrent falls was 30% (95% CI 24%–38%). In multivariate analysis, independent risk factors for recurrent falls were (P < 0.05) levodopa equivalent dose (OR = 1.283 per 100 mg increase; 95% CI = 1.092–1.507), UPDRS-ADL > 16 points (OR = 10.0; 95% CI = 3.6–28.3), FES-I > 30 points (OR = 6.0; 95% CI = 1.6–22.6), and Berg ≤ 48 points (OR = 3.9; 95% CI = 1.2–12.7).We encourage the utilization of these modifiable risk factors in the screening of fall risk.

Postural control in Parkinson's disease

Introduction

Postural instability is one of the most disabling features of Parkinson's disease.

Objective

To evaluate postural balance in Parkinson's disease.

Methods

Thirty patients with Parkinson's disease were compared with controls using Tetrax™ interactive balance system posturography.

Results

For different positions, patients with Parkinson's disease showed a significantly higher weight distribution index, fall index, Fourier transformation at low-medium frequencies (F2–F4), and significantly lower right/left and toe/heel synchronization versus controls.

Conclusion

Postural imbalance in Parkinson's disease patients is characterized by the abnormalities of weight distribution index, synchronization index, Fourier transformation index, and fall index as measured by Tetrax™ posturography.

Prevention of falls in Parkinson's disease: a review of fall risk factors and the role of physical interventions

SUMMARY 

Falls in people with Parkinson's disease (PD) are frequent and recurrent events with devastating and widespread consequences. Despite this, understanding of the predictive and explanatory value of fall risk factors, as well as the development and testing of interventions aimed at reducing falls, are in their infancy. This review focuses on fall prediction and risk factors that are potentially remediable with physical interventions. We show that falls can be predicted with high accuracy using a simple three-step clinical tool. Evidence from recently published randomized controlled trials supports the implementation of balance-challenging exercises in reducing falls. Larger scale trials utilizing technologically advanced monitoring methods will further elucidate those interventions most likely to be cost effective according to individual risk factor profiles.

Factors influencing turning and its relationship with falls in individuals with Parkinson's disease

BACKGROUND

Falls are a major problem for people with Parkinson's disease (PD). Many studies indicate that more than 50% of people with PD have difficulty in turning that may lead to falls during daily activities. The aims of this study were to identify the relationship between turning performance and falls, and to determine the factors that influence turning performance.

METHODS

This study examined 45 patients with idiopathic PD (Hoehn and Yahr stage 1-3) using a battery of tests, including 180° turn time, balance, and muscle strength. The levels of disease severity and freezing of gait were also measured. The number of falls in the past 6 months was recorded.

RESULTS

Sixteen out of forty-five participants experienced falls in the past 6 months. A receiver operating characteristic curve showed that turn time was highly related to falls [more affected side: sensitivity = 0.81, specificity = 0.79, area under the curve (AUC) = 0.83; less affected side: sensitivity = 0.88, specificity = 0.76, AUC = 0.83]. The most important factor influencing turn time was balance ability (both sides: p = 0.000) according to the regression model. Correlations between turn time and dynamic balance were further established with reaction time, movement velocity, endpoint excursion, and maximal excursion of the LOS (limits of stability) test.

CONCLUSION

The time needed to complete a 180° turn during the SQT (step/quick turn) test is a good index to differentiate fallers from non-fallers in persons with PD. Turn time is most influenced by balance. Furthermore, balance control, especially in an anterior or sideways direction, is important for turning performance.

The effect of deep brain stimulation randomized by site on balance in Parkinson's disease

BACKGROUND

The effect of the surgical site of DBS on balance and gait in Parkinson's Disease (PD) is uncertain. This is the first double-blind study of subjects randomized to either the STN (N = 14) or GPi (N = 14) who were assessed on a range of clinical balance measures.

METHODS

Balance testing occurred before and 6 months postsurgery. A control PD group was tested over the same period without surgery (N = 9). All subjects were tested on and off medication and DBS subjects were also tested on and off DBS. The Postural Instability and Gait Disability items of the UPDRS and additional functional tests, which we call the Balance and Gait scale, were assessed. Activities of Balance Confidence and Activities of Daily Living questionnaires were also recorded.

RESULTS

Balance was not different between the best-treated states before and after DBS surgery for both sites. Switching DBS on improved balance scores, and scores further improved with medication, compared to the off state. The GPi group showed improved performance in the postsurgery off state and better ratings of balance confidence after surgery, compared to the STN group.

CONCLUSIONS

Clinical measures of balance function for both the STN and GPi sites showed that balance did not improve beyond the best medically treated state before surgery. Both clinical balance testing in the off/off state and self-reported balance confidence after surgery showed better performance in the GPi than the STN group.

Balance and Gait Training With Augmented Feedback Improves Balance Confidence in People With Parkinson’s Disease

Background. Fear of falling has been identified as an important and independent fall-risk predictor in patients with Parkinson’s disease (PD). However, there are inconsistent findings on the effects of balance and gait training on balance confidence. Objective. To explore whether balance and gait training with augmented feedback can enhance balance confidence in PD patients immediately after treatment and at 3- and 12-month follow-ups. Methods. A total of 51 PD patients were randomly assigned to a balance and gait training (BAL) group or to an active control (CON) group. The BAL group received balance and gait training with augmented feedback, whereas CON participants received lower-limb strength training for 12 weeks. Outcome measures included Activities-Specific Balance Confidence (ABC) Scale, limits-of-stability test, single-leg-stance test, and spatiotemporal gait characteristics. All tests were administered before intervention (Pre), immediately after training (Post), and at 3 months (Post3m) and 12 months (Post12m) after treatment completion. Results. The ABC score improved marginally at Post and significantly at Post3m and Post12m only in the BAL group ( P < .017). Both participant groups increased their end point excursion at Post, but only the BAL group maintained the improvement at Post3m. The BAL group maintained significantly longer time-to-loss-of-balance during the single-leg stance test than the CON group at Post3m and Post12m ( P < .05). For gait characteristics, both participant groups increased gait velocity, but only the BAL group increased stride length at Post, Post3m, and Post12m ( P < .017). Conclusions. Positive findings from this study provide evidence that BAL with augmented feedback could enhance balance confidence and balance and gait performance in patients with PD.

Eight forms of moving meditation for preventing falls in community-dwelling middle-aged and older adults

BACKGROUND

In numerous countries worldwide, fall prevention among older adults is a major public health issue. For older adults, regular participation in moderate physical activity or exercise lowers the risks of falls. However, scant information is available regarding the prevention strategies that the most at-risk groups may undertake. The purpose of this study is to examine the effects of a fall prevention strategy, eight forms of moving meditation (EFMM), on community-dwelling middle-aged and older adults in Taiwan.

METHODS

This was a quasi-experimental study; 84 participants were recruited from Taipei in Taiwan. For 12 weeks, participants in the experimental group performed 30-min EFMM 3 times per week. The measurements included a Functional Reach Test (FRT), Timed Get-up-and-Go Test (TGUG), and a One-Leg Stance Test (OLST) with eyes both opened and closed. All were conducted at the baseline and 12 weeks after intervention.

RESULTS

The participants who performed EFMM showed a significant and positive performance on FRT, TGUG, and OLST with eyes opened and eyes closed compared to those in the control group.

CONCLUSION

The results suggest that EFMM is an effective strategy for enhancing balance and functional mobility and preventing falls among community-dwelling middle-aged and older adults.

Performance of adults with cerebral palsy related to falls, balance and function: a preliminary report

AIM

To describe performance on standardised measures of functional mobility and identify relationships between gait decline, falls history and risk scores, and Gross Motor Function Classification System (GMFCS) level.

METHOD

Adults with cerebral palsy (CP) aged 30-65 years, GMFCS Levels I-III underwent a single assessment to complete performance and questionnaire measures of balance, mobility and falls.

RESULTS

Twenty-five ambulant community dwelling adults with CP participated (mean 41 years) in this study. Fifteen participants (60%) reported gait decline (>age 18). The most frequent self-reported cause of decline was reduced balance (n = 12). Seventeen participants (68%) reported prior falls. Group differences were found between GMFCS levels and falls risk (falls risk for older people-community, p = 0.025), balance (Berg Balance Scale, p = 0.005) and mobility (6 min walk test p = 0.004; timed up and go, p = 0.011).

CONCLUSION

Adults with CP experience mobility decline in early to middle adulthood, with reduced balance performance and elevated falls risk evident. There is urgent need for further research into falls risk factors using prospective falls data.

Influência do fortalecimento muscular no equilíbrio e qualidade de vida em indivíduos com doença de Parkinson

Esse estudo teve como objetivo avaliar o efeito do fortalecimento muscular no equilíbrio, mobilidade e na qualidade de vida (QV) de indivíduos com doença de Parkinson (DP), e verificar a correlação entre fortalecimento muscular e qualidade de vida. Participaram do estudo nove sujeitos, de ambos os sexos, com diagnóstico médico de DP. Eles, inicialmente, passaram por avaliação do equilíbrio e da mobilidade funcional por meio da Escala de Equilíbrio de Berg (EEB) e teste Timed Up and Go (TUG) e da QV pelo questionário Parkinson's Disease Questionnaire (PDQ-39). Os sujeitos realizaram ainda o teste de determinação de carga máxima (1 RM) para os grupos musculares treinados. Depois de verificadas a normalidade e homogeneidade dos dados, foram realizados o teste t de Student e o teste de correlação de Spearman. Foi considerado nível de significância de p<0,05. Foi verificada melhora no equilíbrio (p=0,008) e na QV (p=0,013), e correlação negativa entre equilíbrio e QV (avaliação r=-0,65 e p=0,05; e na reavaliação r=-0,82 e p=0,005). O fortalecimento muscular foi eficaz na melhora no equilíbrio e na qualidade de vida de indivíduos com doença de Parkinson.

Clinical and posturographic correlates of falling in Parkinson's disease

Various clinical tests and balance scales have been used to assess postural stability and the risk of falling in patients with idiopathic Parkinson's disease (IPD). Quantitative posturography allows a more objective assessment but the findings in previous studies have been inconsistent and few studies have investigated which posturographic measures correlate best with a history of falling. The purpose of this study was to determine the efficacy of clinical tests, balance scales, and stable-platform posturography in detecting postural instability and discriminating between fallers and non-fallers in a home-dwelling PD cohort. Forty-eight PD subjects (Hoehn & Yahr stage 1-3) and 17 age-matched controls had the following assessments: Activities-specific Balance Confidence scale, Berg Balance Scale, Unified Parkinson's Disease Rating Scale (UPDRS) (motor), pull-test, timed up-and-go, static posturography, and dynamic posturography to assess multidirectional leaning balance. Of the clinical assessments, all but the pull-test were closely correlated with a history of falling. Static posturography discriminated between PD fallers and controls but not between PD fallers and non-fallers, whereas dynamic posturography (reaction time, velocity, and target hit-time) also discriminated between fallers and non-fallers. Our findings suggest that this combination of clinical and posturographic measures would be useful in the prospective assessment of falls risk in PD patients. A further prospective study is now required to assess their predictive value. © 2013 Movement Disorder Society.

Three simple clinical tests to accurately predict falls in people with Parkinson's disease

Falls are a major cause of morbidity in Parkinson's disease (PD). The objective of this study was to identify predictors of falls in PD and develop a simple prediction tool that would be useful in routine patient care. Potential predictor variables (falls history, disease severity, cognition, leg muscle strength, balance, mobility, freezing of gait [FOG], and fear of falling) were collected for 205 community-dwelling people with PD. Falls were monitored prospectively for 6 months using monthly falls diaries. In total, 125 participants (59%) fell during follow-up. A model that included a history of falls, FOG, impaired postural sway, gait speed, sit-to-stand, standing balance with narrow base of support, and coordinated stability had high discrimination in identifying fallers (area under the receiver-operating characteristic curve [AUC], 0.83; 95% confidence interval [CI], 0.77-0.88). A clinical tool that incorporated 3 predictors easily determined in a clinical setting (falling in the previous year: odds ratio [OR], 5.80; 95% CI, 3.00-11.22; FOG in the past month: OR, 2.39; 95% CI, 1.19-4.80; and self-selected gait speed < 1.1 meters per second: OR, 1.86; 95% CI, 0.96-3.58) had similar discrimination (AUC, 0.80; 95% CI, 0.73-0.86) to the more complex model (P = 0.14 for comparison of AUCs). The absolute probability of falling in the next 6 months for people with low, medium, and high risk using the simple, 3-test tool was 17%, 51%, and 85%, respectively. In people who have PD without significant cognitive impairment, falls can be predicted with a high degree of accuracy using a simple, 3-test clinical tool. This tool enables individualized quantification of the risk of falling. © 2013 Movement Disorder Society.

Postural instability in patients with Parkinson's disease. Epidemiology, pathophysiology and management

Postural instability is one of the cardinal signs in Parkinson's disease (PD). It can be present even at diagnosis, but becomes more prevalent and worsens with disease progression. It represents one of the most disabling symptoms in the advanced stages of the disease, as it is associated with increased falls and loss of independence. Clinical and posturographic studies have contributed to significant advances in unravelling the complex pathophysiology of postural instability in patients with PD, but it still remains yet to be fully clarified, partly due to the difficulty in distinguishing between the disease process and the compensatory mechanisms, but also due to the fact that non-standardized techniques are used to measure balance and postural instability. There is increasing evidence that physical therapy, especially highly challenging balance exercises, can improve postural stability and reduce the risk of falls, although the long-term effects of physical therapy interventions on postural stability need to be explored given the progressive nature of PD. Pharmacotherapy with dopaminergic medications can provide significant improvements in postural instability in early- to mid-stage PD but the effects tend to wane with time consistent with spread of the disease process to non-dopaminergic pathways in advanced PD. Donepezil has been associated with a reduced risk of falls and methylphenidate has shown potential benefit against freezing of gait, but the results are yet to be replicated in large randomized studies. Surgical treatments, including lesioning and deep brain stimulation surgery targeting the subthalamic nucleus and the globus pallidus internus, tend to only provide modest benefit for postural instability. New surgical targets such as the pedunculopontine nucleus have emerged as a potential specific therapy for postural instability and gait disorder but remain experimental.

Evaluation of a multi-component group exercise program for adults with arthritis: Fitness and Exercise for People with Arthritis (FEPA)

BACKGROUND

Research supports the favorable effects of exercise on physical and psychosocial outcomes in those with arthritis. Few easily disseminated, multi-component, arthritis-specific programs have been evaluated using both physical function and psychosocial measures. Fitness and Exercise for People with Arthritis (FEPA) is a new community-based, 3-month, instructor supervised multi-component exercise program for individuals with arthritis designed to increase strength, flexibility, balance, and aerobic conditioning, while emphasizing joint-protection and proper biomechanics.

PURPOSE

To conduct a preliminary evaluation of the effects of the FEPA program on physical function and arthritis-related outcomes in individuals with arthritis.

METHOD

Middle-aged (n = 31, M(age) = 54.8 ± 7.2) and older (n = 79, M(age) = 76.0 ± 6.6) adults with arthritis completed the instructor led FEPA program in community senior centers, churches, and adult education settings. Changes in physical function, measured using the arm curl, back-scratch test, 8-foot up-and-go, and 6 min walk and self-reported arthritis-related pain, perceived physical function, affect, and self-efficacy for symptom management were assessed using RM ANOVA.

RESULTS

Significant improvements (ps < .05) in all physical function measures were found in the older group. In the middle-aged group, significant improvements (ps < .05) were found in the 8-foot up-and-go and 6 min walk. Self-reported physical function, pain perceptions, and self-efficacy for pain management significantly improved (ps < .05) in middle-aged participants, while only self-reported pain perceptions significantly improved in the older group.

CONCLUSIONS

FEPA shows promise for improving health-related outcomes in those with arthritis, and has potential for sustainability in community settings.

Protocol for a home-based integrated physical therapy program to reduce falls and improve mobility in people with Parkinson's disease

Background

The high incidence of falls associated with Parkinson’s disease (PD) increases the risk of injuries and immobility and compromises quality of life. Although falls education and strengthening programs have shown some benefit in healthy older people, the ability of physical therapy interventions in home settings to reduce falls and improve mobility in people with Parkinson’s has not been convincingly demonstrated.

Methods/design

180 community living people with PD will be randomly allocated to receive either a home-based integrated rehabilitation program (progressive resistance strength training, movement strategy training and falls education) or a home-based life skills program (control intervention). Both programs comprise one hour of treatment and one hour of structured homework per week over six weeks of home therapy. Blinded assessments occurring before therapy commences, the week after completion of therapy and 12 months following intervention will establish both the immediate and long-term benefits of home-based rehabilitation. The number of falls, number of repeat falls, falls rate and time to first fall will be the primary measures used to quantify outcome. The economic costs associated with injurious falls, and the costs of running the integrated rehabilitation program from a health system perspective will be established. The effects of intervention on motor and global disability and on quality of life will also be examined.

Discussion

This study will provide new evidence on the outcomes and cost effectiveness of home-based movement rehabilitation programs for people living with PD.

Trial registration

The trial is registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12608000390381).

Cognitive dysfunction in cirrhosis is associated with falls: a prospective study

Falls are frequent among patients with debilitating disorders and can have a serious effect on health status. Mild cognitive disturbances associated with cirrhosis may increase the risk for falls. Identifying subjects at risk may allow the implementation of preventive measures. Our aim was to assess the predictive value of the Psychometric Hepatic Encephalopathy Score (PHES) in identifying patients likely to sustain falls. One hundred and twenty-two outpatients with cirrhosis were assessed using the PHES and were followed at specified intervals. One third of them exhibited cognitive dysfunction (CD) according to the PHES (<-4). Seventeen of the forty-two patients (40.4%) with CD had at least one fall during follow-up. In comparison, only 5 of 80 (6.2%) without CD had falls (P < 0.001). Fractures occurred in 4 patients (9.5%) with CD, but in no patients without CD (P = 0.01). Patients with CD needed more healthcare (23.8% versus 2.5%; P < 0.001), more emergency room care (14.2% versus 2.5%; P = 0.02), and more hospitalization (9.5% versus 0%; P = 0.01) as a result of falls than patients without CD. Patients taking psychoactive treatment (n = 21) had a higher frequency of falls, and this was related to an abnormal PHES. In patients without psychoactive treatment (n = 101), the incidence of falls was 32.4% in patients with CD versus 7.5% in those without CD (P = 0.003). In the multivariate analysis, CD was the only independent predictive factor of falls (odds ratio, 10.2; 95% confidence interval, 3.4-30.4; P < 0.001). The 1-year probability of falling was 52.3% in patients with CD and 6.5% in those without (P < 0.001).

CONCLUSION

An abnormal PHES identifies patients with cirrhosis who are at risk for falls. This psychometric test may be useful to promote awareness of falls and identify patients who may benefit from preventive strategies.

Balance in relation to walking deterioration in adults with spastic bilateral cerebral palsy

BACKGROUND

Balance function is central in walking, and impaired balance function may be related to walking deterioration in adults with spastic bilateral cerebral palsy (CP).

OBJECTIVES

The purposes of this study were: (1) to compare balance confidence, fear of falling, and balance ability in adults with spastic bilateral CP, with and without self-reported walking deterioration; (2) to characterize balance confidence, fear of falling, and balance ability across all participants; and (3) to examine the relationship between balance confidence and balance ability across all participants.

DESIGN

A case-control design was used.

METHODS

Sixteen adults from a 7-year follow-up study who had spastic bilateral CP and were under 40 years of age in the 2006 survey participated. Eight participants reported walking deterioration (cases), and 8 participants did not report walking deterioration (controls). Outcome variables were: the Activities-specific Balance Confidence (ABC) Scale, the Falls Efficacy Scale-International (FES-I), and the Balance Evaluation Systems Test (BESTest).

RESULTS

No differences in any of the outcome variables were found between the cases and the controls. Across all participants, the ABC Scale and FES-I scores were 62% and 24 points, respectively. Reduced ABC Scale scores and increased FES-I scores were found when using escalators, walking in crowds, and walking on slippery surfaces. The BESTest subscale scores were 60% to 79% of the maximum score, but only 31% and 42% of the maximum score in postural responses and anticipatory adjustments, respectively. Balance confidence correlated positively with postural responses, sensory orientation, stability in gait, and BESTest total score.

LIMITATIONS

The lack of reliability and validity tests for the outcome variables in this study population and the small number of participants were limitations of the study.

CONCLUSIONS

Self-reported walking deterioration in this group could not be explained by differences in balance confidence, fear of falling, or balance ability. Across all participants, most balance problems seemed related to reduced postural responses and anticipatory adjustments.

Utility of the Mini-BESTest, BESTest, and BESTest sections for balance assessments in individuals with Parkinson disease

BACKGROUND AND PURPOSE

The Balance Evaluation Systems Test(BESTest) has been shown to be a reliable and valid measure of balance in individuals with Parkinson disease (PD). A less time-consuming assessment may increase clinical utility. We compared the discriminative fall risk ability of the Mini-BESTest with that of the BESTest and determined the reliability and normal distribution of scores for each section of the BESTest and the Mini-BESTest in individuals with PD.

METHODS

Eighty individuals with idiopathic PD were assessed using the BESTest and Mini-BESTest. A faller was defined as an individual with 2 or more falls in the prior 6 months. Subsets of individuals were used to determine interrater (n = 15) and test-retest reliability (n = 24).

RESULTS

The Mini-BESTest, total BESTest score, and all sections of the BESTest showed a significant difference between the average scores of fallers and nonfallers. For both the Mini-BESTest and BESTest, interrater (intraclass correlation ICC ≥ 0.91) and test-retest (ICC ≥ 0.88) reliability was high. The Mini-BESTest and BESTest were highly correlated (r = 0.955). Accuracy of identifying a faller was comparable for the Mini-BESTest and BESTest (area under the receiver operating characteristic plots = 0.86 and 0.84, respectively).

DISCUSSION

No specific section of the BESTest captured the primary balance deficit for individuals with PD. The posttest probabilities for discriminating fallers versus nonfallers were comparable-to-slightly stronger when using the Mini-BESTest.

CONCLUSION

Although the Mini-BESTest has fewer than half of the items in the BESTest and takes only 15 minutes to complete, it is as reliable as the BESTest and has comparable-to-slightly greater discriminative properties for identifying fallers in individuals with PD.

Gait difficulty, postural instability, and muscle weakness are associated with fear of falling in people with Parkinson's disease

The present study aimed to examine the contribution of gait impairment, postural stability and muscle weakness to the level of fear of falling in people with Parkinson's disease (PD). Fifty-seven community-dwelling individuals with PD completed the study. Fear of falling was assessed by the Activities-specific Balance Confidence (ABC) scale. Postural stability and gait difficulty were determined by the posture and gait subscores of the Unified Parkinson's Disease Rating Scale (UPDRS-PG). A Cybex dynamometer was used to measure isokinetic knee muscle strength. Individuals with PD achieved a mean ABC score of 73.6 ± 19.3. In the multiple regression analysis, after accounting for basic demographics, fall history and disease severity, the UPDRS-PG score remained independently associated with the ABC score, accounting for 13.4% of the variance (P < 0.001). The addition of knee muscle strength significantly improved the prediction model and accounted for an additional 7.3% of the variance in the ABC score (P < 0.05). This is the first study to demonstrate that the UPDRS-PG score and knee muscle strength are important and independent determinants of the level of fear of falling in individuals with PD. Improving balance, gait stability and knee muscle strength could be crucial in promoting balance confidence in the appropriately targeted PD population.

Walking ability is a major contributor to fear of falling in people with Parkinson's disease: implications for rehabilitation

Although fear of falling (FOF) is common in people with Parkinson's disease (PD), there is a lack of research investigating potential predictors of FOF. This study explored the impact of motor, nonmotor, and demographic factors as well as complications of drug therapy on FOF among people with PD. Postal survey data (including the Falls Efficacy Scale, FES) from 154 nondemented people with PD were analyzed using multiple regression analyses. Five significant independent variables were identified explaining 74% of the variance in FES scores. The strongest contributing factor to FOF was walking difficulties (explaining 68%), followed by fatigue, turning hesitations, need for help in daily activities, and motor fluctuations. Exploring specific aspects of walking identified three significant variables explaining 59% of FOF: balance problems, limited ability to climb stairs, and turning hesitations. These results have implications for rehabilitation clinicians and suggest that walking ability is the primary target in order to reduce FOF. Specifically, balance, climbing stairs, and turning seem to be of particular importance.

Functional gait assessment and balance evaluation system test: reliability, validity, sensitivity, and specificity for identifying individuals with Parkinson disease who fall

BACKGROUND

Gait impairments, balance impairments, and falls are prevalent in individuals with Parkinson disease (PD). Although the Berg Balance Scale (BBS) can be considered the reference standard for the determination of fall risk, it has a noted ceiling effect. Development of ceiling-free measures that can assess balance and are good at discriminating "fallers" from "nonfallers" is needed.

OBJECTIVE

The purpose of this study was to compare the Functional Gait Assessment (FGA) and the Balance Evaluation Systems Test (BESTest) with the BBS among individuals with PD and evaluate the tests' reliability, validity, and discriminatory sensitivity and specificity for fallers versus nonfallers.

DESIGN

This was an observational study of community-dwelling individuals with idiopathic PD.

METHODS

The BBS, FGA, and BESTest were administered to 80 individuals with PD. Interrater reliability (n=15) was assessed by 3 raters. Test-retest reliability was based on 2 tests of participants (n=24), 2 weeks apart. Intraclass correlation coefficients (2,1) were used to calculate reliability, and Spearman correlation coefficients were used to assess validity. Cutoff points, sensitivity, and specificity were based on receiver operating characteristic plots.

RESULTS

Test-retest reliability was .80 for the BBS, .91 for the FGA, and .88 for the BESTest. Interrater reliability was greater than .93 for all 3 tests. The FGA and BESTest were correlated with the BBS (r=.78 and r=.87, respectively). Cutoff scores to identify fallers were 47/56 for the BBS, 15/30 for the FGA, and 69% for the BESTest. The overall accuracy (area under the curve) for the BBS, FGA, and BESTest was .79, .80, and .85, respectively.

LIMITATIONS

Fall reports were retrospective.

CONCLUSION

Both the FGA and the BESTest have reliability and validity for assessing balance in individuals with PD. The BESTest is most sensitive for identifying fallers.

Whole body vibration therapy in fracture prevention among adults with chronic disease

Due to various physical impairments, individuals with chronic diseases often live a sedentary lifestyle, which leads to physical de-conditioning. The associated muscle weakness, functional decline and bone loss also render these individuals highly susceptible to falls and fragility fractures. There is an urgent need to search for safe and effective intervention strategies to prevent fragility fractures by modifying the fall-related risk factors and enhancing bone health. Whole body vibration (WBV) therapy has gained popularity in rehabilitation in recent years. In this type of treatment, mechanical vibration is delivered to the body while the individual is standing on an oscillating platform. As mechanical loading is one of the most powerful stimuli to induce osteogenesis, it is proposed that the mechanical stress applied to the human skeleton in WBV therapy might be beneficial for enhancing bone mass. Additionally, the vibratory signals also constitute a form of sensory stimulation and can induce reflex muscle activation, which could potentially induce therapeutic effects on muscle strength and important sensorimotor functions such as postural control. Increasing research evidence suggests that WBV is effective in enhancing hip bone mineral density, muscle strength and balance ability in elderly patients, and could have potential for individuals with chronic diseases, who often cannot tolerate vigorous impact or resistance exercise training. This article aims to discuss the potential role of WBV therapy in the prevention of fragility fractures among people with chronic diseases.

Assessment of fall-related self-efficacy and activity avoidance in people with Parkinson's disease

Background

Fear of falling (FOF) is common in Parkinson's disease (PD), and it is considered a vital aspect of comprehensive balance assessment in PD. FOF can be conceptualized differently. The Falls-Efficacy Scale (FES) assesses fall-related self-efficacy, whereas the Survey of Activities and Fear of Falling in the Elderly (SAFFE) assesses activity avoidance due to the risk of falling. This study aimed at investigating the validity and reliability of FES and SAFFE in people with PD.

Methods

Seventy-nine people with PD (mean age; 64 years, SD 7.2) completed the Swedish version of FES(S), SAFFE and the physical functioning (PF) scale of the 36-Item Short-Form Health Survey (SF-36). FES(S) and SAFFE were administered twice, with an 8.8 (SD 2.3) days interval. Assumptions for summing item scores into total scores were examined and score reliability (Cronbach's alpha and test-retest reliability) were calculated. Construct validity was assessed by examining the pattern of Spearman correlations (r_s) between the FES(S)/SAFFE and other variables, and by examining differences in FES(S)/SAFFE scores between fallers and non-fallers, genders, and between those reporting FOF and unsteadiness while turning.

Results

For both scales, item mean scores (and standard deviations) were roughly similar and corrected item-total correlations exceeded 0.4. Reliabilities were ≥0.87. FES(S)-scores correlated strongest (r_s, -0.74, p < 0.001) with SAFFE-scores, whereas SAFFE-scores correlated strongest with PF-scores (r_s, -0.76, p < 0.001). Both scales correlated weakest with age (r_s ≤ 0.08). Experiencing falls, unsteadiness while turning, and FOF was associated with lower fall-related self-efficacy and higher activity avoidance.

Conclusions

This study provides initial support for the score reliability and validity of the FES(S) and SAFFE in people with PD.

Feasibility of an Intensive Trial of Modern Dance for Adults with Parkinson Disease

Although preliminary evidence supports the psychophysical benefits of dance for adults with Parkinson disease, guidelines for community-based dance programs await further scrutiny for safety and efficacy. This pilot study was designed to assess the feasibility of an intensive trial of group-delivered modern dance for 11 adults with early-to-middle stage Parkinson’s. The Timed ‘‘Up and Go’’ test and the Fullerton Advanced Balance scale were administered to assess balance safety and re-administered at closure along with a self-reported feedback questionnaire. Video recordings were analyzed for qualitative behavioral change. Pre/posttest comparisons from the Timed ‘‘Up and Go’’ test were not significant, while those from the Fullerton Advanced Balance Scale were significant at the .05 level for the group as a whole (p = .01) with an average score change of +3.1 points. Although qualitative results generally concurred with the social benefits associated with an enjoyable form of expressive exercise, important indicators surfaced bearing on future research and community program designs. These include need for more rigorous stratification of participants and adapting dance class structure to address specific group needs to promote motor learning for sustained functional gains.