The effect of multidimensional exercises on balance, mobility, and fall risk in community-dwelling older adults

Factors associated with balance confidence in older adults with health conditions affecting the balance and vestibular system

OBJECTIVE

To determine the functional, clinical, and comorbid health condition factors that contribute to balance confidence in persons with balance or vestibular disorders, or both.

DESIGN

Cross-sectional descriptive.

SETTING

Tertiary care center for balance disorders.

PARTICIPANTS

Older adults (N=95) with signs and symptoms of vestibular dysfunction.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Activity-specific Balance Confidence Scale (ABC) was administered on examination for complaints of balance, postural instability, or both.

RESULTS

Balance confidence as measured by the ABC was associated with functional balance performance on the Timed Up & Go test and the Dynamic Gait Index. Duration of symptoms and general health-related quality of life (as measured by the Medical Outcomes Study 36-Item Short-Form Health Survey) were significant covariates of balance confidence. Self-reported treatment for anxiety, depression, or both, significantly reduced balance confidence.

CONCLUSIONS

Balance confidence is a complex construct in older adults with signs and symptoms of balance or vestibular dysfunction, or both. Decreased balance confidence in performing functional activities is associated with actual balance performance, duration of vestibular symptoms, general health-related quality of life, and the presence of comorbid psychological and visual impairments. Understanding these relationships can potentially improve management of older adults who present with balance or vestibular disease, or both.

Effect of a Home Exercise Program on Dynamic Balance in Elderly With a History of Falls

Objective:

To determine exercise efficacy in improving dynamic balance in community-dwelling elderly with a fall history.

Methods:

Thirty-five participants were randomly assigned to a treatment (TG; n = 19, 77 ± 7 yr) or control group (CG; n = 16, 75 ± 8 yr). The TG received an individualized home exercise program, and the CG received phone calls twice per week for 12 weeks. Participants’ dynamic-balance abilities— directional control (DC), endpoint excursion (EE), maximum excursion (ME), reaction time (RT), and movement velocity (MV)—were measured using the Balance Master at 75% limits of stability. Functional reach (FR) was also measured.

Results:

At 12 weeks the TG demonstrated significant improvements in DC (p < .0025), EE (p < .0005), and ME (p < .0005), but the CG did not. No significant group differences were found for MV, RT, or FR.

Conclusions:

Excursion distances and directional control improved but not reaction time, suggesting that exercises requiring quick responses may be needed.

Intra- and interrater reliability and agreement of the Danish version of the Dynamic Gait Index in older people with balance impairments

OBJECTIVES

To examine the intrarater and interrater reliability and agreement of the Danish version of the Dynamic Gait Index (DGI) in hospitalized and community-dwelling older people with balance impairments.

DESIGN

Reliability study.

SETTING

University hospital and outpatient rehabilitation.

PARTICIPANTS

A convenience sample of older people (≥65y); 24 subjects from a hospital and 24 from an outpatient rehabilitation center. All subjects had either 1 or more falls within the last year or balance impairments evaluated by a physical therapist.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

All subjects carried out the DGI twice with a 1.5-hour interval. Each subject was rated by 3 physical therapists in the first attempt (1 for intrarater and 2 for interrater comparison) and by the intrarater in the second attempt, in both settings. The reliability was calculated using the intraclass correlation coefficient (ICC, 2.1), while agreement was calculated as the smallest real difference (SRD).

RESULTS

The ICC for intrarater and interrater reliability of the total DGI was .90 and .92 at the hospital, while the SRD was 2.72 and 2.58 points, respectively. Correspondingly, the ICC for intrarater and interrater reliability of the total DGI at the rehabilitation center was .89 and .82, while the SRD was 3.49 and 3.99 points, respectively.

CONCLUSIONS

The intrarater and interrater reliability of the total DGI ranged from good to excellent in hospitalized and community-dwelling older people. Improvements of 3 and 4 DGI points for hospitalized and community-dwelling older people, respectively, should be regarded as a real change (with a 95% certainty).

The effect of the visual characteristics of obstacles on risk of tripping and gait parameters during locomotion

PURPOSE

Injuries from falls are a serious health issue. Approaches to preventing falls should consider increasing relevant visual information of an obstacle. Obstacle parameters, such as position and height, may be specified by the visible structure of an obstacle. The present study examined the relationship between visible structure of an obstacle and locomotor behaviour. This relationship may be modified as a function of experience with navigating obstacles. Since workers at construction sites must navigate through cluttered environments with varied obstacles, these workers may have superior skills at avoiding obstacles. Therefore, the effect of work experience was also examined.

METHODS

Nine construction workers and 10 age- and gender-matched control subjects participated. Subjects stepped over obstacles in an 8 m walkway. Three different obstacles were examined, arranged according to a hierarchy ranging from most to least visible structure: a solid obstacle, a three-edge outline obstacle and a top-edge obstacle. The obstacles were 10, 20 or 30 cm high. In addition, visual information was decreased with goggles which obstructed the lower visual field, removing information of the obstacle and foot-relative-to-obstacle in the two steps before the obstacle. All conditions were presented randomly.

RESULTS

Higher risk of contact and higher lead and trail toe clearance variability were observed for the top-edge obstacle. Higher risk of contact was observed when the lower visual field was obstructed and for the 30 cm obstacle. Work experience did not influence risk of contact. Construction workers had lower trail toe clearances and lower trail toe clearance variability for the 10 cm obstacle, but were not different from controls for the 30 cm obstacle.

CONCLUSIONS

Decreased visible structure of an obstacle resulted in increased gait variability and increased risk of contact. The changes are consistent with decreased accuracy of the sensory-to-motor transformation used to control the lead and trail limb during obstacle crossing when only the top-edge was visible. There is some evidence that construction workers were better able to transform the visual information to motor actions, as reflected by decreased gait variability, but these findings were not supported by decreased risk of obstacle contact.

Challenges and opportunities in managing the dizzy older adult

Balance disorders are common in elderly people, not only resulting in distressing sensations but also leading to reduced activity levels and quality of life. It has been estimated that 30% of elderly patients experience a balance disorder. Managing these disorders is a substantial challenge for patients and their caregivers and physicians. Moreover, abnormalities in balance are associated with falls, a major cause of morbidity and mortality for elderly people. Management is complicated by the inherent difficulties in assessing the generic complaint of dizziness, as well as the likelihood of multiple, often nonvestibular causes. The authors of this mini-seminar review both vestibular and nonvestibular causes of balance disorders in elderly people, emphasizing practical therapeutic maneuvers that can be used.

Development of a scale to assess avoidance behavior due to a fear of falling: the Fear of Falling Avoidance Behavior Questionnaire

BACKGROUND

A history of falls or imbalance may lead to a fear of falling, which may lead to self-imposed avoidance of activity; this avoidance may stimulate a vicious cycle of deconditioning and subsequent falls.

OBJECTIVE

The purpose of this study was to develop a questionnaire that would quantify avoidance behavior due to a fear of falling.

DESIGN

This study consisted of 2 parts: questionnaire development and psychometric testing. Questionnaire development involved an expert panel and 39 residents of an assisted living facility. Sixty-three community-dwelling individuals with various health conditions participated in psychometric testing.

METHOD

Questionnaire development included the evaluation of face and content validity and factor analysis of the initial questionnaire. The final result of questionnaire development was the Fear of Falling Avoidance Behavior Questionnaire (FFABQ). In order to determine its psychometric properties, reliability and construct validity were assessed through administration of the FFABQ to participants twice, 1 week apart, and comparison of the FFABQ with other questionnaires related to fear of falling, functional measures of balance and mobility, and daily activity levels using an activity monitor.

RESULTS

The FFABQ had good overall test-retest reliability (intraclass correlation coefficient=.812) and was found to differentiate between participants who were considered "fallers" (ie, at least one fall in the previous year) and those who were considered "nonfallers." The FFABQ predicted time spent sitting or lying and endurance.

LIMITATIONS

A relatively small number of people with a fear of falling were willing to participate.

CONCLUSION

Results from this study offer evidence for the reliability and validity of the FFABQ and support the notion that the FFABQ measures avoidance behavior rather than balance confidence, self-efficacy, or fear.

Rasch analyses of the Activities-specific Balance Confidence Scale with individuals 50 years and older with lower-limb amputations

OBJECTIVES

To explore shortened response formats for use with the Activities-specific Balance Confidence (ABC) Scale and then evaluate the unidimensionality of the scale, the item difficulty, the scale for redundancy and content gaps, and the item standard error of measurement (SEM) and internal consistency reliability among aging individuals with a lower-limb amputation living in the community.

DESIGN

Secondary analysis of cross-sectional survey and chart review data.

SETTING

Outpatient amputee clinics, Ontario, Canada.

PARTICIPANTS

Community living adults (N=448; ≥50y; mean, 68y) who have used a prosthesis for at least 6 months for a major unilateral lower-limb amputation. Of the participants, 325 (72.5%) were men.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

ABC Scale.

RESULTS

A 5-option response format outperformed 4- and 6-option formats. Factor analyses confirmed a unidimensional scale. The distance between response options is not the same for all items on the scale, evident by the Rasch Partial Credit Model (PCM) having a better fit to the data than the Rasch Rating Scale Model. Two items, however, did not fit the PCM within statistical reason. Revising the wording of the 2 items may resolve the misfit and improve the construct validity and lower the standard error of measurement. Overall, the difficulty of the scale's items is appropriate for use with aging individuals with lower-limb amputation, and is most reliable (Cronbach α=0.94) for use with individuals with moderately low balance confidence levels.

CONCLUSIONS

The ABC Scale with a simplified 5-option response format is a valid and reliable measure of balance confidence for use with individuals aging with a lower-limb amputation.

Cognitive and motor mechanisms underlying older adults' ability to divide attention while walking

BACKGROUND

An impaired ability to allocate attention to gait during dual-task situations is a powerful predictor of falls.

OBJECTIVE

The primary purpose of this study was to examine the relative contributions of participant characteristics and motor and cognitive factors to the ability to walk while performing cognitive tasks. The impact of cognitive task complexity on walking also was examined.

DESIGN

A cross-sectional, exploratory study design was used.

METHODS

Seventy-seven community-dwelling older adults with a mean (SD) age of 75.5 (5.8) years completed comprehensive testing. Participant characteristics were assessed via questionnaires. The motor test battery included measures of strength (force-generating capacity), gait speed, and static and dynamic balance. The cognitive abilities test battery assessed psychomotor and perceptual speed, recall and working memory, verbal and spatial ability, and attention (sustained, selective, and divided). Time to walk while performing 4 cognitive tasks was measured. In addition, dual-task costs (DTCs) were calculated. Multiple hierarchical regressions explored walking under dual-task conditions.

RESULTS

The ability to walk and perform a simple cognitive task was explained by participant characteristics and motor factors alone, whereas walking and performing a complex cognitive task was explained by cognitive factors in addition to participant and motor factors. Regardless of the cognitive task, participants walked slower under dual-task conditions than under single-task conditions. Increased cognitive task complexity resulted in greater slowing of gait: gait DTCs were least for the simplest conditions and greatest for the complex conditions. Limitations Walking performance was characterized by a single parameter (time), whereas other spatiotemporal parameters have been related to dual-task performance. However, this type of measurement (timed performance) will be easy to implement in the clinic.

CONCLUSIONS

Two factors-participant characteristics and motor abilities-explained the majority of variance of walking under dual-task conditions; however, cognitive abilities also contributed significantly to the regression models. Rehabilitation focused on improving underlying balance and gait deficits, as well as specific cognitive impairments, may significantly improve walking under dual-task conditions.

Contribution of hip abductor strength to physical function in patients with total knee arthroplasty

BACKGROUND

Investigating modifiable factors that contribute to functional limitations in patients with total knee arthroplasty (TKA) may guide changes in rehabilitation protocols and improve functional outcomes. Whereas quadriceps muscle weakness has been demonstrated to contribute to functional limitations in TKA, the role of hip abductor weakness has not received attention.

OBJECTIVE

The purpose of this study was to determine whether hip abductor strength (force-generating capacity) contributes to physical function beyond what can be explained by quadriceps muscle strength in patients after a TKA.

DESIGN

A cross-sectional design was used in the study.

SETTING

The study was conducted in a clinical laboratory at an academic center.

PATIENTS

Thirty-one people with TKA (74% female; mean age=68 years, SD=8; mean body mass index=31 kg/m(2), SD=5) participated in the study.

MEASUREMENTS

Strength of quadriceps muscles and hip abductors was measured using an isokinetic dynamometer. Performance-based physical function was assessed with 4 measures: self-selected walking speed, the Figure-of-8 Walk Test, the Stair Ascend/Descend Test, and the 5-Chair Rise Test. Self-reported physical function was assessed with the Western Ontario and McMaster Universities Osteoarthritis Index Physical Function Subscale.

RESULTS

In hierarchical regression models, after accounting for demographic and anthropometric factors, quadriceps muscle strength was associated with performance on the Stair Ascend/Descend Test. After accounting for demographic, anthropometric, and quadriceps strength, hip abductor strength was associated with performance on the Stair Ascend/Descend Test, the Figure-of-8 Walk Test, and the 5-Chair Rise Test.

LIMITATIONS

The study design precluded ascertainment of causal relationships.

CONCLUSIONS

After TKA, hip abductor strength influenced physical function in participants more than did demographic or anthropometric measures or quadriceps strength. Longitudinal studies with larger samples are warranted. If findings are replicated, they will justify targeting the hip abductors during rehabilitation after TKA.

Application of vibrotactile feedback of body motion to improve rehabilitation in individuals with imbalance

BACKGROUND AND PURPOSE

Balance rehabilitation and vestibular or balance prostheses are both emerging fields that have a potential for synergistic interaction. This article reviews vibrotactile prosthetic devices that have been developed to date and ongoing work related to the application of vibrotactile feedback for enhanced postural control. A vibrotactile feedback device developed in the author's laboratory is described.

METHODS

Twelve subjects with vestibular hypofunction were tested on a platform that moved randomly in a plane, while receiving vibrotactile feedback in the anteroposterior direction. The feedback allowed subjects to significantly decrease their anteroposterior body tilt but did not change mediolateral tilt. A tandem walking task performed by subjects with vestibulopathies demonstrated a reduction in their mediolateral sway due to vibrotactile feedback of mediolateral body tilt, after controlling for the effects of task learning. Published findings from 2 additional experiments conducted in the laboratories of collaborating physical therapists are summarized.

RESULTS

The Dynamic Gait Index scores in community-dwelling elderly individuals who were prone to falls were significantly improved with the use of mediolateral body tilt feedback.

DISCUSSION AND CONCLUSIONS

Although more work is needed, these results suggest that vibrotactile tilt feedback of subjects' body motion can be used effectively by physical therapists for balance rehabilitation. A preliminary description of the third-generation device that has been reduced from a vest format to a belt format is described to demonstrate the progressive evolution from research to clinical application.

Psychometric comparisons of 3 functional ambulation measures for patients with stroke

BACKGROUND AND PURPOSE

We compared the test-retest reliability, validity, and responsiveness of the Dynamic Gait Index, the 4-item Dynamic Gait Index, and the Functional Gait Assessment for assessment of walking in patients with stroke.

METHODS

Forty-five outpatients participating in the validity and responsiveness study were tested using the 3 walking measures as well as the 10-m walk test, Barthel Index, and Postural Assessment Scale for Stroke Patients. We tested them during the first week, then again after 2 months and 5 months of therapy. Another 48 chronic patients completed the 3 measures twice, 1 week apart, in the test-retest reliability study.

RESULTS

Thirty-five participants completed 3 time-point assessments. The Functional Gait Assessment showed the least floor and ceiling effects, indicating it has the best discriminative ability for patients with stroke with high walking function. We found the 3 measures were highly correlated with each other, indicating excellent concurrent validity, and all measures at the first week of therapy were moderately to highly correlated with the Barthel Index scores at 5 months, indicating good predictive validity. Responsiveness of the 3 measures was moderate during a 5-month period, and all showed good test-retest reliability. The minimal detectable changes between tests indicate acceptable random error.

CONCLUSIONS

All 3 measures showed sufficient validity, responsiveness, and reliability for assessment of walking function in patients with stroke undergoing rehabilitation, but the Functional Gait Assessment is recommended for its psychometric properties.

Screening for falls and osteoporosis: prevention practice for the hand therapist

Fractures of the upper extremity are considered a hallmark of underlying osteopenia or osteoporosis and strong predictors of subsequent fractures. Falling is the strongest single risk factor for fractures in older adults. Studies have shown that interventions to prevent falls can significantly reduce this risk factor. Hand therapists working with patients with an upper extremity injury from a fall cannot assume that screening for osteoporosis or the likelihood of falls has been addressed by other health care professionals. The purposes of this article are to 1) summarize osteoporosis and falls risk screening, 2) describe how fall prevention strategies can be integrated into hand therapy practice, and 3) present evidence for federal and professional organizational support of prevention practice.

Dual task interference in estimating the risk of falls and measuring change: a comparative, psychometric study of four measurements

Objective: The aim is to examine the validity and reliability of the Timed Up and Go Test with dual task for predicting the risk of falls. Standard values for the TUG with dual task were determined, taking account of age and gender.

Design: Validation study

Setting: Data was recorded for 120 volunteers in an outpatient physiotherapy centre.

Subjects: The sample comprised 120 healthy men and women aged 60 to 87 years living at home. Twenty-three subjects selected at random were tested again, after one day and after one week, in order to ascertain the retest reliability.

Main measures: Berg Balance Scale, times for Timed Up and Go Test with manual dual task (TUGman) and with cognitive dual task (TUGcog).

Results: Strong correlations between the TUGman and the BBS (r = -0.72) and between the TUGcog and the BBS (r = -0.66) indicate high criterion validity. The retest reliability of the TUGman (rT1-T2 = 0.97 and rT1-T3 = 0.98) and TUGcog (rT1-T2 = 0.98 and rT1-T3 = 0.98) is very good. The intra-rater reliability is very high with an ICC = 0.99 for the TUGman and an ICC = 0.94 for the TUGcog. The mean time needed to perform the TUGman is 11.6 s (95% CI 11.2—11.9); the mean time needed to perform the TUGcog is 9.8 s (95% CI 9.5—10.2).

Conclusions: The tests with dual task can be recommended because they possess high criterion validity and very good retest reliability. Faster and simpler performance of the TUG-DT is another factor in its favour.

Static stretching does not impair performance in active middle-aged adults

Recent investigations with young, healthy adult subjects suggest that static stretching before activity decreases performance and should, therefore, be avoided. The purpose of this study was to assess the effects of an acute static stretching protocol on balance and jump/hop performance in active middle-aged adults. Ten subjects (6 men and 4 women aged 40-60 yr) from a martial arts school volunteered to take part in this research study. This was a repeated measures design. Subjects who stretched for 10 minutes using a 30-second hold during 1 session sat quietly for 10 minutes during the alternate session. Sessions were randomly assigned. The following dependent variables were compared: Dynamic Stability Index (DSI) for single-leg dynamic balance (smaller DSI = improved balance); distances for broad jump, single hop, triple hop, and crossover hop; elapsed time for a 6-m timed hop. Group means for balance were significantly different between the stretch and no-stretch conditions (3.5 +/- 0.7 vs. 4.3 +/- 1.4 DSI, respectively; p < 0.05). No significant differences were found between the group means of the stretch and no-stretch conditions for the dependent measures of broad jump, single hop, triple hop, crossover hop, and 6-m timed hop performance. Ten minutes of acute static stretching enhances dynamic balance and does not affect jump/hop performance in active middle-aged adults. Static stretching should be included before competition and before exercise in fitness programs of active middle-aged adults.

Predictors of change in quality of life after distributed constraint-induced therapy in patients with chronic stroke

BACKGROUND

There are no reports of predictive models or predictors for quality of life (QoL) after constraint-induced therapy (CIT).

OBJECTIVE

This investigation identified predictors of change in stroke-related QoL after distributed CIT using the Chi-squared Automatic Interaction Detector (CHAID) method.

METHODS

A total of 58 patients with chronic stroke were treated with CIT for 2 hours daily for 3 weeks. The 7 potential predictors were age, gender, side of lesion, time since stroke, cognitive status, motor impairment of upper extremity, and activities of daily living (ADL). QoL was measured by the Stroke Impact Scale (SIS). CHAID analysis was used to examine for associations between the 7 predictors and each SIS domain. The validity of each model generated by the analysis was evaluated.

RESULTS

Daily functional performance as measured by the Functional Independence Measure (FIM) was found to determine SIS outcomes, including overall score (P = .006) and the ADL/instrumental ADL (IADL) domain (P = .004). None of the potential predictors emerged as significant predictors of the strength, memory, emotion, communication, mobility, hand function, and participation domains of SIS. The misclassification risk estimates were small, indicating good validity for the CHAID models.

CONCLUSIONS

The functional independence score of the FIM can predict the overall SIS score as well as the ADL/IADL domain of the SIS in chronic stroke patients who receive CIT, but larger databases are needed to confirm this. CHAID analysis was a useful approach for an exploratory study.

The effects of multidimensional exercise on functional decline, urinary incontinence, and fear of falling in community-dwelling elderly women with multiple symptoms of geriatric syndrome: a randomized controlled and 6-month follow-up trial

This study assessed the effects of multidimensional exercises on functional decline, urinary incontinence, and fear of falling in community-dwelling Japanese elderly women with multiple symptoms of geriatric syndrome (MSGS). Sixty-one participants were randomly assigned either to an intervention (n=31) or to a control group (n=30). For 3-month period, the intervention group received multidimensional exercise, twice a week, aiming to increase the muscle strength, walking ability, and pelvic floor muscle (PFM). Outcome variables were measured at baseline, and after intervention and follow-up. The functional decline of the intervention group decreased from 50.0% at baseline to 16.7% after intervention and follow-up (Q=16.67, p<0.001). For urinary incontinence, the intervention group decreased from 66.7% at baseline to 23.3% after intervention and 40.0% at follow-up (Q=13.56, p=0.001), whereas the control group showed no improvement. Intervention group showed greater and significant decrease in the score of MSGS compared to control group (F=12.66, p=0.001). Within the subjects that showed improvement to normal status of MSGS, a significantly higher proportion demonstrated increased maximum walking speed at follow-up (Q=6.50, p=0.039). These results suggest that multidimensional exercise is an effective strategy for reducing geriatric syndromes in elderly population. An increase in walking ability may contribute to the improvement of MSGS.

Impairment variables predicting activity limitation in individuals with lower limb amputation

The purpose of this study was to determine whether measures of impairment (i.e., muscle strength, balance), personal factors (i.e., comorbidities, demographic information) and amputation specific variables (i.e., time since amputation, cause of amputation, level of amputation) were able to predict performance on the six-minute walk test, a measure of activity limitation, in individuals with lower limb amputation. A total of 72 individuals with lower limb amputation ranging in age from 21-83 were tested for balance, limb muscle strength and function. Medical comorbidities were recorded and activity limitation was measured using the six-minute walk test. Data were analyzed and multivariate relationships were examined using multiple linear regression. Impairment variables of strength, balance, subject demographics, time since amputation, cause of amputation and level of amputation were all significant predictors and explained 72% of the variance in the outcome variable. Strength of the hip extensors was the strongest predictor, accounting for 30.9% of the total variance. Multiple factors impact six minute walk scores in individuals with lower limb amputation. Impairments in hip strength and balance appear to be the two most significant. The findings of this study support the use of the six-minute walk test to underscore impairments of the musculoskeletal system that can affect ambulation ability in the amputee.

Gait Disorders and Falls

Since approximately 30% of persons over the age of 65 fall each year, prevention of falls is a very important topic. Gait disorders and diminished ability to walk safely are associated with an increased risk of falling. In older adults, falls commonly lead to injuries, institutionalization, and early death. The resultant decline in activities of daily living further contributes to loss of mobility and independence. Gait analysis using the dual-task paradigm (e.g., walking and carrying a cup of tea) offers a sensible tool for detecting older persons prone to falling. Changes in gait patterns due to simultaneously performing a secondary attention-demanding task are interpreted as interference by competing demands for attentional resources in gait control. Exercise interventions such as Jaques-Dalcroze eurhythmics address these attentional properties and aim to decrease such interference. To fully stress physical capacities in older adults, not only does automaticity of walking have to be trained, but also simultaneous performance of additional tasks. Exercise interventions for fall prevention should focus on developing basic skeletal muscle strength as a prerequisite to training gait automaticity in dual or multiple task situations. Recommendations for further research center on new approaches to combine exercises with additional tasks to improve gait and functionality in older adults.

Episodes of falling among elderly people: a systematic review and meta-analysis of social and demographic pre-disposing characteristics

CONTEXT

The multifactorial nature of falls among elderly people is well-known. Identifying the social-demographic characteristics of elderly people who fall would enable us to define the typical profile of the elderly who are at risk of falling.

OBJECTIVE

We aimed to isolate studies in which the social-demographic risk factors for falls among the elderly have been evaluated and to carry out a meta-analysis by combining the results of all of these selected studies.

METHOD

We did a systematic literature review using the key words "accidental fall / numerical data" and "risk factors." Inclusion criteria entailed the selection of articles with the following characteristics: population of subjects aged 60 years or over, falls that took place in everyday life, and social-demographic risk factors for falls.

RESULTS

3,747 indexed articles published between 1981 and 2007 were identified, and 177 studies with available data were included, of which 129 had data on social-demographic risk factors for falls. Difficulties in activities of daily living (ADL) or in instrumental activities of daily living (IADL) double the risk of falling: The OR and 95% Cl were 2.26 (2.09, 2.45) for disturbance ADL and 2.10 (1.68, 2.64) for IADL. The OR and 95% Cl for Caucasians were 1.68 (0.98 - 2.88) and 0.64 (0.51 - 0.80) for Hispanics. In the subgroup of patients older than eighty, being married protected people from falling with an OR and 95% Cl =0.68 (0.53 - 0.87).

CONCLUSION

Defining factors that create a risk of falling and protect elderly people from falls using social-demographic characteristics lets us focus on an "at risk" population for which a specific program could be developed.

Gender differences in dual task gait performance in older adults

Although attention-dividing dual tasks hinder gait performance in older persons, gender differences in gait have not been examined. The purpose of this study was to examine whether gait performance differs between older men and women during dual task walking. A total of 44 healthy adults (20 men and 24 women) aged 65 years or older participated in the study. Participants walked under normal and dual task (backward spelling) conditions at self-selected speeds. Mean gait speed and stride-to-stride variability in gait speed were quantified with GAITRite( ®) instrumentation. Whereas gait speed decreased and variability in gait speed increased in both groups during dual task walking, men walked with greater variability during dual task walking than did women. The magnitude of the increase in variability in gait speed observed in men indicates that stride-to-stride variability in gait speed during dual task walking requires more investigation as a potential risk factor for falls in older men.

Multidimensional exercise for people with Parkinson's disease: A case report

The primary impairments associated with Parkinson's disease occur in combination with the secondary, preventable effects of immobility. A community-based fitness program may help increase activity and maintain function in people in the early or middle stages of the disease. This article describes a unique program designed to reduce fall risk and promote independent exercise for people with Parkinson's disease. Two 66-year-old males, both community ambulators and in early or middle stages of Parkinson's disease, participated in 3 months of various physical activities. Group balance classes were held twice weekly during the first month, participants joined a fitness center and self-directed their exercise program during the second month, and group Tai Chi classes were held twice weekly during the third month. At conclusion of the program, participants were given suggestions for continued physical fitness activities. After the 3-month program, improvements were noted for both individuals in functional reach, Timed Up and Go, and Berg Balance scores. Both participants continued to exercise regularly for at least 8 months following the program. Two individuals with Parkinson's disease demonstrated improvement in their balance test performance over a 3-month period. Perhaps most importantly, these participants independently continued exercising after completing this program.

A new treatment programme to improve balance in elderly people--an evaluation of an individually tailored home-based exercise programme in five elderly women with a feeling of unsteadiness

PURPOSE

The aim of this study was to evaluate an individually tailored home-based exercise programme of balance in the elderly. The aim was also to examine if the degree of confidence of a person in performing common daily activities without falling could be influenced by training and if there were any relations between different physical factors and balance as well as between the degree of confidence in performing common daily activities without falling and balance.

METHOD

A multiple baseline design in a single case format was used and five women were included in the study. These five women trained by walking outdoors for six weeks, they trained neck rotation isolated and integrated in activities for 4 weeks and performed an individual balance programme for 2 weeks.

RESULTS AND CONCLUSIONS

The results showed that four of the five women had improved their balance and increased their degree of confidence in performing common daily activities without falling. The improved balance could be related to the increased activity level through walking outdoors. The treatment programme can be a useful model for physiotherapists in their work with balance problems in elderly people.

Predicting the probability of falls in community dwelling persons with brain injury: A pilot study

PRIMARY OBJECTIVES

To determine the usefulness of select balance and functional mobility measures in predicting fall risk in community dwelling persons with brain injury (BI) and to develop a model to quantify fall risk.

RESEARCH DESIGN

An exploratory pilot study to predict fall risk in persons with BI. Non-manipulated independent variable was fall status with two levels, non-faller and faller. Dependent variables were scores on the Berg Balance Scale (BBS), the Dynamic Gait Index (DGI) and the Falls Efficacy Scale (FES); age, gender, supervision required and assistive device use.

METHODS AND PROCEDURES

Twenty-six participants recruited from support groups and community re-entry programmes were divided into two groups, fallers and non-fallers. The FES, BBS and DGI were administered.

MAIN OUTCOMES AND RESULTS

T-tests and chi-square tests revealed between group differences for age, FES, BBS, DGI and assistive device use. Spearman's rho statistic showed moderate relationships among the variables, FES, BBS, DGI and assistive device use. Logistic regression determined the DGI to best predict fall risk.

CONCLUSIONS

This study developed a predictive model that could be used by therapists to determine an individual's fall risk in the home or outpatient settings. Assessing risk allows therapists to identify individuals who would benefit from intervention designed to improve balance and gait ability, possibly preventing future falls and a second head injury.

Dizziness after traumatic brain injury: Overview and measurement in the clinical setting

Traumatic brain injury (TBI) may result in a variety of cognitive, behavioural and physical impairments. Dizziness has been reported in up to 80% of cases within the first few days after injury. The literature was reviewed to attempt to delineate prevalence of dizziness as a symptom, impairments causing dizziness, the functional limitations it causes and its measurement. The literature provides widely differing estimates of prevalence and vestibular system dysfunction appears to be the best reported of impairments contributing to this symptom. The variety of results is discussed and other possible causes for dizziness were reviewed. Functional difficulties caused by dizziness were not reported for this population in the literature and review of cognitive impairments suggests that existing measurement tools for dizziness may be problematic in this population. Research on the functional impact of dizziness in the TBI population and measurement of these symptoms appears to be warranted.

A lower-limb training program to improve balance in healthy elderly women using the T-bow device

Ageing impairs balance, which increases the risk of falls. Fall-related injuries are a serious health problem associated with dependency and disability in the elderly and results in high costs to public health systems. This study aims to determine the effects of a training program to develop balance using a new device called the T-Bow. A total of 28 women > 65 years were randomly assigned to an experimental group (EG) (n = 18; 69.50 [0.99] years), or a control group (CG) (n = 10; 70.70 [2.18] years). A program for lower limbs was applied for 8 weeks using 5 exercises on the T-Bow: squat, lateral and frontal swings, lunges, and plantarflexions. The intensity of the exercises was controlled by time of exposure, support base, and ratings of perceived exertion. Clinical tests were used to evaluate variables of balance. Static balance was measured by a 1-leg balance test (unipedal stance test), dynamic balance was measured by the 8-foot-up-and-go test, and overall balance was measured using the Tinetti test. Results for the EG showed an increase of 35.2% in static balance (P < 0.005), 12.7% in dynamic balance (P < 0.005), and 5.9% in overall balance (P > 0.05). Results for the CG showed a decline of 5.79% in static balance (P > 0.05) but no change in the other balance variables. Thus the data suggest that implementing a training program using the T-Bow could improve balance in healthy older women.

Fear of Falling among Elderly Patients with Dizziness and Syncope in a Tilt Setting

Les objectifs de cette étude étaient de mesurer la prévalence de la crainte de tomber chez les patients âgés de plus de 60 ans à cause d’étourdissements, de chutes et de syncopes et d’analyser les facteurs de risque que l’on associe à ce syndrome, y compris les données provenant du test d’inclinaison. Cette étude transversale a inclus 200 patients qui ont été dirigés vers une clinique gériatrique externe spécialisée dans les étourdissements, les chutes et les syncopes. Le premier résultat mesuré a été la proportion de patients qui ont expérimenté la crainte de tomber (oui ou non) et si cette crainte causait une restriction au moment de sortir seuls ou d’effectuer les activités de la vie quotidienne. La crainte de tomber est apparue chez 50 pour cent des patients de cette population. Parmi eux, 44 pour cent avaient cessé de sortir seuls et 10 pour cent avaient cessé d’effectuer les activités de base de la vie quotidienne. Chez les patients de 75 ans et plus, les étourdissements à répétition, la dépression et les symptômes ressentis lorsqu’ils se lèvent ont été des facteurs associés à la crainte de tomber. Le fait d’avoir subi des chutes au préalable n’a pas été un facteur associé.

WITHDRAWN: Interventions for preventing falls in elderly people

BACKGROUND

Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care).

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 19), CINAHL (1982 to April 2003), The National Research Register, Issue 2, 2003, Current Controlled Trials (www.controlled-trials.com accessed 11 July 2003) and reference lists of articles. No language restrictions were applied. Further trials were identified by contact with researchers in the field.

SELECTION CRITERIA

Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or falls. Trials reporting only intermediate outcomes were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate.

MAIN RESULTS

Sixty two trials involving 21,668 people were included.Interventions likely to be beneficial:Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 0.60, 95%CI 0.50 to 0.73) A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98) Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 0.66, 95% CI 0.54 to 0.81) Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -5.20, 95%CI -9.40 to -1.00) A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). Interventions of unknown effectiveness:Group-delivered exercise interventions (9 trials, 1387 participants) Individual lower limb strength training (1 trial, 222 participants) Nutritional supplementation (1 trial, 46 participants) Vitamin D supplementation, with or without calcium (3 trials, 461 participants) Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants) Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants) Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants) Home hazard modification for older people without a history of falling (1 trial, 530 participants) Hormone replacement therapy (1 trial, 116 participants) Correction of visual deficiency (1 trial, 276 participants).Interventions unlikely to be beneficial:Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants).

AUTHORS' CONCLUSIONS

Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.

Prevention of slip-related backward balance loss: the effect of session intensity and frequency on long-term retention

OBJECTIVE

To examine the effects of session intensity (number of slip exposures) and frequency on the retention of acquired adaptation for prevention of backward balance loss after repeated-slip training.

DESIGN

A 4-group, randomized, and controlled study.

SETTING

Biomechanics research laboratory.

PARTICIPANTS

Healthy young subjects (N=46; 21 men).

INTERVENTIONS

Twenty-four subjects experienced a high-intensity session of 24 repeated right-side slips; 12 received additional single-slip sessions at a frequency of 1 week, 2 weeks, and 1 month, whereas the rest got no ancillary training. Another 24 subjects received a low-intensity initial session of a single slip; 12 received the same high-frequency ancillary training, whereas the rest got none. All groups were retested with a single slip 4 months after the first session.

MAIN OUTCOME MEASURES

The incidence of backward balance loss, gait stability, and limb support.

RESULTS

The high-intensity groups, irrespective of ancillary training, displayed similar improvements in all 3 outcome measures. Remarkably, the low-intensity group receiving ancillary training also significantly improved in all measures, with retention comparable to that observed in the other 2 groups. A single-slip exposure without ancillary sessions was insufficient to yield a longer-term effect.

CONCLUSIONS

Frequent ancillary sessions may be unnecessary for slip-related fall prevention up to 4 months if the initial session intensity is sufficient. Furthermore, the minimum of a single slip may be as effective if the subject is exposed to frequent ancillary sessions.

Rehabilitation for older people in long-term care

BACKGROUND

Examination of demographic trends indicates that the worldwide population is progressively ageing. It is expected that such longevity will be associated with an increase in morbidity and demand for long-term residential care. This review examines whether there is evidence that physical rehabilitation benefits older people in long-term care.

OBJECTIVES

To evaluate physical rehabilitation interventions directed at improving physical function among older people in long-term care.

SEARCH STRATEGY

We searched the trials registers of the following Cochrane entities: Stroke Group (searched March 2008), Effective Practice and Organisation of Care Group (searched August 2006) and the Rehabilitation and Related Therapies Field, (searched August 2006). In addition, we searched 17 relevant electronic databases including the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3), MEDLINE (1966 to 1 October 2007), EMBASE (1980 to 1 October 2007), CINAHL (1982 to 1 October 2007), AMED (1985 to 1 October 2007), PsycINFO (1967 to 1 October 2007) and PEDro (searched 1 October 2007). We also searched trials and research registers and conference proceedings, checked reference lists, and contacted authors and researchers in the field and other relevant Cochrane entities.

SELECTION CRITERIA

Randomised studies comparing a rehabilitation intervention designed to maintain or improve physical function with either no intervention or an alternative intervention in older people aged 60 years or over who have permanent long-term care residency.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Forty-nine trials involving 3611 participants were included. On average, 74 (range 12 to 468) participants were randomised into trials at baseline. Of studies which reported age, the overall mean age was 82 years (range of 69 to 89). Most interventions lasted less than 20 weeks, and comprised approximately three 30 to 45-minute group sessions per week. Twelve trials conducted post-intervention follow up (maximum one year). Most often a 'usual care' control group was used, but social activity and alternative interventions also featured. The primary outcome, daily activity restriction, was reported by 38 trials. A range of secondary outcomes are also reported.

AUTHORS' CONCLUSIONS

Provision of physical rehabilitation interventions to long-term care residents is worthwhile and safe, reducing disability with few adverse events.Most trials reported improvement in physical condition. However, there is insufficient evidence to make recommendations about the best intervention, improvement sustainability and cost-effectiveness.

The Relationship between Age and Change in Physical Functions after Exercise Intervention. Trainability of Japanese Community-Dwelling Older Elderly

The purposes of this study were to evaluate the relationship between age and changes in physical measurements after exercise intervention and to investigate the trainability of the older elderly. Two hundred seventy-six community-dwelling people aged 60 years and older practiced exercise intervention for 3 months. The measurements of physical functions were one-legged standing with eyes open and closed (OLS-O, OLS-C), functional reach test (FR), timed up and go test (TUG), maximum walking velocity, flexibility, and muscle strength. We evaluated the associations between age and the changes in these physical measurements. All measurements except for OLS-C significantly improved after intervention. The magnitude of the changes in hand-grip strength and FR after the intervention showed weak negative correlations with the subject's age, but other measurements showed no correlations. In addition, there were no differences between younger elderly persons and older elderly persons with regard to changes in any measurements. These results suggested that the exercise intervention we applied could improve physical fitness in community-dwelling older people, regardless of their age. The older elderly were comparable to the younger elderly in trainability to improve physical fitness.