Using machine learning algorithms to detect fear of falling in people with multiple sclerosis in standardized gait analysis

INTRODUCTION

Multiple sclerosis (MS) is the most common chronic inflammatory disease of the central nervous system. The progressive impairment of gait is one of the most important pathognomic symptoms which are associated with falls and fear of falling (FOF) in people with MS (pwMS). 60 % of pwMS show a FOF, which leads to restrictions in mobility as well as physical activity and reduces the quality of life in general. Therefore, early detection of FOF is crucial because it enables early implementation of rehabilitation strategies as well as clinical decision-making to reduce progression. Qualitative and quantitative evaluation of gait pattern is an essential aspect of disease assessment and can provide valuable insights for personalized treatment decisions in pwMS. Our objective was to identify the most appropriate clinical gait analysis methods to identify FOF in pwMS and to detect the optimal machine learning (ML) algorithms to predict FOF using the complex multidimensional data from gait analysis.

METHODS

Data of 1240 pwMS was recorded at the MS Centre of the University Hospital Dresden between November 2020 and September 2021. Patients performed a multidimensional gait analysis with pressure and motion sensors, as well as patient-reported outcomes (PROs), according to a standardized protocol. A feature selection ensemble (FS-Ensemble) was developed to improve the classification performance. The FS-Ensemble consisted of four filtering methods: Chi-square test, information gain, minimum redundancy maximum relevance and ReliefF. Gaussian Naive Bayes, Decision Tree, k-Nearest Neighbor, and Support Vector Machines (SVM) were used to identify FOF.

RESULTS

The descriptive analysis showed that 37 % of the 1240 pwMS had a FOF (n = 458; age: 51 ± 16 years, 76 % women, median EDSS: 4.0). The FS-Ensemble improved classification performance in most cases. The SVM showed the best performance of the four classification models in detecting FOF. The PROs showed the best F1 scores (Early Mobility Impairment Questionnaire F1 = 0.81 ± 0.00 and 12-item Multiple Sclerosis Scale F1 = 0.80 ± 0.00).

CONCLUSION

FOF is an important psychological risk factor associated with an increased risk of falls. To integrate a functional early warning system for fall detection into MS management and progression monitoring, it is necessary to detect the relevant gait parameters as well as assessment methods. In this context, ML strategies allow the integration of gait parameters from clinical routine to support the initiation of early rehabilitation measures and adaptation of course-modifying therapeutics. The results of this study confirm that patients' self-assessments play an important role in disease management.

Are history of falls and fear of falling associated with mobility in community-dwelling older adults?

Evidence has suggested that a history of falls and fear of falling (FOF) are associated with reduced mobility among older adults. Although many studies have explored the association between the history of falls and FOF in the context of decreased mobility, most have had small sample sizes, limiting the generalizability of the results. Therefore, this study sought to contribute to the body of knowledge around these constructs to further support the previous findings. To investigate the association between a history of falls and FOF with low mobility in community-dwelling older adults. This cross-sectional study included 308 older adults (69.9 ± 7.1 years, 57.8% female). The Timed Up and Go (TUG) test was used to classify mobility limitations in participants and the Falls Efficacy Scale-International - Brazil was used to quantify FOF. Participants were also asked if they had fallen in the previous 12 months. Multivariable logistic regression was used. The prevalence rates of a history of falls and FOF were 32.7 and 48.4%, respectively. Older adults with a history of falls and FOF had 2.20 (95%CI: 1.20; 4.02) and 3.80 (95%CI: 1.90; 7.58) greater odds of presenting low mobility than older adults without these health problems, respectively. History of falls and FOF are associated with higher odds of low mobility in community-dwelling older adults. Therefore, it is of the utmost importance to introduce public health programs aimed at preventing falls in older adults to reduce possible adverse health outcomes, including low mobility.

Are Middle- or Older-Aged Adults With a Spinal Cord Injury Engaging in Leisure-Time Physical Activity? A Systematic Review and Meta-Analysis

Objectives

To investigate the amount of Leisure-Time Physical Activity (LTPA) that people over 45 years with a spinal cord injury (SCI) performed and to determine the frequency, duration, intensity, and modality of LTPA performed.

Data Sources

We searched 5 major electronic databases (CINAHL, SCOPUS, EMBASE, MEDLINE, and PubMed) from inception to March 2023.

Study Selection

Cross-sectional, longitudinal studies and control arm of controlled trials that assessed LTPA in participants over 45 years old, with a SCI. We included 19 studies in the review and 11 in the meta-analysis.

Data Extraction

We followed the PRISMA checklist for Systematic Reviews. Two review authors independently assessed the risk of bias and extracted data on participants' demographics, injury characteristics, and LTPA participation of the included studies. Risk of bias was assessed using the Joanne Briggs Institute critical appraisal tool for cross-sectional studies. Any conflicts were resolved by a third author.

Data Synthesis

We found considerable variability in LTPA participation in adults 45 years and older with SCI. An estimated 27%-64% of participants did not take part in any LTPA. A random effects meta-analysis model was completed for studies that reported total or moderate-to-heavy LTPA scores in minutes per week. Overall, participants (n=1675) engaged in 260 [205;329] (mean [95% CI]) mins/week of total LTPA. Those participating in moderate-heavy intensity LTPA (n=364) completed 173 [118; 255] (mean [95% CI]) mins/week. LTPA modalities included walking, wheeling, hand-cycling, basketball, and swimming, among others.

Conclusions

While many older adults with SCI seem to be meeting the recommended weekly physical activity volume, many still remain sedentary. There was significant variation in reporting of frequency, intensity, and duration of LTPA and reporting on modality was limited. Because of differences in reporting, it was challenging to compare results across studies. Data constraints prevented subgroup analysis of LTPA disparities between paraplegia and tetraplegia.

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

Anxiety in Response to Sustaining Spinal Cord Injuries and Disorders: When Should Clinicians Be Concerned?

OBJECTIVE

To recommend a cut-off score for the brief 2-item Generalized Anxiety Disorder (GAD-2) measure for persons with spinal cord injuries/disorders (PwSCI/D) and to estimate anxiety occurrence within this population using the full 7-item Generalized Anxiety Disorder (GAD-7).

DESIGN

Multicenter retrospective analyses.

SETTING

One inpatient rehabilitation center and 2 community sites for PwSCI/D.

PARTICIPANTS

PwSCI/D 18 years or older (N=909) were included for analysis using retrospectively collected GAD-2 and GAD-7 data.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Occurrence of anxiety symptoms were compared using cut-off scores of ≥8 and ≥10 on the GAD-7. A cut-off score recommendation for the GAD-2 was determined using ROC curve, and sensitivity and specificity analyses.

RESULTS

Occurrence of anxiety symptoms was 21% using a GAD-7 cut-off of ≥8 and 15% using a cut-off of ≥10. Analyses indicated optimal sensitivity for a GAD-2 score of ≥2 when a GAD-7 cut-off of ≥8 was used.

CONCLUSIONS

Anxiety occurrence is elevated among PwSCI/D compared with the general population. For PwSCI/D, it is recommended that a cut-off score of ≥2 is used for the GAD-2 to maximize sensitivity and that a threshold of ≥8 is used for the GAD-7 to ensure the maximum number of individuals presenting with symptoms of anxiety are recognized for diagnostic interview. Study limitations are discussed.

Measurement properties of the Falls Efficacy Scale-International (FES-I) in persons with late effects of polio: a cross-sectional study

BACKGROUND

Fear of falling (FoF) is very common in persons with late effects of polio (LEoP). An internationally recognized rating scale to assess FoF is the Falls Efficacy Scale-International (FES-I). Yet, there is limited knowledge about its measurement properties in persons with LEoP.

OBJECTIVE

To investigate the measurement properties of FES-I (16-item version) and short FES-I (7-item version) in persons with LEoP.

DESIGN

Explorative factor analysis and Rasch model analysis of cross-sectional data.

SETTING

University Hospital.

PARTICIPANTS

A total of 321 persons with LEoP (mean age 70 ± 10 years, 173 women).

MAIN OUTCOME MEASUREMENT

The FES-I and short FES-I, comprising four response options about concerns of falling ranging from 1 (not at all concerned) to 4 (very concerned).

METHODS

Data were collected by a postal survey. First, a factor analysis was performed to investigate unidimensionality of the scale. Thereafter, a Rasch model analysis was used to further analyze the measurement properties of FES-I and short FES-I, such as local dependency, targeting, hierarchical order of items, Differential Item Functioning (DIF), response category functioning and reliability (Person Separation Index, PSI). Raw score transformation to interval measurements was also performed.

RESULTS

The factor analysis revealed that FES-I was unidimensional, even though the Rasch analysis showed some misfit to the Rasch model and local dependency. Targeting for FES-I and short FES-I was somewhat suboptimal as the participants on average reported less FoF than expected. A negligible gender DIF was found for two items in FES-I and for one item in short FES-I. Reliability was high (PSI >0.86), and the response category thresholds worked as intended for both FES-I, and short FES-I.

CONCLUSION

The FES-I and the short FES-I have sufficient measurement properties in persons with LEoP. Both versions can be used to assess fear of falling in this population. This article is protected by copyright. All rights reserved.

Social Support, General Self-Efficacy, Fear of Falling, and Physical Activity Among Older Adults in a Middle-Income Country

Objectives: To investigate the levels and interrelationships between fear of falling (FOF), physical activity (PA), social support (SS), and general self-efficacy (GSE) among older adults in a Nigerian community. Methods: This was a cross-sectional survey involving 100 older adults (65.0% females; mean age = 74.25 ± 8.01 years) consecutively recruited from Nnewi community. Participants’ FOF, PA, GSE, and SS were assessed using standardized questionnaires. Data were analyzed using descriptive statistics, Spearman rank order correlation, and structural equation modeling at a 0.05 level of significance. Results: The participants’ mean FOF, PA, GSE, and SS scores were 15.22 ± 7.43 (fearful), 114.76 ± 90.18 (low), 21.64 ± 8.25 (low) and 5.72 ± 1.19 (high) respectively. There were significant correlations between each pair of FOF, PA, GSE, and SS scores of the participants (p < .05). FOF and GSE were significant predictors of PA while GSE and SS were significant predictors of FOF. Conclusion: FOF and SS were high while PA and GSE were low in this sample of Nigerian older adults. Significant correlations existed between FOF, SS, GSE, and PA, with FOF and GSE being predictors of PA while GSE and SS significantly predicted FOF. Measures should be geared towards reducing FOF and improving PA, GSE, and SS in this group.

Methods and Strategies for Reconditioning Motor Output and Postural Balance in Frail Older Subjects Prone to Falls

In frail older subjects, the motor output of the antigravity muscles is fundamental in resisting falls. These muscles undergo accelerated involutions when they are inactive and the risk of falling increases during leisure and domestic physical activity. In order to reduce their risk of falling, frail older subjects limit their physical activities/exercises. The problem is that the less they exercise, the less they are able to exercise and the greater the risk in exercising. Hence, a vicious circle sets up and the antigravity muscles inevitably continue to deteriorate. This vicious circle must be broken by starting a reconditioning program based on developing the strength of antigravity muscles (especially lower-limb muscles). To begin with, for each increase in muscle strength, postural balance is improved. Once this increase reaches the threshold beyond which postural balance no longer improves, it seems appropriate to implement exercises aimed at concomitantly improving motor output and postural balance in order to counteract or even reverse the involution process of the postural balance system. Methods and strategies toward this end are proposed in this present communication. However, the transfer effects between strength increase and postural balance ability are not yet totally known and future research should evaluate the relationship between muscle strength and postural balance throughout rehabilitation programs (i.e., program follow-ups) in frail older subjects in order to advance knowledge of this relationship.

Anwendung von Wearables bei Multipler Sklerose

Wearables sind mit Sensoren ausgestattete Geräte oder Funktionskleidung, welche im Bereich der Multiplen Sklerose bis dato v. a. zur Messung von Bewegung in Form von Accelerometern in Verwendung sind. Im Gegensatz zu technisch aufwendigen Ganganalysesystemen und neurologischen Funktionstests können solche Wearables im Alltag einfach eingesetzt werden und bieten die Möglichkeit Ausmaß, Geschwindigkeit und Dauer von Bewegung auch über längere Zeiträume zu erfassen. Zusätzlich können auch spezifischere Parameter wie Schrittlänge, Bewegungsumfang einzelner Gelenke sowie physiologische und pathologische Bewegungsmuster dokumentiert werden. Die durch Accelerometer erhobenen Informationen korrelieren gut mit der körperlichen Aktivität im Alltag, kardiorespiratorischen Biomarkern der Bewegung, dem Ausmaß der Behinderung aber auch mit technisch aufwendigen Ganganalysen.

Insofern werden Wearables in Zukunft eine immer wichtigere Rolle spielen, wenn es darum geht, die Beweglichkeit als einen der wichtigsten Faktoren der Lebensqualität von Personen mit MS im Alltag reliabel und einfach zu messen.

Effectiveness of Physical Therapy Interventions in Reducing Fear of Falling Among Individuals With Neurologic Diseases: A Systematic Review and Meta-analysis

OBJECTIVE

To summarize the effectiveness of physical therapy interventions to reduce fear of falling (FOF) among individuals living with neurologic diseases.

DATA SOURCES

PubMed, Physiotherapy Evidence Database, Scopus, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, and SportDiscuss were searched from inception until December 2019.

STUDY SELECTION

Clinical trials with either the primary or secondary aim to reduce FOF among adults with neurologic diseases were selected.

DATA EXTRACTION

Potential articles were screened for eligibility, and data were extracted by 2 independent researchers. Risk of bias was assessed by the Cochrane Risk of Bias tool for randomized controlled trials and the National Institutes of Health Quality Assessment Tool for pre-post studies. A meta-analysis was performed among trials presenting with similar clinical characteristics. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to rate the overall quality of evidence.

RESULTS

Sixty-one trials with 3954 participants were included in the review and 53 trials with 3524 participants in the meta-analysis. The included studies presented, in general, with a low to high risk of bias. A combination of gait and balance training was significantly more effective compared with gait training alone in reducing FOF among individuals with Parkinson disease (PD) (mean difference [MD]=11.80; 95% CI, 8.22-15.38; P<.001). Home-based exercise and leisure exercise demonstrated significant improvement in reducing FOF over usual care in multiple sclerosis (MS) (MD=15.27; 95% CI, 6.15-24.38; P=.001). No statistically significant between-groups differences were reported among individuals with stroke and spinal cord injury. The overall quality of evidence presented in this review ranges from very low to moderate according to the assessment with the GRADE approach.

CONCLUSIONS

Gait with lower limb training combined with balance training is effective in reducing FOF in individuals with PD. Also, home-based or leisure exercise is effective among individuals with MS. However, because of several limitations of the included studies, further research is needed to examine the effectiveness of FOF intervention among individuals with neurologic diseases.