Psychometric properties of four fear of falling rating scales in people with Parkinson's disease

Psychometric properties of the Brazilian-Portuguese version of the Falls Behavioral Scale in people with Parkinson's disease

PURPOSE

To verify the psychometric properties of the Brazilian-Portuguese version of the Falls Behavioral (FaB-Brazil) Scale in Parkinson's disease (PD).

MATERIAL AND METHODS

Participants (n = 96) were assessed by disease-specific, self-report and functional mobility measures. Internal consistency of the FaB-Brazil scale was evaluated using Cronbach's alpha and inter-rater and test-retest reliability using intraclass correlation coefficients (ICC). The standard error of measurement (SEM), minimal detectable change (MDC), ceiling and floor effects, and convergent and discriminative validity were evaluated.

RESULTS

Internal consistency was moderate (α = 0.77). Excellent inter-rater (ICC = 0.90; p < 0.001) and test-retest (ICC = 0.91; p < 0.001) reliability were found. The SEM was 0.20 and MDC was 0.38. Ceiling and floor effects were not found. Convergent validity was established by the positive correlations between the FaB-Brazil scale and age, modified Hoehn and Yahr, PD duration, Movement Disorders Society-Unified Parkinson's Disease Rating Scale, Motor Aspects of Experiences of Daily Living, Timed Up & Go and 8-item Parkinson's Disease Questionnaire, and negative correlations between the FaB-Brazil scale and community mobility, Schwab & England, and Activities-specific Balance Confidence scale. Females showed greater protective behaviors than males; recurrent fallers showed greater protective behaviors than non-recurrent fallers (p < 0.05).

CONCLUSIONS

The FaB-Brazil scale is reliable and valid for assessing people with PD.

The psychometric properties of the modified fear of falling avoidance behavior questionnaire in Parkinson's disease and older adults

Introduction

The Fear of Falling Avoidance Behavior Questionnaire (FFABQ) has good psychometric properties. However, we have recently modified the FFABQ (mFFABQ) to improve the clarity of the questions and Likert responses. This study aimed to examine the reliability and validity of this modified version in older adults and people with Parkinson's disease (PD).

Methods

A total of 88 participants, 39 with PD (age = 72.2 ± 9.5; 29 males, 10 females) and 49 older adults (age = 72.8 ± 5.0; 13 males, 36 females), answered the mFFABQ twice, separated by 1 week, for test-retest reliability. Construct validity was evaluated through correlational analyses with fall history, Activities-Specific Balance Confidence Scale (ABC), Berg Balance Scale (BBS), Timed Up and Go, 30-Second Sit to Stand, Sensory Organization Test, Zung Anxiety Scale, Beck Depression Inventory, Consequences of Falling Questionnaire (CoFQ), and average daily activity levels using an activity monitor.

Results

The mFFABQ had good overall test-retest reliability (intraclass correlational coefficient [ICC] = 0.822; older adult ICC = 0.781, PD ICC = 0.806). The mFFABQ correlated with fall history (r = -0.430) and exhibited high correlation with the ABC (rho = -0.804) and moderate correlations with CoFQ (rho = 0.582) and BBS (rho = -0.595). The mFFABQ also correlated with time stepping (rho = -0.298) and number of steps (rho = -0.358).

Conclusion

These results provide supportive evidence for the reliability and validity of the mFFABQ in older adults and people with PD, which supports its suitability as a clinical and research tool for the assessment of fear of falling avoidance behavior.

Balance telerehabilitation and wearable technology for people with Parkinson's disease (TelePD trial)

BACKGROUND

Balance impairments, that lead to falls, are one of the main symptoms of Parkinson's disease (PD). Telerehabilitation is becoming more common for people with PD; however, balance is particularly challenging to assess and treat virtually. The feasibility and efficacy of virtual assessment and virtual treatment of balance in people with PD are unknown. The present study protocol has three aims: I) to determine if a virtual balance and gait assessment (instrumented L-shape mobility test) with wearable sensors can predict a gold-standard, in-person clinical assessment of balance, the Mini Balance Evaluation Systems Test (Mini-BESTest); II) to explore the effects of 12 sessions of balance telerehabilitation and unsupervised home exercises on balance, gait, executive function, and clinical scales; and III) to explore if improvements after balance telerehabilitation transfer to daily-life mobility, as measured by instrumented socks with inertial sensors worn for 7 days.

METHODS

The TelePD Trial is a prospective, single-center, parallel-group, single-blind, pilot, randomized, controlled trial. This trial will enroll 80 eligible people with PD. Participants will be randomized at a 1:1 ratio into receiving home-based balance exercises in either: 1) balance telerehabilitation (experimental group, n = 40) or 2) unsupervised exercises (control group, n = 40). Both groups will perform 12 sessions of exercise at home that are 60 min long. The primary outcome will be Mini-BESTest. The secondary outcomes will be upper and lower body gait metrics from a prescribed task (instrumented L-shape mobility test); daily-life mobility measures over 7 days with wearable sensors in socks, instrumented executive function tests, and clinical scales. Baseline testing and 7 days of daily-life mobility measurement will occur before and after the intervention period.

CONCLUSION

The TelePD Trial will be the first to explore the usefulness of using wearable sensor-based measures of balance and gait remotely to assess balance, the feasibility and efficacy of balance telerehabilitation in people with PD, and the translation of balance improvements after telerehabilitation to daily-life mobility. These results will help to develop a more effective home-based balance telerehabilitation and virtual assessment that can be used remotely in people with balance impairments.

TRIAL REGISTRATION

This trial was prospectively registered on ClinicalTrials.gov (NCT05680597).

A systematic review and meta-analysis of the measurement properties of concerns-about-falling instruments in older people and people at increased risk of falls

BACKGROUND

The 16-item Falls Efficacy Scale International (FES-I) is widely used to assess concerns-about-falling. Variants include 7-item Short FES-I, 30-item Iconographical Falls Efficacy Scale (Icon FES) and 10-item short Icon FES. No comprehensive systematic review and meta-analysis has been conducted to synthesise evidence regarding the measurement properties of these tools.

OBJECTIVES

To conduct a systematic review and meta-analysis of the measurement properties of four FES-I variants.

METHODS

MEDLINE, Embase, CINAHL Plus, PsycINFO and Web of Science were searched systematically and articles were assessed for eligibility independently. The methodological quality of eligible studies was assessed using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. The quality of measurement properties was assessed using COSMIN criteria for good measurement properties. Where possible, meta-analysis was conducted; otherwise, narrative synthesis was performed. Overall certainty of evidence was rated using a modified Grading of Recommendations, Assessment, Development and Evaluation system approach.

RESULTS

The review included 58 studies investigating measurement properties of the four instruments. There was high-quality evidence to support internal consistency, reliability and construct validity of all instruments. Moderate- to high-certainty evidence suggests one-factor structure of FES-I with two underlying dimensions, one-factor structure of Short FES-I and two-factor structure of Icon FES. There was high-certainty evidence to support the responsiveness of FES-I, with further research needed for the other instruments.

CONCLUSION

There is evidence for excellent measurement properties of all four instruments. We recommend the use of these tools with healthy older people and people at a greater risk of falls due to conditions that might affect mobility and balance.

Validity and Reliability of the Thai Version of the Freezing of Gait Questionnaire in Individuals With Parkinson's disease

OBJECTIVE

To evaluate the validity and reliability of the Thai version of the Freezing of Gait Questionnaire (FOG-Q) in individuals with Parkinson's disease (PD).

METHODS

The FOG-Q was translated into Thai according to the standard process. Fifty-six individuals with PD participated in the study. The content validity was assessed using the content validity index (CVI). The construct validity was evaluated by correlating Thai FOG-Q with Thai version of the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) items 2.13 and 3.11, Thai version of the Falls Efficacy Scale-International (FES-I), Timed Up and Go test (TUG) and Berg Balance Scale (BBS) using Spearman's correlation coefficient (rS). The correlation between Thai FOG-Q and clinical characteristics, for example, duration of PD and modified Hoehn and Yahr (mH&Y) stage was evaluated. Internal consistency and test-retest reliability were evaluated with Cronbach's alpha (Cα) and intraclass correlation coefficient (ICC), respectively.

RESULTS

The Thai FOG-Q had high content validity (CVI=0.96). The mean FOG-Q score was 9.0±4.9. The construct validity showed a strong positive correlation with MDS-UPDRS item 2.13 (rS=0.81), and moderate correlations with MDS-UPDRS item 3.11, FES-I, and TUG (rS=0.42-0.60). A negative correlation with BBS was found (rS=-0.32). It had a moderate correlation with mH&Y stage (rS=0.40). The Thai FOG-Q had good internal consistency (Cα=0.87) with excellent test-retest reliability (ICC=0.91).

CONCLUSION

The Thai FOG-Q has excellent validity and reliability. It is a useful instrument for the evaluation of FOG in individuals with PD.

Psychometric Properties of the Falls Efficacy Scale-International, Cut-off Points, and Validating its Short Version Among Iranian Older People

Objectives

Older people have a fear of falling, which is far more difficult than falling itself. We measured the extent of this feeling using a short and valid Falls Efficacy Scale-International (FES-I) 7-item questionnaire for the aging community in Iran.

Methods

The present psychometric work deals with outlining the validation and translation of FES-I (short version) among 9117 Persian-speaking elderly people with a mean age of 70.2±8.3 years (54.1% female and 45.9% male) in July 2021. Investigations were performed on confirmatory factor analysis, exploratory factor analysis, internal consistency, and construct validity along with test-retest reliability, receiver operating characteristic analysis, inter-rater, and convergent validity.

Results

72.4% of the subjects were living alone, 92.9% required support in activities of daily living, and 93.0% experienced falling in the past two years. A one-factor solution was assigned by exploratory factor analysis for FES-I. Thus, this model was proved by the confirmatory factor analysis with valid fit indices. Based on Cronbach's alpha, intra-cluster correlation coefficient, and McDonald's omega (≥ 0.80), internal consistency was confirmed. The exact cut-off value was represented by the receiver operating characteristic analysis for male/female and between with/without fear of falling among older samples with higher measures of specificity and sensitivity. Moreover, a significant effect of age, aging in place, loneliness, hospitalization rate, frailty, and sense of anxiety (effect size ≥ 0.80, p ≤ 0.05) on fear of falls was detected using analysis of variance.

Conclusions

The psychometric properties of the original scale were preserved by the Persian version of FES-I seven items as a self-reported measure of fear of falling. It could be assuredly a measure in both community and clinical settings. The possible uses and limitations of the Iranian FES-I were also discussed.

Clinical Usefulness of Retropulsion Tests in Persons with Mild to Moderate Parkinson's Disease

People with Parkinson's disease (PwPD) have an increased risk for falls and near falls. They have particular difficulties with maintaining balance against an external perturbation, and several retropulsion tests exist. The Unified PD Rating Scale item 30 (UPDRS30) is the most common, involving an expected shoulder pull. Others recommend using an unexpected shoulder pull, e.g., the Nutt Retropulsion Test (NRT). We aimed to evaluate the clinical usefulness of these tests for detecting future fallers. By using two different golden standards related to self-reported prospective falls and near falls over 6 months following two different time points with 3.5 years between, we estimated sensitivity/specificity, Youden index, predictive values, and likelihood ratios for each test. The different time points yielded a different prevalence of falls and near falls, as well as different predictive values. When comparing the performance of the NRT and UPDRS30 for detecting future fallers, we found that the NRT consistently performed better than UPDRS30. However, neither test exhibited optimal performance in terms of predictive values and associated likelihood ratios. Our findings speak against using either of these tests as a single assessment for this purpose and support previous recommendations of using a multifactorial approach when targeting balance problems in PwPD.

Telerehabilitation for Individuals with Parkinson's Disease and a History of Falls: A Pilot Study

Purpose: Falls among persons with Parkinson's disease (PD) decrease health-related quality of life (HRQOL) and are a risk factor for hospitalization. Although physiotherapy can decrease falls and improve functional capacity, people living in remote areas have limited access to such services. This pilot study aimed to document the feasibility of a physiotherapy telerehabilitation intervention for patients with PD and to estimate the change over time in functional capacity, HRQOL, and the rate of falls. Methods: Eleven persons with PD participated in an 8-week physiotherapy telerehabilitation intervention. We assessed feasibility by computing retention rate and assiduity, number of undesirable health events, and technical problems. We assessed functional capacity, HRQOL, and falls at baseline, after the intervention, and at the 3-month follow-up. Results: Retention rate and assiduity were 91% and 100%. We resolved all technical problems (21.9% of sessions). No undesirable health events occurred. Point estimates suggest an improvement in functional capacity (Mini-BESTest) and HRQOL. Forty percent of participants fell during the intervention phase. Conclusion: Physiotherapy telerehabilitation is feasible and safe for persons with PD. Improvements in functional capacity and HRQOL must be confirmed with an appropriate design.

A cross-sectional study of walking, balance and upper limb assessment scales in people with cervical dystonia

Cervical dystonia (CD) is a neurological movement disorder causing the neck to move involuntarily away from the neutral position. CD is a network disorder, involving multiple brain areas and, therefore, may impair movement in parts of the body other than the neck. This study used clinical assessments to investigate walking, balance and upper limb function (UL) in people with CD; the reliability of scoring these assessments and examined for relationship between CD severity, usual exercise and clinical assessments. We conducted a prospective observational cohort study of participants with isolated, focal, idiopathic CD. Participants were assessed by experienced physiotherapists and completed three questionnaires and eight clinical assessments of fear of falling, balance confidence, walking, balance, UL function and usual exercise. Results were compared to published data from healthy adults and other neurological populations. Twenty-two people with mild to moderate CD participated. Fear of falling, gross UL function and usual exercise were worse in people with CD compared with healthy adults, while walking, balance and distal UL function were similar to healthy populations. All assessments were reliably performed by physiotherapists, and we found no correlations between the severity of dystonia or usual exercise and performance on the physical assessments. Routine performance of clinical assessment of walking and balance are likely not required in people with mild to moderate CD; however, fear of falling and gross upper limb function should be assessed to determine any problems which may be amenable to therapy.

Assessing avoidance behavior due to concerns about falling: Psychometric properties of the FES-IAB in a sample of older adults of an online panel

BACKGROUND AND OBJECTIVES

The Falls Efficacy Scale-International (FES-I) and its shorter version (Short FES-I) are widely used measures of concerns about falling (CaF) and have consistently demonstrated good psychometric properties. The FES-I Avoidance Behavior (FES-IAB) and Short FES-IAB were developed to gain insight into activity avoidance due to CaF and add a question to each item of the FES-I and Short FES-I. The objective was to assess the psychometric properties of the FES-IAB and Short FES-IAB in community-dwelling older people.

METHODS

A community-dwelling sample of the Dutch population (n = 744) aged 60 and over completed the FES-IAB twice with one month in between (with a follow-up response rate of 92.2%).

RESULTS

Confirmatory factor analysis confirmed the unidimensionality of the FES-IAB, with high factor loadings and very good fit. The scale correlated strongly with the FES-I, and moderately with ADL disability and 1-item questions of activity avoidance and CaF. The FES-IAB discriminated well between groups based on age, sex, fall history. Internal consistency and test-retest reliability were high (Cronbach's alpha: 0.92, intraclass correlation coefficient: 0.85). FES-IAB scores were positively skewed; 343 people (46.1%) had the lowest possible score of 16. The psychometric properties of the Short FES-IAB were comparable. No problems were identified with the feasibility of the FES-IAB and Short FES-IAB.

DISCUSSION

Overall, the FES-IAB and Short FES-IAB demonstrated good psychometric properties in assessing activity avoidance due to CaF in community-dwelling older people. These instruments may help researchers and clinicians to investigate the behavioral consequences of CaF.

Effectiveness of a dance-physiotherapy combined intervention in Parkinson's disease: a randomized controlled pilot trial

BACKGROUND

Physical therapies have been recommended as crucial components in Parkinson's disease (PD) rehabilitation.

OBJECTIVE

The study aims to examine the effectiveness of a new dance-physiotherapy combined intervention, called DArT method, in mild PD patients.

METHODS

A prospective, randomized, single-blind, controlled pilot trial was conducted on 38 mild PD patients under dopaminergic therapy. The intervention consisted in an add-on protocol: the control group received 1 h of conventional physiotherapy followed by 1 h of conventional physiotherapy each day, 3 times a week, for 5 weeks. The experimental group received 1 h of conventional physiotherapy followed by 1 h of dance class each day, 3 times a week, for 5 weeks. The week before and after the training period, patients were assessed for motor, cognitive, emotional, and sensory components of PD, with MDS-UPDRS-III as primary outcome measure.

RESULTS

DArT method was associated with a 2.72-point reduction in the post-treatment MDS-UPDRS-III total score compared to control group (95% CI - 5.28, - 0.16, p = 0.038, d = 0.71), and with a 2.16-point reduction in the post-treatment MDS-UPDRS-III upper body subscore (95% CI - 3.56, - 0.76, p = 0.003, d = 1.02). Conversely, conventional physiotherapy program was associated with a 2.95-point reduction in the post-treatment trait anxiety compared to the experimental group (95% CI 0.19, 5.71, p = 0.037, d = 0.70). Withdrawal and fall rates were equal to 0% in both groups.

CONCLUSION

DArT method showed to be safe, well accepted, and more effective than an intensive program of conventional physiotherapy in improving motor impairment in mild PD.

Predictive Factors of Fall-Related Activity Avoidance in People With Parkinson Disease-A Longitudinal Study With a 3-Year Follow-up

BACKGROUND AND PURPOSE

Knowledge of predictive factors can foster the development of preventive approaches. This study examined how prevalence and severity of fall-related activity avoidance evolve over a 3-year period in people with Parkinson disease (PD). A specific aim was to identify predictive factors of fall-related activity avoidance (ie, modified Survey of Activities and Fear of Falling in the Elderly [mSAFFE] scores) after 3 years.

METHODS

The sample included 151 people with PD (mean [SD] age: 68 [8.8] years). The mSAFFE score was the dependent variable in multivariable linear regression analyses, with 17 potential predictors. On the basis of a collinearity check, 2 models studying various risk factors were developed. Model 1 included concerns about falling and model 2 walking difficulties.

RESULTS

After 3 years, more participants reported fall-related activity avoidance, that is, 34% versus 50% (P < 0.001). Regression model 1 explained 63% of the variance. The strongest predictive factor was concerns about falling (standardized regression coefficient, β = 0.589), followed by pain (β = 0.161), unsteadiness while turning (β = 0.137), and age (β = 0.136). These variables remained significant when adjusting for mSAFFE baseline scores.In model 2 (explained 50% of the variance), the strongest predictive factor was perceived walking difficulties (β = 0.392), followed by age (β = 0.238), unsteadiness while turning (β = 0.198), and pain (β = 0.184). Unlike the other factors, walking difficulties were not significant when adjusting for mSAFFE baseline scores.

DISCUSSION AND CONCLUSIONS

Fall-related activity avoidance increased over time in people with PD. If fall-related activity avoidance is to be targeted, this study suggests that interventions should address concerns about falling, pain, unsteadiness while turning, and walking difficulties.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A310).

Psychometric Assessment of the Connor-Davidson Resilience Scale for People With Lower-Limb Amputation

OBJECTIVE

The purpose of this study was to (1) determine the psychometric properties of the 25- and 10-item Connor-Davidson Resilience Scales (CD-RISC25, CD-RISC10) for people with lower-limb amputation (LLA) in middle age or later, and (2) describe relationships of the CD-RISC with biopsychosocial, sociodemographic, and health variables.

METHODS

Participants were included if their most recent LLA was 1 or more years prior, if they were independently walking with a prosthesis, and if they were between 45 and 88 years of age (N = 122; mean = 62.5 years of age [SD = 8]; 59.5 [mean = 58] months since LLA; 88.5% male; 82.0% with dysvascular etiology; 68.0% with unilateral transtibial LLA). Psychometric analyses included assessment of skewness, floor and ceiling effects, internal consistency, and agreement between versions. Correlation analyses were used to determine associations between the CD-RISC with disability, perceived functional capacity, falls efficacy, life-space, anxiety, depression, self-efficacy, social support, sociodemographic, and health variables. Additionally, quartiles of participants were identified using CD-RISC25 and CD-RISC10 scores and compared using ANOVA and post-hoc comparisons for disability, perceived functional capacity, falls efficacy, and life-space.

RESULTS

Skewness, floor, and ceiling effects of both CD-RISC versions were acceptable. Both versions of the CD-RISC were internally consistent (CD-RISC25: α = .92; CD-RISC10: α = .89). The CD-RISC25 and CD-RISC10 were highly correlated with disability, perceived functional capacity, falls efficacy, anxiety, depression, and self-efficacy (r = 0.52-0.67). CD-RISC25 and CD-RISC10 quartile differences, especially the lowest quartile, were identified for disability, perceived functional capacity, falls efficacy, and life-space.

CONCLUSION

The CD-RISC25 and CD-RISC10 have acceptable psychometric properties for use with people who have LLA. CD-RISC scores are associated with clinically relevant biopsychosocial measures targeted by physical therapist intervention following LLA.

IMPACT

The CD-RISC may be an appropriate tool to measure resilience following LLA.

Neurorehabilitation in dystonia: a holistic perspective

Rehabilitation for isolated forms of dystonia, such as cervical or focal hand dystonia, is usually targeted towards the affected body part and focuses on sensorimotor control and motor retraining of affected muscles. Recent evidence, has revealed people who live with dystonia experience a range of functional and non-motor deficits that reduce engagement in daily activities and health-related quality of life, which should be addressed with therapeutic interventions. These findings support the need for a holistic approach to the rehabilitation of dystonia, where assessment and treatments involve non-motor signs and symptoms, and not just the dystonic body part. Most studies have investigated Cervical Dystonia, and in this population, it is evident there is reduced postural control and walking speed, high fear of falling and actual falls, visual compensation for the impaired neck posture, and a myriad of non-motor symptoms including pain, fatigue, sleep disorders and anxiety and depression. In other populations of dystonia, there is also emerging evidence of falls and reduced vision-related quality of life, along with the inability to participate in physical activity due to worsening of dystonic symptoms during or after exercise. A holistic approach to dystonia would support the management of a wide range of symptoms and signs, that if properly addressed could meaningfully reduce disability and improve quality of life in people living with dystonia.

A new postural stability-indicator to predict the level of fear of falling in Parkinson's disease patients

BACKGROUND

Fear of falling (FoF) is defined as a lasting concern about falling that causes a person to limit or even stop the daily activities that he/she is capable of. Seventy percent of Parkinson's disease (PD) patients report activity limitations due to FoF. Timely identification of FoF is critical to prevent its additional adverse effects on the quality of life. Self-report questionnaires are commonly used to evaluate the FoF, which may be prone to human error.

OBJECTIVES

In this study, we attempted to identify a new postural stability-indicator to objectively predict the intensity of FoF and its related behavior(s) in PD patients.

METHODS

Thirty-eight PD patients participated in the study (mean age, 61.2 years), among whom 10 (26.32%) were identified with low FoF and the rest (73.68%) with high FoF, based on Falls Efficacy Scale-International (FES-I). We used a limit of stability task calibrated to each individual and investigated the postural strategies to predict the intensity of FoF. New parameters (FTRis; functional time ratio) were extracted based on the center of pressure presence pattern in different rectangular areas (i = 1, 2, and 3). The task was performed on two heights to investigate FoF-related behavior(s).

RESULTS

FTR1/2 (the ratio between FTR1 and FTR2) was strongly correlated with the FES-I (r = - 0.63, p < 0.001), Pull test (r = - 0.65, p < 0.001), Timed Up and Go test (r = - 0.57, p < 0.001), and Berg Balance Scale (r = 0.62, p < 0.001). The model of FTR1/2 was identified as a best-fitting model to predicting the intensity of FoF in PD participants (sensitivity = 96.43%, specificity = 80%), using a threshold level of ≤ 2.83.

CONCLUSIONS

Using the proposed assessment technique, we can accurately predict the intensity of FoF in PD patients. Also, the FTR1/2 index can be potentially considered as a mechanical biomarker to sense the FoF-related postural instability in PD patients.

Prediction of Life Satisfaction in People with Parkinson's Disease

Introduction

People with Parkinson's disease (PD) have lower life satisfaction (LS) than healthy peers. No study has yet identified predictors of LS in people with PD. Such information would be valuable for health care and future interventions that aim to maintain or increase LS.

Aim

To examine how LS evolved in people with PD over a 3-year period, as well as to identify predictive factors of LS.

Methods

We used data from baseline assessments and a 3-year follow-up of 163 people with PD (baseline, mean age 68 years; median PD duration 8 years, 35% women). LS was assessed with item 1 of the Life Satisfaction Questionnaire (LiSat-11). Dichotomized LS data from the 3-year follow-up were used as the dependent variable in multivariable logistic regression analyses. In the first step, independent variables included baseline information on sex, education, general self-efficacy, motor symptoms, perceived walking difficulties, fall-related activity avoidance, and difficulties with/need help in activities of daily living. At the second step, depressive symptoms were added as an independent variable.

Results

The proportion of those who reported being satisfied with their lives reduced from 63.2% at baseline to 49.7% 3 years later (p=0.003). When depressive symptoms were not included in the analysis, general self-efficacy (odds ratio, OR = 1.081; 95% CI = 1.019–1.147) and perceived walking difficulties (OR = 0.962; 95% CI = 0.929–0.997) were significant (p < 0.05) predictors of LS 3 years later. With depressive symptoms included, the influence of walking difficulties diminished, and depressive symptoms (OR = 0.730; 95% CI = 0.607–0.877) and general self-efficacy (OR = 1.074; 95% CI = 1.010–1.142) were the only significant predictors of LS 3 years later.

Conclusions

LS is reduced over a 3-year period. The study suggests that perceived walking difficulties, general self-efficacy, and depressive symptoms are important predictors of LS in people with PD.

Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates

BACKGROUND

Patients with chronic diseases commonly report fears of illness or symptoms recurring or worsening. These fears have been addressed from an illness-specific perspective (e.g., fear of cancer recurrence), a generic illness perspective (e.g., fear of progression), and a psychiatric perspective (DSM-5 illness anxiety disorder and somatic symptom disorder). The broader concept of health anxiety (HA) can also be applied to patients with a chronic disease. This review was conducted to investigate the conceptual, theoretical, measurement-overlap, and differences between these distinct perspectives. We also aimed to summarize prevalence, course, and correlates of these fears in different chronic illnesses.

METHODS

We used PsycINFO, PubMED, CINAHL, Web of Science, SCOPUS, and PSYNDEX to conduct a systematic review of studies pertaining to these fears in chronic illness published from January 1996 to October 2017. A total of 401 articles were retained.

RESULTS

There were commonalities across different conceptualizations and diseases: a high prevalence of clinical levels of fears (>20%), a stable course over time, and a deleterious impact on quality of life. Reviewed studies used definitions, models, and measures that were illness-specific, with only a minority employing a psychiatric perspective, limiting cross-disease generalizability. There appears to be some applicability of DSM-5 disorders to the experience of fear of illness/symptoms in patients with a chronic illness. While conceptualizing HA on a continuum ranging from mild and transient to severe may be appropriate, there is a lack of agreement about when the level of fear becomes 'excessive.' The definitions, models, and measures of HA across chronic illnesses involve affective, cognitive, behavioral, and perceptual features.

CONCLUSIONS

The concept of HA may offer a unifying conceptual perspective on the fears of illness/symptoms worsening or returning commonly experienced by those with chronic disease.

The association between freezing of gait, fear of falling and anxiety in Parkinson's disease: a longitudinal analysis

Aim: We studied the longitudinal associations between freezing of gait (FoG), fear of falling (FoF) and anxiety, and how these associations are influenced by confounding factors. Materials & methods: We analyzed longitudinal motor and nonmotor measurements from 153 Parkinson's disease patients. Possible confounding factors were divided into three subgroups: demographics, disease characteristics, medication use and adverse effects of medication. Results: All crude associations between FoG, FoF and anxiety were significant and remained so after adjusting for confounders. When analyzing FoF and anxiety together as independent variables, the association between FoG and FoF remained, and the association between FoG and anxiety diminished. Conclusion: We confirm the complex interactions between motor and nonmotor symptoms in Parkinson's disease, and plead for a multidisciplinary approach.

Additional Physical Interventions to Conventional Physical Therapy in Parkinson's Disease: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Parkinson’s disease (PD) represents the second most common neurodegenerative disease. Currently, conventional physical therapy is complemented by additional physical interventions with recreational components, improving different motor conditions in people with PD. This review aims to evaluate the effectiveness of additional physical interventions to conventional physical therapy in Parkinson’s disease. A systematic review and meta-analysis of randomized controlled trials were performed. The literature search was conducted in PubMed, Physiotherapy Evidence Database (PEDro), Scopus, SciELO and Web of Science. The PEDro scale was used to evaluate the methodological quality of the studies. A total of 11 randomized controlled trials were included in this review. Five of them contributed information to the meta-analysis. The statistical analysis showed favorable results for dance-based therapy in motor balance: (Timed Up and Go: standardized mean difference (SMD) = −1.16; 95% Confidence Interval (CI):(−2.30 to −0.03); Berg Balance Scale: SMD = 4.05; 95%CI:(1.34 to 6.75)). Aquatic interventions showed favorable results in balance confidence (Activities-Specific Balance Confidence: SMD=10.10; 95%CI:(2.27 to 17.93)). The results obtained in this review highlight the potential benefit of dance-based therapy in functional balance for people with Parkinson’s disease, recommending its incorporation in clinical practice. Nonetheless, many aspects require clarification through further research and high-quality studies on this subject.

Group-based music intervention in Parkinson's disease - findings from a mixed-methods study

Objective:

To evaluate a group-based music intervention in patients with Parkinson’s disease.

Design:

Parallel group randomized controlled trial with qualitative triangulation.

Setting:

Neurorehabilitation in primary care.

Subjects:

Forty-six patients with Parkinson’s disease were randomized into intervention group (n = 26), which received training with the music-based intervention, and control group (n = 20) without training.

Interventions:

The intervention was delivered twice weekly for 12 weeks.

Main measures:

Primary outcome was Timed-Up-and-Go subtracting serial 7’s (dual-task ability). Secondary outcomes were cognition, balance, concerns about falling, freezing of gait, and quality of life. All outcomes were evaluated at baseline, post-intervention, and three months post-intervention. Focus groups and individual interviews were conducted with the intervention group and with the delivering physiotherapists.

Results:

No between-group differences were observed for dual-task ability. Between-group differences were observed for Falls Efficacy Scale (mean difference (MD) = 6.5 points; 95% confidence interval (CI) = 3.0 to 10.0, P = 0.001) and for Parkinson Disease Questionnaire-39 items (MD = 8.3; 95% CI = 2.7 to 13.8, P = 0.005) when compared to the control group post-intervention, but these were not maintained at three months post-intervention. Three themes were derived from the interviews: Expectations versus Results, Perspectives on Treatment Contents, and Key Factors for Success.

Conclusion:

Patient-reported outcomes and interviews suggest that the group-based music intervention adds value to mood, alertness, and quality of life in patients with Parkinson’s disease. The study does not support the efficacy in producing immediate or lasting gains in dual-tasking, cognition, balance, or freezing of gait.

The Reliability and Validity of the Turkish Version of the Survey of Activities and Fear of Falling in the Elderly

BACKGROUND AND PURPOSE

The Survey of Activities and Fear of Falling in the Elderly (SAFE) was originally developed in English to determine the level of fear of falling and its interactions with activities of daily living. The purpose of this study was to translate and cross-culturally adapt the SAFE instrument into Turkish and investigate its psychometric properties.

PARTICIPANTS

One hundred eleven older adults (72 females) with a mean age of 69 years (SD = 7.22; range, 60-87) were included.

METHODS

For cross-cultural adaptation, 2 bilingual translators used the back-translation procedure. Within a 5- to 7-day period after the first assessment, the participants completed the Turkish version of the SAFE (SAFE-T) to evaluate test-retest reliability. Cronbach's α was used to assess internal consistency. The correlation with the Turkish version of the Falls Efficacy Scale-International (FES-T) was determined to check the validity.

RESULTS

The SAFE-T had excellent internal consistency (α = 0.96) and test-retest reliability (intraclass correlation coefficient [ICC2,1] = 0.96 for activity level, ICC2,1 = 0.95 for fear of falling, and ICC2,1 = 0.86 for activity restriction subscales). The SAFE-T activity level and SAFE-T activity restriction subscales were moderately correlated with the FES-I (ρ = -0.51, P < .001; ρ = 0.55, P < .001, respectively). A strong positive correlation was found between the SAFE-T fear of falling subscale and the FES-I (ρ = 0.75, P < .001), indicating good concurrent validity.

CONCLUSIONS

The results show that the SAFE-T is semantically and linguistically adequate to assess the fear of falling in adults older than 60 years. Excellent internal validity and test-retest reliability of the SAFE-T were defined to evaluate the fear of falling among Turkish speaking older adults.

Choreographing life-experiences of balance control in people with Parkinson's disease

BACKGROUND

Parkinson's disease (PD) is a devastating neurodegenerative disorder. Reduced balance is one of the cardinal symptoms of PD, predisposing people living with PD to experience difficulties with the execution of tasks and activities, as well as hindering their involvement in meaningful life areas. The overarching aim of this study was to explore how deficits in balance control manifest in everyday life and how it is managed by people with PD (PwPD).

METHODS

Qualitative description was used as methodology, and in-depth interviews were conducted with 18 participants, between the ages of 46 to 83 years, with mild to severe PD. Interview transcripts were analyzed using qualitative content analysis, following an inductive approach.

RESULTS

One theme emerged from the analysis: Increased planning-choreographing life. Within this overarching theme, two categories were identified, namely Limitations in mobility and New restricted functioning in everyday life, each with 3-4 sub-categories. The categories described how PwPD handled decreased balance control in their everyday life by using motor and cognitive strategies as a consequence of not trusting their body's capacity to control balance. Activities in everyday life, as well as the ability to partake in leisure and social activities were profoundly affected.

CONCLUSION

People with mild to severe PD used strategies to handle decreased balance and they choreographed their lives around their individual current state of mobility and balance. The knowledge gained from this study can be used to develop targeted interventions addressing the nuances of balance deficits in everyday life.

Evaluating the psychometric properties of the iconographical falls efficacy scale (ICON-FES)

OBJECTIVE

This study aims to analyze the construct and content validity of the Iconographical Falls Efficacy Scale (Icon-FES) in order to measure the fear of falling in community-dwelling older adults.

METHODS

The Icon-FES was applied to 333 older adults. An exploratory factor analysis was performed to assess internal consistency. Item response theory (IRT) and confirmatory factor analysis (CFA) were used to evaluate the consistency of the questionnaire and whether it corresponded satisfactorily to the construct "concern about falling." Concurrent validity with the Falls Efficacy Scale-International (FES-I) and convergent validity with the Senior Fitness Test (SFT) were also assessed. Receiving operator characteristic (ROC) curves were used to determine the sensitivity and specificity.

RESULTS

The structural model of the 30-item and 10-item Icon-FES showed some theoretical fragility. The final model of the new short version of the Icon-FES consisted of 13 items, yielding a theoretically satisfactory structural model. Validity analyses indicated that the 13-item Icon-FES had a moderate relationship with the SFT, a strong relationship with the FES-I, and good sensitivity and specificity for a history of falls.

CONCLUSION

The 13-item Icon-FES has excellent psychometric properties for measuring fear of falling in community-dwelling older adults. It can be recommended as a screening tool for fear of falling for both research and clinical purposes.

Predictive Factors of Concerns about Falling in People with Parkinson's Disease: A 3-Year Longitudinal Study

Introduction

Fear of falling (FOF) is more common in people with Parkinson's disease (PD) than in healthy controls. It can lead to several negative consequences such as restrictions in everyday life. Moreover, FOF is a risk factor for future falls.

Aim

This study aimed to identify predictive factors of FOF (conceptualized as concerns about falling) after three years, with and without adjusting for concerns about falling at baseline, in people with PD.

Methods

This study included 151 participants (35% women) with PD. At baseline, their mean (SD) age and PD duration were 68 (±9.0) and 9 (±6.1) years, respectively. The Falls Efficacy Scale-International (FES-I) was used as the dependent variable in multivariable linear regression analyses.

Results

The mean (SD) FES-I score increased from 28.1 (11.9) to 33.1 (14.0) three years later (p < 0.001). The strongest (according to the standardized regression coefficient, β) predictor of concerns about falling was walking difficulties (β = 0.378), followed by age (0.227), problems maintaining balance while dual tasking (0.172), and needing help in daily activities (0.171). When adjusting for baseline FES-I scores, the strongest predictive factor was problems maintaining balance while dual tasking (β = 0.161), which was followed by age (0.131) and female sex (0.105).

Conclusions

This study pinpoints several predictive factors of concerns about falling that are modifiable and which could be addressed in rehabilitation: perceived walking difficulties, having problems maintaining balance while dual tasking, and dependence on others in daily activities. The importance of dual tasking is a novel finding, which future studies need to confirm or refute. One should be aware of the fact that an increased age predicts concerns about falling with and without adjusting for baseline FES-I scores, whereas female sex predicts concerns about falling only when adjusting for baseline FES-I scores.

Measures of balance and falls risk prediction in people with Parkinson's disease: a systematic review of psychometric properties

OBJECTIVE

To investigate the psychometric properties of measures of balance and falls risk prediction in people with Parkinson's disease (PD).

DATA SOURCES

PubMed, Embase, CINAHL, Ovid Medline, Scopus, and Web of Science were searched from inception to August 2019.

REVIEW METHOD

Studies testing psychometric properties of measures of balance and falls risk prediction in PD were included. The four-point COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) assessed quality.

RESULTS

Eighty studies testing 68 outcome measures were reviewed; 43 measures assessed balance, 9 assessed falls risk prediction, and 16 assessed both. The measures with robust psychometric estimation with acceptable properties were the (1) Mini-Balance Evaluation Systems Test (Mini-BEST), (2) Berg Balance Scale, (3) Timed Up and Go test, (4) Falls Efficacy Scale International, and (5) Activities-Specific Balance Confidence scale. These measures assess balance and falls risk prediction at the body, structure and function level, falls risk and balance, and falls risk at the activity level. The motor examination of the Unified Parkinson's Disease Rating Scale (UPDRS-ME) with robust psychometric analysis is a condition-specific measure with acceptable properties. Except the UPDRS-ME and Mini-BESTest, the responsiveness of the other four measures has yet to be established.

CONCLUSION

Six of the 68 outcome measures have strong psychometric properties for the assessment of balance and falls risk prediction in PD. Measures assessing balance and falls risk prediction at the participatory level are limited in number with a lack of psychometric validation.

A Core Set of Outcome Measures for Adults With Neurologic Conditions Undergoing Rehabilitation: A CLINICAL PRACTICE GUIDELINE

Supplemental Digital Content is Available in the Text.

Background:

Use of outcome measures (OMs) in adult neurologic physical therapy is essential for monitoring changes in a patient's status over time, quantifying observations and patient-reported function, enhancing communication, and increasing the efficiency of patient care. OMs also provide a mechanism to compare patient and organizational outcomes, examine intervention effectiveness, and generate new knowledge. This clinical practice guideline (CPG) examined the literature related to OMs of balance, gait, transfers, and patient-stated goals to identify a core set of OMs for use across adults with neurologic conditions and practice settings.

Methods:

To determine the scope of this CPG, surveys were conducted to assess the needs and priorities of consumers and physical therapists. OMs were identified through recommendations of the Academy of Neurologic Physical Therapy's Evidence Database to Guide Effectiveness task forces. A systematic review of the literature on the OMs was conducted and additional OMs were identified; the literature search was repeated on these measures. Articles meeting the inclusion criteria were critically appraised by 2 reviewers using a modified version of the COnsensus-based Standards for the selection of health Measurement INstruments. (COSMIN) checklist. Methodological quality and the strength of statistical results were determined. To be recommended for the core set, the OMs needed to demonstrate excellent psychometric properties in high-quality studies across neurologic conditions.

Results/Discussion:

Based on survey results, the CPG focuses on OMs that have acceptable clinical utility and can be used to assess change over time in a patient's balance, gait, transfers, and patient-stated goals. Strong, level I evidence supports the use of the Berg Balance Scale to assess changes in static and dynamic sitting and standing balance and the Activities-specific Balance Confidence Scale to assess changes in balance confidence. Strong to moderate evidence supports the use of the Functional Gait Assessment to assess changes in dynamic balance while walking, the 10 meter Walk Test to assess changes in gait speed, and the 6-Minute Walk Test to assess changes in walking distance. Best practice evidence supports the use of the 5 Times Sit-to-Stand to assess sit to standing transfers. Evidence was insufficient to support use of a specific OM to assess patient-stated goals across adult neurologic conditions. Physical therapists should discuss the OM results with patients and collaboratively decide how the results should inform the plan of care.

Disclaimer:

The recommendations included in this CPG are intended as a guide for clinicians, patients, educators, and researchers to improve rehabilitation care and its impact on adults with neurologic conditions. The contents of this CPG were developed with support from the APTA and the Academy of Neurologic Physical Therapy (ANPT). The Guideline Development Group (GDG) used a rigorous review process and was able to freely express its findings and recommendations without influence from the APTA or the ANPT. The authors declare no competing interest.

Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A214.

Quantifying physical activity in early Parkinson disease using a commercial activity monitor

INTRODUCTION

Physical inactivity in Parkinson disease (PD) has an impact on motor and non-motor symptoms of the disease. It is unclear whether this decline in physical activity occurs early in the disease, in addition to any decline due to aging, and whether commercial activity monitors can be used to self-monitor physical activity levels in this population.

OBJECTIVE

To compare the quantity and intensity of physical activity (PA), as measured by commercial activity monitors, in people with mild PD and healthy older adults (HOA). A secondary objective was to assess adherence and user experience with wearing the activity monitoring device.

METHODS

An observational descriptive study design examined PA levels over a 14-day period using commercially-available activity monitors (Fitbit Charge HR).

RESULTS

Individuals with PD (n = 30) and HOA (n = 30) both demonstrated high adherence with wear time (PD = 13.8 [0.5] days, HOA = 13.9 [0.4] days, p = 0.55). People with PD took fewer steps per day than HOA (PD = 6416.9 (2795.5), HOA = 11441.3 (3932.1), p < 0.001). Compared to HOA, individuals with PD spent fewer minutes per day engaged in moderate to vigorous intensity activity (PD = 33.0 (22.5), HOA = 72.0(37.3), p < 0.001) and more minutes per day sedentary (PD = 803.74 (154.9), HOA = 578.26 (103.7), p < 0.001). Both groups reported that ease of use and satisfaction with the activity monitor were high.

CONCLUSIONS

People with mild PD demonstrated reduced quantity and intensity of PA compared to HOA. Both the PD and the HOA groups had good adherence wearing a commercial activity monitor that provided feedback regarding activity levels.

Fear of falling in obese women under 50 years of age: a cross-sectional study with exploration of the relationship with physical activity

Background

An understanding of capacity for physical activity in obese populations should help guide interventions to promote physical activity. Fear of falling is a phenomenon reported in the elderly, which is associated with reduced mobility and lower physical activity levels. However, although falls are reportedly common in obese adults, fear of falling and its relationship with activity has not been investigated in younger obese populations.

Methods

In a cross-sectional study, fear of falling was measured in 63 women aged 18 to 49 years, with mean BMI 42.1 kg/m² (SD 10.3) using the Modified Falls Efficacy (MFES), the Consequences of Falling (COF) and the Modified Survey of Activities and Fear of Falling in the Elderly (MSAFFE) scales. The choice of scales was informed by prior qualitative interviews with obese younger women. Physical activity levels were measured at the same time using the International Physical Activity Questionnaire. The mean score for fear of falling scales, with 95% confidence intervals, were estimated. Chi-square tests and t-tests were used to explore differences in age, body mass index and fear of falling scores between fallers and non-fallers. For each fear of falling scale, binomial logistic regression was used to explore its relationship with physical activity.

Results

Mean scores suggested high levels of fear of falling: MFES [mean 7.7 (SD 2.7); median 8.5]; COF [mean 31.3 (SD 9.4)]; MSAFFE [mean 25.9 (SD 8.7); median 23]. Scores were significantly worse in fallers (n = 42) compared to non-fallers (n = 21). MFES and MSAFFE were independently associated with lower levels of physical activity [odds ratio = 0.65, 95% Cl 0.44 to 0.96 and odds ratio = 1.14, 95% CI 1.01 to 1.28 respectively], when adjusted for age, BMI and depression.

Conclusions

This study confirms that fear of falling is present in obese women under 50 years of age. It suggests that it is associated with low levels of physical activity. These novel findings warrant further research to understand capacity for physical and incidental activity in obese adults in both genders and suggest innovative interventions to promote lifestyle changes and/or consideration of falls prevention in this population.

Differentiating cognitive or motor dimensions associated with the perception of fall-related self-efficacy in Parkinson's disease

In Parkinson's disease (PD), concurrent declines in cognitive and motor domain function can severely limit an individual's ability to conduct daily tasks. Current diagnostic methods, however, lack precision in differentiating domain-specific contributions of cognitive or motor impairments based on a patients' clinical manifestation. Fear of falling (FOF) is a common clinical manifestation among the elderly, in which both cognitive and motor impairments can lead to significant barriers to a patients' physical and social activities. The present study evaluated whether a set of analytical and machine-learning approaches could be used to help delineate boundary conditions and separate cognitive and motor contributions to a patient's own perception of self-efficacy and FOF. Cognitive and motor clinical scores, in conjunction with FOF, were collected from 57 Parkinson's patients during a multi-center rehabilitation intervention trial. Statistical methodology was used to extract a subset of uncorrelated cognitive and motor components associated with cognitive and motor predictors, which were then used to independently identify and visualize cognitive and motor dimensions associated with FOF. We found that a central cognitive process, extracted from tests of executive, attentional, and visuoperceptive function, was a unique and significant independent cognitive predictor of FOF in PD. In addition, we provide evidence that the approaches described here may be used to computationally discern specific types of FOF based on separable cognitive or motor models. Our results are consistent with a contemporary model that the deterioration of a central cognitive mechanism that modulates self-efficacy also plays a critical role in FOF in PD.

Validation of Fear of Falling and Balance Confidence Assessment Scales in Persons With Dystonia

BACKGROUND AND PURPOSE

Falls are problematic for people living with neurological disorders and a fear of falling can impact on actual falls. Fear of falling is commonly assessed using the Falls Self-Efficacy Scale International (FES-I) or the Activities-specific Balance Confidence (ABC) Scale. These scales can predict risk of falling. We aimed to validate the FES-I and the ABC in persons with dystonia.

METHODS

We conducted an online survey of people with dystonia, collecting information on demographics, 6-month falls history, dystonia disability, and the FES-I and ABC scales. Scales were validated for structural validity and internal consistency. We also examined goodness-of-fit, convergent validity, and predictive validity, and determined cutoff scores for predicting falls risk.

RESULTS

Survey responses (n = 122) showed that both FES-I and ABC scales have high internal validity and convergent validity with the Functional Disability Questionnaire in persons with dystonia. Each scale examines a single factor, fear of falling (FES-I) and balance confidence (ABC). At least one fall was reported by 39% of participants; the cutoff value for falls risk was found to be 29.5 and 71.3 for the FES-I and the ABC respectively.

DISCUSSION AND CONCLUSIONS

The FES-I and the ABC scales are valid scales to examine fear of falling and balance confidence in persons with dystonia. Fear of falling is high and balance confidence is low and both are worse in those with dystonia who have previously fallen.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A182).

Balance and fear of falling in subjects with Parkinson's disease is improved after exercises with motor complexity

Resistance training with instability (RTI) uses exercises with high motor complexity that impose high postural control and cognitive demands that may be important for improving postural instability and fear of falling in subjects with Parkinson's disease (PD). Here, we hypothesized that: 1) RTI will be more effective than resistance training (RT) in improving balance (Balance Evaluation Systems Test [BESTest] and overall stability index [Biodex Balance System^®]) and fear of falling (Falls Efficacy Scale-International [FES-I] score) of subjects with Parkinson's disease (PD); and 2) changes in BESTest and FES-I after RTI will be associated with changes in cognitive function (Montreal Cognitive Assessment [MoCA] score - previously published) induced by RTI. Thirty-nine subjects with moderate PD were randomly assigned to a nonexercising control, RT, and RTI groups. While RT and RTI groups performed progressive RT twice a week for 12 weeks, the RTI group added progressive unstable devices to increase motor complexity of the resistance exercises. There were significant group × time interactions for BESTest, overall stability index, and FES-I scores (P < 0.05). Only RTI improved BESTest, overall stability index and FES-I scores, and RTI was more effective than RT in improving biomechanical constraints and stability in gait (BESTest sections) at post-training (P < 0.05). There were strong correlations between relative changes in BESTest and MoCA (r = 0.72, P = 0.005), and FES-I and MoCA (r = -0.75, P = 0.003) after RTI. Due to the increased motor complexity in RTI, RTI is recommended for improving balance and fear of falling, which are associated with improvement in cognitive function of PD.

Experiences of fear of falling in persons with Parkinson's disease - a qualitative study

Background

Fear of falling is common among persons with Parkinson’s disease and is negatively associated with quality of life. However a lack of in-depth understanding of fear of falling as a phenomenon persists. This qualitative study aimed to explore the experiences of fear of falling in persons with Parkinson’s disease.

Methods

Individual interviews were performed with twelve persons with Parkinson’s disease (median age 70 years, median Parkinson duration 9 years, 50% women). The interviews were semi-structured and followed a study-specific interview guide. The transcribed interviews were analyzed using qualitative content analysis.

Results

Fear of falling was experienced as a disturbing factor in everyday life. It generated a feeling of vulnerability and made daily activities and everyday environments seem potentially hazardous. Persons also missed performing previous activities. The fear of falling was a varying experience, fueled by an awareness of falls and near falls, Parkinson-related symptoms and disabilities, and by others in their environment. The persons adopted different strategies to handle their fear of falling. Activities were adapted, avoided, performed with help, or carried out despite their fear of falling.

Conclusions

The experiences of fear of falling were complex, multifaceted and varied over time and in relation to different activities and environments. This indicates that interventions targeting fear of falling need to be individually tailored for persons with Parkinson’s disease and should focus on several aspects, such as Parkinson-related symptoms and disabilities, activities and environmental factors. This study provides new information that increases the understanding of fear of falling, which has implications for researchers as well as clinicians working with persons with Parkinson’s disease and fear of falling.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0735-1) contains supplementary material, which is available to authorized users.

Psychometric Evaluation of the Parkinson's Disease Activities of Daily Living Scale

Objective

To evaluate a set of psychometric properties (i.e., data completeness, targeting, and external construct validity) of the Parkinson's disease Activities of Daily Living Scale (PADLS) in people with Parkinson's disease (PD). Specific attention was paid to the association between PADLS and PD severity, according to the Hoehn & Yahr (H&Y) staging.

Methods

The sample included 251 persons with PD (mean age 70 [SD 9] years). Data collection comprised a self-administered postal survey, structured interviews, and clinical assessments at home visits.

Results

Data completeness was 99.6% and the mean PADLS score was 2.1. Floor and ceiling effects were 22% and 2%, respectively. PADLS scores were more strongly associated (r_s > 0.5) with perceived functional independence, ADL dependency, walking difficulties, and self-rated PD severity than with variables such as PD duration and cognitive function (r_s < 0.5). PADLS scores differed across H&Y stages (Kruskal-Wallis test, p < 0.001). Those in H&Y stages IV-V had more ADL disability than those in stage III (Mann–Whitney U test, p < 0.001), whereas there were no significant differences between the other stages.

Conclusion

PADLS revealed excellent data completeness, acceptable targeting, and external construct validity. It seems to be well suited as a rough estimate of ADL disability in people with PD.

Impairments of balance, stepping reactions and gait in people with cervical dystonia

BACKGROUND

Impaired balance is common in neurological disorders. Cervical dystonia is a neurological movement disorder affecting the neck. The effect of this aberrant head posture on physical function is unknown.

OBJECTIVES

To compare balance, mobility, gait and stepping reactions between ten people with cervical dystonia and ten control adults.

METHODS

Spatiotemporal gait parameters and walking speed were assessed using a computerised walkway. Step length and time, time in double support and gait variability were calculated, then normalised to gait speed. Centre of pressure path length was assessed with eyes open and eyes closed to calculate a Romberg Quotient. Simple and choice reaction times were measured using customised apparatus while mobility was assessed by the timed up and go. Cervical spine range of motion was measured using a head mounted goniometer. Self-reported scales included Falls Self Efficacy Scale and Dystonia Discomfort Scale.

RESULTS

There was a difference between groups for most outcome measures. The timed up-and-go and walking speed was slower (both P<0.005) and the Romberg Quotient lower (P=0.046) in cervical dystonia. People with cervical dystonia had lower falls self-efficacy (P=0.0002). Reduced cervical range of motion was correlated with balance, stepping reaction time and mobility (all P<0.05). Timed up and go was positively associated with stepping reaction time (P<0.01). Dystonia discomfort did not impact function.

CONCLUSIONS

People with cervical dystonia displayed deficits in balance, gait and stepping reactions, and expressed higher fear of falling. Studies to further elucidate functional limitations and their impact on activity and participation in daily life are required.

Psychometric properties of the original and short versions of the Falls Efficacy Scale-International (FES-I) in people with Parkinson's disease

BACKGROUND

Fear of falling is common in people with Parkinson's disease (PD) and is associated with an increased risk for future falls, activity limitations and a reduced quality of life. The Falls Efficacy Scale-International (FES-I) assesses fear of falling conceptualized as concerns about falling. The original FES-I has good psychometric properties in people with PD, but whether this applies also for the short version of FES-I remains to be shown. The aim of the present study was to evaluate the psychometric properties of the short FES-I and to compare these with the original FES-I in the same sample of people with PD. The investigated psychometric properties included known groups validity, data completeness, scaling assumptions, targeting and reliability.

METHODS

A postal survey, which included the original, full-length FES-I, was distributed to 174 people with PD. Responders received a second survey after two weeks. From these data, short FES-I total scores were calculated by extracting the items that are included in the short version of the scale.

RESULTS

Median age and PD duration of the 101 responders (43% women) were 73 and 5 years, respectively. The original as well as the short FES-I scores were able to discriminate (p < 0.001) between groups with and without fear of falling, activity avoidance, falls, near falls, and with various self-rated PD severity, respectively. Both versions of FES-I had a high level of data completeness (0.7 to 0.9% missing item responses). Scaling assumptions were acceptable for the original as well as the short FES-I. While the short FES-I had 19% floor effect, the original version was better targeted. Both versions were reliable and obtained high values for internal consistency (Cronbach's alpha >0.8) and test-retest reliability (Intraclass Correlation Coefficient > 0.9).

CONCLUSIONS

Both the original and short FES-I revealed generally good psychometric properties in people with PD, although the original scale was better targeted. Due to the higher floor effect in the short FES-I, the present findings favors using the original, full-length FES-I in longitudinal follow-ups, intervention studies and clinical practice when addressing concerns about falling.

A training approach to improve stepping automaticity while dual-tasking in Parkinson's disease: A prospective pilot study

BACKGROUND

Deficits in motor movement automaticity in Parkinson's disease (PD), especially during multitasking, are early and consistent hallmarks of cognitive function decline, which increases fall risk and reduces quality of life. This study aimed to test the feasibility and potential efficacy of a wearable sensor-enabled technological platform designed for an in-home music-contingent stepping-in-place (SIP) training program to improve step automaticity during dual-tasking (DT).

METHODS

This was a 4-week prospective intervention pilot study. The intervention uses a sensor system and algorithm that runs off the iPod Touch which calculates step height (SH) in real-time. These measurements were then used to trigger auditory (treatment group, music; control group, radio podcast) playback in real-time through wireless headphones upon maintenance of repeated large amplitude stepping. With small steps or shuffling, auditory playback stops, thus allowing participants to use anticipatory motor control to regain positive feedback. Eleven participants were recruited from an ongoing trial (Trial Number: ISRCTN06023392). Fear of falling (FES-I), general cognitive functioning (MoCA), self-reported freezing of gait (FOG-Q), and DT step automaticity were evaluated.

RESULTS

While we found no significant effect of training on FES-I, MoCA, or FOG-Q, we did observe a significant group (music vs podcast) by training interaction in DT step automaticity (P<0.01).

CONCLUSION

Wearable device technology can be used to enable musically-contingent SIP training to increase motor automaticity for people living with PD. The training approach described here can be implemented at home to meet the growing demand for self-management of symptoms by patients.

Depressive symptoms associated with concerns about falling in Parkinson's disease

BACKGROUND

Concerns about falling, a construct related to fear of falling, is increased in people with Parkinson's disease (PD) and is recognized as a barrier for exercise, negatively affecting health-related quality of life and participation.

AIM

To investigate modifiable factors associated with concerns about falling in elderly with mild-to-moderate PD.

METHODS

Eighty-nine elderly (39 females, mean age 73 years) with mild-to-moderate PD were recruited. Concerns about falling were assessed with the Falls Efficacy Scale-international, that is, the dependent variable in multiple linear regression analysis. Independent variables included both motor (e.g., objective measures of physical activity and gait) and nonmotor aspects such as depressive symptoms.

RESULTS

A model with three significant independent variables explained 33% of the variance in concerns about falling. According to the standardized regression coefficients (β), the strongest contributing factor was depressive symptoms (0.40), followed by balance performance (-0.25), and use of mobility devices (0.24).

CONCLUSIONS

The findings imply that factors associated with concerns about falling are a multifactorial phenomenon. For its management in elderly with mild-to-moderate PD, one should consider depressive symptoms, balance deficits, and mobility devices.

External validation of a 3-step falls prediction model in mild Parkinson's disease

The 3-step falls prediction model (3-step model) that include history of falls, history of freezing of gait and comfortable gait speed <1.1 m/s was suggested as a clinical fall prediction tool in Parkinson’s disease (PD). We aimed to externally validate this model as well as to explore the value of additional predictors in 138 individuals with relatively mild PD. We found the discriminative ability of the 3-step model in identifying fallers to be comparable to previously studies [area under curve (AUC), 0.74; 95 % CI 0.65–0.84] and to be better than that of single predictors (AUC, 0.61–0.69). Extended analyses generated a new model for prediction of falls and near falls (AUC, 0.82; 95 % CI 0.75–0.89) including history of near falls, retropulsion according to the Nutt Retropulsion test (NRT) and tandem gait (TG). This study confirms the value of the 3-step model as a clinical falls prediction tool in relatively mild PD and illustrates that it outperforms the use of single predictors. However, to improve future outcomes, further studies are needed to firmly establish a scoring system and risk categories based on this model. The influence of methodological aspects of data collection also needs to be scrutinized. A new model for prediction of falls and near falls, including history of near falls, TG and retropulsion (NRT) may be considered as an alternative to the 3-step model, but needs to be tested in additional samples before being recommended. Taken together, our observations provide important additions to the evidence base for clinical fall prediction in PD.

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.

Concerns About Falling in Parkinson's Disease: Associations with Disabilities and Personal and Environmental Factors

BACKGROUND

Fear of falling can be conceptualized in different ways, e.g., as concerns about falling or low fall-related self-efficacy. It is common in people with Parkinson's disease (PD), and there is growing knowledge about its contributing factors. However, previous multivariate studies have mainly focused on fear of falling in relation to PD-related disabilities, and less is known about the associations between fear of falling and personal and environmental factors.

OBJECTIVE

To identify explanatory factors of concerns about falling in people with PD by focusing on personal and environmental factors as well as PD-related disabilities.

METHODS

Data were collected from 241 persons with PD (39% women, median age 70 years, PD duration 8 years). Concerns about falling (assessed with the Falls Efficacy Scale-International, FES-I; categorized into low, moderate, or high concerns) were used as the dependent variable in a multivariate ordinal regression analysis. Personal factors, environmental factors and PD-related disabilities constituted independent variables.

RESULTS

Low, moderate and high concerns about falling were reported by 29% , 24% and 47% of the participants, respectively. Walking difficulties, orthostatism, motor symptoms, age, and fatigue (presented in order of importance) were significant (p <  0.05) explanatory factors of concerns about falling.

CONCLUSIONS

Several factors significantly explained concerns about falling in people with PD. Walking difficulties was by far the strongest explanatory factor. This suggests that minimizing walking difficulties should be a primary target when aiming at reducing concerns about falling in people with PD.

Fall-related activity avoidance in relation to a history of falls or near falls, fear of falling and disease severity in people with Parkinson's disease

BACKGROUND

There is limited knowledge concerning fall-related activity avoidance in people with Parkinson's disease (PD); such knowledge would be of importance for the development of more efficient PD-care and rehabilitation. This study aimed to examine how fall-related activity avoidance relates to a history of self-reported falls/near falls and fear of falling (FOF) as well as to disease severity in people with PD.

METHODS

Data were collected from 251 (61 % men) participants with PD; their median (min-max) age and PD duration were 70 (45-93) and 8 (1-43) years, respectively. A self-administered postal survey preceded a home visit which included observations, clinical tests and interview-administered questionnaires. Fall-related activity avoidance was assessed using the modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE) as well as by using a dichotomous (Yes/No) question. Further dichotomous questions concerned: the presence of FOF and the history (past 6 months) of falls or near falls, followed by stating the number of incidents. Disease severity was assessed according to the Hoehn and Yahr (HY) stages.

RESULTS

In the total sample (n = 251), 41 % of the participants reported fall-related activity avoidance; the median mSAFFE score was 22. In relation to a history of fall, the proportions of participants (p < 0.001) that reported fall-related activity avoidance were: non-fallers (30 %), single fallers (50 %) and recurrent fallers, i.e. ≥ 2 falls (57 %). Among those that reported near falls (but no falls), 51 % (26 out of 51) reported fall-related activity avoidance. Of those that reported FOF, 70 % reported fall-related activity avoidance. Fall-related activity avoidance ranged from 24 % in the early PD-stage (HY I) to 74 % in the most severe stages (HY IV-V).

CONCLUSIONS

Results indicate that fall-related activity avoidance may be related to a history of self-reported falls/near falls, FOF and disease severity in people with PD. Importantly, fall-related activity avoidance is reported among those that do not fall and already in mild PD-stages (HY I-II). Although further studies are needed, our findings indicate that fall-related activity avoidance needs to be addressed early in order to prevent sedentary behavior and participation restrictions.

Measurement instruments to assess posture, gait, and balance in Parkinson's disease: Critique and recommendations

BACKGROUND

Disorders of posture, gait, and balance in Parkinson's disease (PD) are common and debilitating. This MDS-commissioned task force assessed clinimetric properties of existing rating scales, questionnaires, and timed tests that assess these features in PD.

METHODS

A literature review was conducted. Identified instruments were evaluated systematically and classified as "recommended," "suggested," or "listed." Inclusion of rating scales was restricted to those that could be used readily in clinical research and practice.

RESULTS

One rating scale was classified as "recommended" (UPDRS-derived Postural Instability and Gait Difficulty score) and 2 as "suggested" (Tinetti Balance Scale, Rating Scale for Gait Evaluation). Three scales requiring equipment (Berg Balance Scale, Mini-BESTest, Dynamic Gait Index) also fulfilled criteria for "recommended" and 2 for "suggested" (FOG score, Gait and Balance Scale). Four questionnaires were "recommended" (Freezing of Gait Questionnaire, Activities-specific Balance Confidence Scale, Falls Efficacy Scale, Survey of Activities, and Fear of Falling in the Elderly-Modified). Four tests were classified as "recommended" (6-minute and 10-m walk tests, Timed Up-and-Go, Functional Reach).

CONCLUSION

We identified several questionnaires that adequately assess freezing of gait and balance confidence in PD and a number of useful clinical tests. However, most clinical rating scales for gait, balance, and posture perform suboptimally or have been evaluated insufficiently. No instrument comprehensively and separately evaluates all relevant PD-specific gait characteristics with good clinimetric properties, and none provides separate balance and gait scores with adequate content validity for PD. We therefore recommend the development of such a PD-specific, easily administered, comprehensive gait and balance scale that separately assesses all relevant constructs. © 2016 International Parkinson and Movement Disorder Society.

Psychometric properties of the General Self-Efficacy Scale in Parkinson's disease

OBJECTIVE

This study aimed to investigate the psychometric properties of the General Self-Efficacy Scale (GSE) in people with Parkinson's disease (PD). More specifically, we investigated data completeness, scaling assumptions, targeting, reliability, and construct validity.

MATERIALS AND METHODS

This study involves data available from two different projects that included people diagnosed with PD for at least 1 year, yielding two samples (1 and 2). The combined total sample (N=346; 60% men) had a mean (SD) age and PD duration of 71 (8.9) and 9 years (6.3), respectively. Both samples received a self-administered survey by mail, which was administered twice in sample 2. Additional data (e.g., clinical assessments) were available for Sample 1.

RESULTS

Total GSE scores were computable for 336 participants (97%). Corrected item-total correlations exceeded 0.4. Principal component analyses identified one component (the eigenvalue of the first component extracted was 6.9), explaining 69% of the total variance. Floor and ceiling effects were <6%. Internal consistency (coefficient alpha) was 0.95. Analyses of test-retest reliability yielded (ICC) values from 0.69 to 0.80. The highest value refers to those (n=47) with identical self-ratings of mobility (in the on condition) at both tests; the standard error of measurement was 3.1 points. Construct validity was further supported by correlations in accordance with a priori expectations.

CONCLUSIONS

This study provides support for the validity and reliability of GSE scores in people with PD; the GSE can thus serve as a valuable outcome measurement in clinical practice and research.

Fear of falling in people with chronic obstructive pulmonary disease

BACKGROUND

Increased fear of falling (FOF) has been associated with impaired physical function, reduced physical activity and increased fall risk in older adults. Preliminary evidence suggests that individuals with chronic obstructive pulmonary disease (COPD) may have an increased FOF. This study aims to compare the level of FOF in people with COPD with healthy controls, and to determine the associations between FOF and measures of physical function, physical activity and fall risk in COPD.

METHODS

FOF was assessed in 40 participants with COPD and 25 age- and gender-matched controls using the Falls Efficacy Scale-International (FES-I). Physical function was evaluated using quadriceps hand-held dynamometry, the Berg Balance Scale and the Six-minute Walk Test. Associations between FOF, physical activity and fall risk were evaluated using the Physical Activity Scale for the Elderly and the Falls Risk in Older People - Community Setting. Pearson's correlation coefficient and stepwise multivariate linear regression were used.

RESULTS

Individuals with COPD (mean ± SD; age: 71 ± 8 years, FEV1: 45 ± 16 %pred) had higher FOF compared to controls (FES-I: 25.0 ± 7.9 vs 20.2 ± 5.2, p=0.01). Higher FOF was associated with lower quadriceps strength (p=0.02) and an impaired balance (p < 0.01); these explained 26% of the FOF variance. Reduced levels of physical activity (p=0.01) and a higher fall risk (p < 0.01) were associated with an increased FOF in COPD.

CONCLUSION

People with COPD have a higher FOF compared to the healthy peers, which is related to lower quadriceps muscle strength, impaired balance, lower levels of physical activity and an increased fall risk.

Prediction of falls and/or near falls in people with mild Parkinson's disease

OBJECTIVE

To determine factors associated with future falls and/or near falls in people with mild PD.

METHODS

The study included 141 participants with PD. Mean (SD) age and PD-duration were 68 (9.7) and 4 years (3.9), respectively. Their median (q1-q3) UPDRS III score was 13 (8-18). Those >80 years of age, requiring support in standing or unable to understand instructions were excluded. Self-administered questionnaires targeted freezing of gait, turning hesitations, walking difficulties in daily life, fatigue, fear of falling, independence in activities of daily living, dyskinesia, demographics, falls/near falls history, balance problems while dual tasking and pain. Clinical assessments addressed functional balance performance, retropulsion, comfortable gait speed, motor symptoms and cognition. All falls and near falls were subsequently registered in a diary during a six-month period. Risk factors for prospective falls and/or near falls were determined using logistic regression.

RESULTS

Sixty-three participants (45%) experienced ≥ 1 fall and/or near fall. Three factors were independent predictors of falls and/or near falls: fear of falling (OR = 1.032, p<0.001) history of near falls (OR = 3.475, p = 0.009) and retropulsion (OR = 2.813, p = 0.035). The strongest contributing factor was fear of falling, followed by a history of near falls and retropulsion.

CONCLUSIONS

Fear of falling seems to be an important issue to address already in mild PD as well as asking about prior near falls.