Can we predict the risk of falls in elderly patients with instability?

A machine learning approach to identify important variables for distinguishing between fallers and non-fallers in older women

Falls are a significant ongoing public health concern for older adults. At present, few studies have concurrently explored the influence of multiple measures when seeking to determine which variables are most predictive of fall risks. As such, this cross-sectional study aimed to identify those functional variables (i.e. balance, gait and clinical measures) and physical characteristics (i.e. strength and body composition) that could best distinguish between older female fallers and non-fallers, using a machine learning approach. Overall, 60 community-dwelling older women (≥65 years), retrospectively classified as fallers (n = 21) or non-fallers (n = 39), attended three data collection sessions. Data (281 variables) collected from tests in five separate domains (balance, gait, clinical measures, strength and body composition) were analysed using random forest (RF) and leave-one-variable-out partial least squares correlation analysis (LOVO PLSCA) to assess variable importance. The strongest discriminators from each domain were then aggregated into a multi-domain dataset, and RF, LOVO PLSCA, and logistic regression models were constructed to identify the important variables in distinguishing between fallers and non-fallers. These models were used to classify participants as either fallers or non-fallers, with their performance evaluated using receiver operating characteristic (ROC) analysis. The study found that it is possible to classify fallers and non-fallers with a high degree of accuracy (e.g. logistic regression: sensitivity = 90%; specificity = 87%; AUC = 0.92; leave-one-out cross-validation accuracy = 63%) using a combination of 18 variables from four domains, with the gait and strength domains being particularly informative for screening programmes aimed at assessing falls risk.

What could posturography tell us about balance in essential tremor?

BACKGROUND

Essential tremor (ET) is a neurological disorder characterized primarily by action tremor. Balance impairments in ET patients were formerly considered to be uncommon and simply age-related. However quantitative assessment with posturography has revealed impairments in control of both static and dynamic balance.

RESEARCH QUESTION

The aim of the present study is to assess postural stability with different posturographic techniques in ET patients.

METHODS

A prospective cross-sectional study conducted in two University Hospitals. Eleven patients diagnosed with essential tremor and twelve healthy controls were included. Balance assessment were performed with: sensory organization test (SOT) and limits of stability (LOS) of the computer dynamic posturography (CDP), results of free-field body sway analysis with mobile posturography (Vertiguard®), modified timed up and go test (TUG), Dizziness handicap inventory (DHI) and activities-specific balance confidence scale (ABC).

RESULTS

Patients with ET showed poorer scores in the SOT than controls for composite balance and somatosensory input. They also performed worse in LOS tests and Vertiguard® device indicated a higher risk of falling. There were no differences in the modified TUG. The mean score of DHI was 15.64 and 85.16 for ABC.

SIGNIFICANCE

Posturography assessment (CDP and Vertiguard®) is more accurate in showing balance impairment in ET patients than clinical evaluation (modified TUG). Balance impairment involves deteriorated processing of somatosensory input which could be explained by cerebellar dysfunction. Balance deficits could be included into future diagnostic criteria.

Migraine and balance impairment: Influence of subdiagnosis, otoneurological function, falls, and psychosocial factors

OBJECTIVE

To assess the balance sensory organization among patients with migraine, considering the influence of migraine subdiagnosis, otoneurological function, falls, and psychosocial factors.

BACKGROUND

Migraine has been associated with vestibular symptoms and balance dysfunction; however, neither comprehensive balance assessment nor associated factors for greater impairment have been addressed thus far.

METHODS

Patients from a tertiary headache clinic with a diagnosis of episodic migraine with aura (MWA), without aura (MWoA), and chronic migraine (CM) were included for this cross-sectional study (30 patients per group). Thirty headache-free controls (CG) were recruited. Participants underwent a comprehensive evaluation protocol, including the Sensory Organization Test (SOT) and otoneurological examination. Questionnaires about fear of falls, dizziness disability, and kinesiophobia were administered.

RESULTS

All migraine groups presented lower composite SOT scores than controls (CG: 82.4 [95% confidence interval (CI): 79.5-85.3], MWoA: 76.5 [95% CI: 73.6-79.3], MWA: 66.5 [95% CI: 63.6-69.3], CM: 69.1 [95% CI: 66.3-72.0]; p < 0.0001). Compared to controls and to MWoA, MWA and CM groups exhibited greater vestibular (CG: 75.9 [95% CI: 71.3-80.4], MWoA: 67.3 [95% CI: 62.7-71.8], MWA: 55.7 [95% CI: 51.2-60.3], CM: 58.4 [95% CI: 53.8-63.0]; p < 0.0001) and visual functional impairment (CG: 89.6 [95% CI: 84.2-94.9], MWoA: 83.2 [95% CI: 77.9-88.6], MWA: 68.6 [95% CI: 63.3-74.0], CM: 71.9 [95% CI: 66.5-77.2], p < 0.0001). Fall events during the assessment were documented more often among patients with migraine (CG: 0.0, interquartile range [IQR], 0.0, 0.0); MWoA: 1.0 [IQR: 1.0, 1.0], MWA: 2.0 [IQR: 1.8, 4.3], CM: 1.0 [IQR: 1.0, 2.0]; p = 0.001). The SOT scores correlated with fear of falls (r = -0.44), dizziness disability (r = -0.37), kinesiophobia (r = -0.38), and migraine frequency (r = -0.38). There was no significant influence of the vestibular migraine diagnosis in the study outcomes when used as a covariate in the analysis (composite score [F = 3.33, p = 0.070], visual score [F = 2.11, p = 0.149], vestibular score [F = 1.88, p = 0.172], somatosensory score [F = 0.00, p = 0.993]).

CONCLUSIONS

Aura and greater migraine frequency were related to falls and balance impairment with sensory input manipulation, although no otoneurological alterations were detected. The diagnosis of vestibular migraine does not influence the balance performance. The vestibular/visual systems should be considered in the clinical examination and treatment of patients with migraine.

Gastrocnemius Medial Head Stiffness Is Associated with Potential Fall Risk in Community-Dwelling Older Adults

The aim of this study is to compare the muscle strength, balance ability, thickness, and stiffness of the tibialis anterior and gastrocnemius muscle in the elderly, with (fallers) and without (non-fallers) fall experience, and confirmed the correlation between the variables mentioned above and muscle stiffness in the faller. We selected 122 elderly participants, comprising 40 fallers and 82 non-fallers, and measured the muscle strength of the tibialis anterior (TA) and the gastrocnemius (GA). Balance ability was measured by the functional reach test (FRT), timed up and go test (TUG), short physical performance battery (SPPB), and gait speed (GS). We used shear wave elastography (SWE) to determine the thickness of the TA and the medial (GAmed) and lateral head (GAlat) of the gastrocnemius and the stiffness during relaxation and contraction. Balance ability, except muscle strength, was significantly lower in fallers compared with non-fallers. The GAmed and GAlat thickness were significantly lower in fallers than that in non-fallers. In fallers, the thickness, rest, and contractive stiffness of GAmed were correlated with the FRT, GS, SPPB. Low rest and GAmed contractive stiffness were related to lower balance ability in fallers. The muscle stiffness measurement using SWE was a novel method to assess potential fall risk.

Reliability and learning effects of repeated exposure to the Bertec Balance Advantage sensory organisation test in healthy individuals

BACKGROUND

The Sensory Organisation Test (SOT) of computerised dynamic posturography (CDP) is a well-established clinical test used to measure postural control. Advances in technology have enabled new CDP systems to use immersive virtual reality, such as the Bertec® Balance Advantage®. While the Bertec provides an innovative approach to posturography, the reliability and learning effects of the Bertec in administering the SOT has not been thoroughly investigated.

RESEARCH QUESTION

To evaluate the reliability and performance during repeated administration of the Bertec® Balance Advantage® SOT.

METHODS

Fourteen healthy adults (age 27.17 ± 5.5years; 10 females) participated. Each participant performed five SOTs over three sessions. The first two sessions were approximately two days apart and the third one month later. In the first two sessions, two SOTs were conducted, and in the third session, one was performed. Composite, equilibrium, and ratio scores were used for analysis.

RESULTS

Poor within-session reliability was found in the first session for the composite score (ICC: 0.73, 95% CI: 0.32-0.91), which improved by the second session (ICC: 0.84, 95% CI: 0.58-0.94). Poor within-session reliability (ICC <0.5) was found for all ratio and equilibrium scores, except for the equilibrium score of condition 3, which demonstrated moderate reliability (ICC: 0.84, 95% CI: 0.57-0.95). Poor between-session reliability was found for all outcomes. There was an increase in the composite and equilibrium scores for conditions 5 and 6 over the 5 tests, which plateaued after the fourth test, and were retained at 1 month.

SIGNIFICANCE

The data demonstrate a steady increase in performance with repeated exposure to the Bertec SOT, which was maintained one month later, indicating a learning effect. We recommend that a minimum of two familiarisation sessions should be administered to establish baseline performance and improve reliability.

Trunk muscle function and anterior and posterior limits of stability in community-dwelling older adults

BACKGROUND

Understanding of the influence of trunk muscles on the older adult's limit of stability (LOS) is important for clinical practice.

OBJECTIVE

To compare the anterior and posterior LOS and the flexor and extensor trunk muscle function; verify the association of trunk muscles and LOS, and the association of LOS and the previous falls of community-dwelling older adults.

METHODS

Sample characterization data, trunk muscle function (peak torque - PT and torque steadiness - TS), LOS and previous falls (6 months) were collected from 79 older people. Comparisons were made between the variables of the anterior/posterior LOS (Reaction time, Movement velocity, Maximum excursion, Directional control), between trunk extensors/flexors muscle function and between TS at 10% and at 50%. Associations were made between the anterior/posterior LOS and the number of previous falls and between LOS and trunk muscle function.

RESULTS

The posterior LOS was worse than the anterior LOS, except for the reaction time. The flexor muscles obtained a lower PT, but better performance in TS. The TS at 10% of the trunk extensor was associated with the posterior directional control (p = 0.032). There was no association between trunk muscle function and the anterior LOS, or between previous falls and LOS.

CONCLUSIONS

The older adults presented worse performance in the posterior LOS and worse TS in the trunk extensor muscles, although the trunk extensor muscles presented a higher PT. Although no association between LOS and previous falls, the better the TS at 10% of the trunk extensors, better posterior directional control.

Older Adults with Hypertension: Prevalence of Falls and Their Associated Factors

Falls are prominent health issues among older adults. Among hypertensive older adults, falls may have a detrimental effect on their health and wellbeing. The purpose of this study is to determine the prevalence of falls among hypertensive older adults and to identify the associated factors that contribute to their falls. This was a cross-sectional study conducted among two hundred and sixty-nine hypertensive older adults who were selected via systematic random sampling in two primary health clinics in Kuala Terengganu, Malaysia. Data on their socio-demographic details, their history of falls, medication history and clinical characteristics were collected. Balance and gait were assessed using the Performance Oriented Mobility Assessment (POMA). It was found that 32.2% of participants reported falls within a year. Polypharmacy (adjusted OR 2.513, 95% CI 1.339, 4.718) and diuretics (adjusted OR 2.803, 95% CI 1.418, 5.544) were associated with an increased risk of falls. Meanwhile, a higher POMA score (adjusted OR 0.940, 95% CI 0.886, 0.996) and the number of antihypertensives (adjusted OR 0.473, 95% CI 0.319, 0.700) were associated with a low incidence of falling among hypertensive older adults. Falls are common among hypertensive older adults. Older adults who are taking diuretics and have a polypharmacy treatment plan have a higher incidence of falls. However, older adults taking a higher number of anti-hypertensive medications specifically were not associated with an increased prevalence of falls.

Validation of a next-generation sensory organization test in adults with and without vestibular dysfunction

BACKGROUND

The traditional Sensory Organization Test (T-SOT) is a gold standard balance test; however, the psychometric properties of assessing sensory organization with a virtual-reality-based posturography device have not been established.

OBJECTIVE

Our overall aims were to assess the criterion, concurrent, and convergent validity of a next-generation Sensory Organization Test (NG-SOT).

METHODS

Thirty-four adults (17 vestibular-impaired) participated. We compared the area under the curve (AUC) for receiver operator characteristic (ROC) analysis for the T-SOT and NG-SOT composite scores. Between-group and between-test differences for the composite and sensory analysis scores from each SOT were assessed using Wilcoxon Rank Sum tests. Additionally, we ran Spearman correlations between the NG-SOT composite score and outcomes of interest.

RESULTS

The AUCs for the NG-SOT and T-SOT were 0.950 (0.883, 1) and 0.990 (0.969, 1) respectively (p = 0.168). The median composite, vision, and visual preference scores were lower on the NG-SOT compared to the T-SOT; whereas, the median somatosensory score was higher on the NG-SOT compared to the T-SOT. Associations between the composite score and patient-reported or performance-based outcomes ranged from poor to strong.

CONCLUSIONS

The NG-SOT is a valid measure of balance in adults. However, the results of the NG-SOT and T-SOT should not be used interchangeably.

Modified Timed Up and Go Test for Tendency to Fall and Balance Assessment in Elderly Patients With Gait Instability

Objective: To compare the results from the modified Timed Up and Go Test (TUG) with posturographic variables, the subjective perception of disability due to gait instability, and the number of falls in a sample of the elderly population with imbalance, to confirm that the TUG Test is a useful clinical instrument to assess the tendency to fall in individuals of this age group.

Materials and Methods: Cross-sectional study conducted in a tertiary university hospital, in 174 people aged 65 years or older with gait instability. Modified TUG Test was performed; time, step count and the need for support during the test were the analyzed variables. They were compared with the number of falls, Computerized Dynamic Posturography scores, and questionnaires scores (Dizziness Handicap Inventory and a shortened version of the Falls Efficacy Scale-International).

Results: The average time to complete the TUG Test was 21.24 ± 8.18 s, and the average step count was 27.36 ± 7.93. One hundred two patients (58.6%) required no support to complete the test, whereas the other 72 (41.4%) used supports. The time taken to complete the Test was significantly related with having or not having fallen in the previous year, with the scores of the questionnaires, and with various parameters of dynamic posturography. A higher percentage of patients who took more than 15 s had fallen in the previous year than those who took up to 15 s to complete the test [P = 0.012; OR = 2.378; 95% CI (1.183, 4.780)]. No significant correlation was found between the step count and the number of falls in the previous year, with falling during the test or not, or with being a single or a frequent faller. No relation was found between the need for supports and the number of falls, with having or not having fallen in the previous year, or with being a single or frequent faller.

Conclusion: The modified TUG Test is in relation with the presence or absence of falls. Time is the essential parameter for analyzing the risk of falling and the 15-s threshold is a good value to differentiate elderly patients at high risk of falling.

Unique Identifier: NCT03034655, www.clinicaltrials.gov.

Stable and Unstable Load Carriage Effects on the Postural Control of Older Adults

The aim of this study was to investigate the effects of backpack load carriage on quiet standing postural control and limits of stability (LOS) of older adults. Fourteen older adults (65 [6] y) performed quiet standing and a forward, right, and left LOS test in 3 conditions, unloaded, stable, and unstable backpack loads while activity of 4 leg muscles was recorded. Stable and unstable loads decreased postural sway (main effect ηp2=.84, stable P < .001, unstable P < .001), mediolateral (main effect ηp2=.49, stable P = .002, unstable P = .018) and anterior-posterior (main effect ηp2=.64, stable P < .001, unstable P = .001) fractal dimension, and LOS distance (main effect ηp2=.18, stable P = .011, unstable P = .046) compared with unloaded. Rectus femoris (main effect ηp2=.39, stable P = .001, unstable P = .010) and gastrocnemius (main effect ηp2=.30, unstable P = .027) activity increased in loaded conditions during LOS and quiet standing. Gastrocnemius-tibialis anterior coactivation was greater in unstable load than stable loaded quiet standing (main effect ηp2=.24, P = .040). These findings suggest older adults adopt conservative postural control strategies minimizing the need for postural corrections in loaded conditions. Reduced LOS may also increase fall risk when carrying a load. However, there was no difference between unstable and stable loads for postural control variables.

Does patient environment have any influence on balance?

BACKGROUND

Although patient environment is a factor to consider when planning a vestibular rehabilitation program, there are no studies correlating this factor to outcomes of balance assessment.

AIM

To evaluate whether there are differences in objective evaluation of balance in elderly patients at risk of falls according to the environment in which they live (urban or rural) and their lifestyle (considering cardiovascular risk factors).

METHODS

Cross-sectional study of a sample of 139 elderly patients with high risk of falls assessed with objective outcome measures: Computer Dynamic Posturography (CDP), and the modified Timed Up-and-Go (TUG) test; and subjective outcome measures: Dizziness Handicap Inventory (DHI) and short Falls Efficacy Scale-International (short FES-I). Rural or urban environment was defined according to administrative and legal criteria.

RESULTS

Elderly patients at risk of fall living in rural environment show better composite results in SOT with better scores in Condition 6 and fewer falls during the CDP. They also require fewer steps to perform the TUG test.

DISCUSSION

The present study provides evidence that patient environment has an influence in balance.

CONCLUSION

Patient environment should be considered when analyze tests evaluating static and dynamic balance.

Postural Stability in Obese Preoperative Bariatric Patients Using Static and Dynamic Evaluation

INTRODUCTION

Globally, 300 million adults have clinical obesity. Heightened adiposity and inadequate musculature secondary to obesity alter bipedal stance and gait, diminish musculoskeletal tissue quality, and compromise neuromuscular feedback; these physiological changes alter stability and increase injury risk from falls. Studies in the field focus on obese patients across a broad range of body mass indices (BMI >30 kg/m2) but without isolating the most morbidly obese subset (BMI ≥40 kg/m2). We investigated the impact of obesity in perturbing postural stability in morbidly obese subjects elected for bariatric intervention, harboring a higher-spectrum BMI.

SUBJECTS AND METHODS

Traditional force plate measurements and stabilograms are gold standards employed when measuring center of pressure (COP) and postural sway. To quantify the extent of postural instability in subjects with obesity before bariatric surgery, we assessed 17 obese subjects with an average BMI of 40 kg/m2 in contrast to 13 nonobese subjects with an average BMI of 30 kg/m2. COP and postural sway were measured from static and dynamic tasks. Involuntary movements were measured when patients performed static stances, with eyes either opened or closed. Two additional voluntary movements were measured when subjects performed dynamic, upper torso tasks with eyes opened.

RESULTS

Mean body weight was 85% (p < 0.001) greater in obese than nonobese subjects. Following static balance assessments, we observed greater sway displacement in the anteroposterior (AP) direction in obese subjects with eyes open (87%, p < 0.002) and eyes closed (76%, p = 0.04) versus nonobese subjects. Obese subjects also exhibited a higher COP velocity in static tests when subjects' eyes were open (47%, p = 0.04). Dynamic tests demonstrated no differences between groups in sway displacement in either direction; however, COP velocity in the mediolateral (ML) direction was reduced (31%, p < 0.02) in obese subjects while voluntarily swaying in the AP direction, but increased in the same cohort when swaying in the ML direction (40%, p < 0.04).

DISCUSSION AND CONCLUSION

Importantly, these data highlight obesity's contribution towards increased postural instability. Obese subjects exhibited greater COP displacement at higher AP velocities versus nonobese subjects, suggesting that clinically obese individuals show greater instability than nonobese subjects. Identifying factors contributory to instability could encourage patient-specific physical therapies and presurgical measures to mitigate instability and monitor postsurgical balance improvements.

Slowed sensory reweighting and postural illusions in older adults: the moving platform illusion

We investigated whether postural aftereffects witnessed during transitions from a moving to a stable support are accompanied by a delayed perception of platform stabilization in older adults, in two experiments. In experiment 1, postural sway and muscle cocontraction were assessed in 11 healthy young, 11 healthy older, and 11 fall-prone older adults during blindfolded stance on a fixed platform, followed by a sway-referenced platform and then by a fixed platform again. The sway-referenced platform was more compliant for young adults, to induce similar levels of postural sway in both age groups. Participants were asked to press a button whenever they perceived that the platform had stopped moving. Both older groups showed significantly larger and longer postural sway aftereffects during platform stabilization compared with young adults, which were pronounced in fall-prone older adults. In both older groups elevated muscle cocontraction aftereffect was also witnessed. Importantly, these aftereffects were accompanied by an illusory perception of prolonged platform movement. After this, experiment 2 examined whether this illusory perception was a robust age effect or an experimental confound due to greater surface compliance in young adults, which could create a larger perceptual discrepancy between moving and stable conditions. Despite exposure to the same surface compliance levels during sway-reference, the perceptual illusion was maintained in experiment 2 in a new group of 14 healthy older adults compared with 11 young adults. In both studies, older adults took five times longer than young adults to perceive platform stabilization. This supports that sensory reweighting is inefficient in older adults. NEW & NOTEWORTHY This is the first paper to show that postural sway aftereffects witnessed in older adults after platform stabilization may be due to a perceptual illusion of platform movement. Surprisingly, in both experiments presented it took older adults five times longer than young adults to perceive platform stabilization. This supports a hypothesis of less efficient sensory reintegration in this age group, which may delay the formation of an accurate postural percept.

Optimising costs in reducing rate of falls in older people with the improvement of balance by means of vestibular rehabilitation (ReFOVeRe study): a randomized controlled trial comparing computerised dynamic posturography vs mobile vibrotactile posturography system

BACKGROUND

Accidental falls, especially for the elderly, are a major health issue. Balance disorders are one of their main causes. Vestibular rehabilitation (VR) has proven to be useful in improving balance of elderly patients with instability. Its major handicap is probably its cost, which has prevented its generalisation. So, we have designed a clinical trial with posturographic VR, to assess the optimum number of sessions necessary for a substantial improvement and to compare computerised dynamic posturography (CDP) (visual feedback) and mobile posturography (vibrotactile feedback).

METHODS

Design: randomized controlled trial. It is an experimental study, single-center, open, randomized (balanced blocks of patients) in four branches in parallel, in 220 elderly patients with high risk of falls; follow-up period: twelve months.

SETTING

Department of Otorhinolaryngology of a tertiary referral hospital.

PARTICIPANTS

people over 65 years, fulfilling two or more of the following requirements: a) at least one fall in the last twelve months. b) take at least 16 s or require some support in perform the "timed up and go" test. c) a percentage of average balance in the sensory organization test (SOT) of the CDP < 68%. d) at least one fall in any of the conditions in SOT-CDP. e) a score in Vertiguard's gSBDT > 60%.

INTERVENTION

Four differents protocols of vestibular rehabilitation (randomization of the patients).

MAIN OUTCOME MEASURE

The percentage of average balance in the SOT-CDP. Secondary measures: time and supports in the "timed up and go" test, scores of the CDP and Vertiguard, and rate of falls.

DISCUSSION

Posturographic VR has been proven to be useful for improving balance and reducing the number of falls among the aged. However, its elevated cost has limited its use. It is possible to implement two strategies that improve the cost-benefit of posturography. The first involves optimising the number of rehabilitation sessions; the second is based on the use of cheaper posturography systems.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03034655. Registered on 25 January 2017.

The Vestibular System and Ageing

The world's population is ageing due to increased hygiene and improved medical care. Dizziness and imbalance frequently affect the elderly and is most common among individuals over the age of 60. In this age group approximately 30% of the population experience these debilitating symptoms at some point. They contribute to falls and frailty, which often result in hospitalization causing tremendous cost for the health care systems, and increased mortality. To make the matters worse balance disorders are often complex. Physicians face the difficulty of diagnosing the patient with the exact disorder especially since each disorder may manifest differently in each patient. In addition, several treatment options exist, however, with a low level of evidence. This chapter summarizes the underlying degenerative processes of the peripheral as well as the central vestibular system, diagnostic tools, the most common balance disorders in the elderly, and possible treatment options of these disorders.

Impairments in Postural Control and Retest Reliability of Dynamic Posturographic Measures After Lung Transplantation

OBJECTIVES

The aims of the study were to classify impairments in postural control using computerized posturography in lung transplant recipients undergoing subacute rehabilitation and to examine the retest reliability of these measures.

METHODS

In a prospective repeated-measures study, 50 lung transplant recipients underwent clinical and quantitative posturographic testing (SMART EquiTest), which included the sensory organization test, motor control test, and limits of stability test. Testing was repeated after 1 to 2 days and upon completion of rehabilitation, 2 mos later. Main outcome measures were the following: sensory organization test-composite score, motor control test-latency and amplitude scaling, limits of stability test-movement velocity, and endpoint excursion/maximum excursion.

RESULTS

At the beginning of rehabilitation, the mean sensory organization test-composite score and limits of stability test, but not the motor control test scores, were below normative reference values and and did not return to normal after rehabilitation. Intraclass correlation coefficients(2,1) yielded excellent relative reliability for all posturographic tests. The smallest detectable differences observed for the sensory organization test and limits of stability test exceeded the mean changes observed upon completion of rehabilitation.

CONCLUSIONS

Impairments in sensory and anticipatory postural control were insufficiently restored after subacute lung transplantation rehabilitation. The little sensitivity of the sensory organization test-composite score or limits of stability test scores to detect a minimal change in performance due to rehabilitation limits the clinical applicability of these tests as objective outcome measures in lung transplantation rehabilitation.

Primary knee osteoarthritis increases the risk of falling

OBJECTIVES

The aim of this study was to investigate the effect of primary knee osteoarthritis on the risk of falling.

MATERIALS AND METHODS

One hundred participants (50 with knee osteoarthritis and 50 healthy controls) were included in this study. Primary knee osteoarthritis was diagnosed according to the American College of Rheumatology (ACR) criteria. Patients who were grade 2 or 3 by Kellgren-Lawrence criteria according to weight-bearing knee radiographs were included in this study. The risk of falling was evaluated by the interactive balance and coordination device both in the osteoarthritis and control groups. The functional status and pain were evaluated with respectively Lequesne Index and Visual Analogue Scale.

RESULTS

No statistically significant differences were found between the group of primary knee osteoarthritis and control in terms of age, BMI, and gender. The median falling index was 52 in the group with knee OA, whereas it was 31 in the control group. It was determined that primary knee osteoarthritis increased the risk of falling significantly and grade 3 primary knee osteoarthritis was statistically significantly higher than grade 2 (p < 0.001). The pain and functional status did not appear to be effective on the risk of falling in those patients (p > 0.05).

DISCUSSION

Falling is among the important causes of mortality and morbidity in advanced age. Therefore, assessment of risk factors for falling and the strategies to prevent it are important. Primary knee osteoarthritis is one of the risk factors associated with falling. Therefore, medical approaches, proprioception training, balance-gait training, muscle strengthening exercises, and arrangements to prevent domestic injurious falling should be planned to reduce the risk of falling in the presence of primary knee osteoarthritis.

Comparison of Walking, Muscle Strength, Balance, and Fear of Falling Between Repeated Fall Group, One-time Fall Group, and Nonfall Group of the Elderly Receiving Home Care Service

PURPOSE

The purpose of this study was to provide information to develop a program to prevent repeated falls by analyzing the difference in gait, muscle strength, balance, and fear of falling according to their fall experience.

METHODS

The study subjects were 110 elderly individuals aged over 60 years who agreed to their participation in this research. The study participants were categorized into a repeated fall group (n = 40), a one-time fall group (n = 15), and a nonfall group (n = 46) of the elderly. Measurements of gait, muscle strength, balance, and fear of falling were taken in each group.

RESULTS

With regard to gait, there were significant differences among three groups in gait cycle (F = 3.50, p = .034), speed (F = 13.06, p < .001), and cadence (F = 5.59, p = .005). Regarding muscle strength in the upper and lower limbs, statistically significant differences were shown among three groups in muscle strength of upper (F = 16.98, p < .001) and lower (F = 10.55, p < .001) limbs. With regard to balance, the nonfall group had significantly greater results than the one-time fall group and repeated fall group in dynamic balance (F = 10.80, p < .001) and static balance (F = 8.20, p = .001). In the case of the fear of falling, the repeated fall group had significantly higher score than other two groups (F = 20.62, p < .001).

CONCLUSION

This study suggests that intervention program should be tailored to fall risk factors to enhance gait and balance and lower body muscle strength and reduce the fear of falling to prevent repeated incidences of falls in this population.

Efficacy of CDP and ENG in Detecting Balance Impairment Associated With Cerebral White Matter Changes

OBJECTIVE

To examine the relationship between white matter changes (WMCs) and abnormal balance test results on computerized dynamic posturography (CDP) and electronystagmography (ENG). Also, to compare the utility of CDP with ENG for this purpose.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care referral center.

PATIENTS

A retrospective review of 137 subjects was conducted. The CDP and ENG results were compared between patients with (80) and without (57) WMCs as detected byT2/fluid attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI).

MAIN OUTCOME MEASURES

CDP analysis consisted of both sensory organization test (SOT) and motor control test (MCT) results, and ENG analysis included positional, oculomotor, and bithermal caloric testing. Multivariate logistic regression was performed to control for age and hearing loss discrepancies between the two groups.

RESULTS

Ninety three percent of patients with WMCs had an abnormal CDP result, as compared with 44% of patients lacking WMCs (p < 0.001). Eighty six percent of patients with WMCs had an abnormal ENG, as did 81% of patients without WMCs (p = 0.435). Multivariate regression analysis maintained that an abnormal CDP result was significantly associated with WMCs when controlling for age and hearing loss (p < 0.001).

CONCLUSION

These findings suggest that patients with cerebral small-vessel ischemic changes are significantly more likely to have an abnormal balance result as detected by CDP, than by ENG. Hence, CDP may be a better study to identify and document patients who have balance dysfunction associated with this central finding. Such identification will permit additional evaluation and treatment based on objective confirmation of balance dysfunction, in this group of balance-impaired subjects who may have normal ENG's.

Balance Performance Is Task Specific in Older Adults

Balance ability among the elderly is a key component in the activities of daily living and is divided into two types: static and dynamic. For clinicians who wish to assess the risk of falling among their elderly patients, it is unclear if more than one type of balance test can be used to measure their balance impairment. In this study, we examined the association between static balance measures and two dynamic balance field tests. One hundred and twelve community-dwelling older adults (mean age 74.6) participated in the study. They underwent the Tetrax static postural assessment and then performed the Timed Up and Go (TUG) and the Functional Reach (FR) Test as dynamic balance tests. In general, low-moderate correlations were found between the two types of balance tests. For women, age and static balance parameters explained 28.1–40.4% of the variance of TUG scores and 14.6–24% of the variance of FR scores. For men, age and static balance parameters explained 9.5–31.2% of the variance of TUG scores and 23.9–41.7% of the variance of FR scores. Based on our findings, it is suggested that a combination of both static and dynamic tests be used for assessing postural balance ability.

Ankle Proprioception-Associated Gait Patterns in Older Adults: Results from the Baltimore Longitudinal Study of Aging

INTRODUCTION

Ankle proprioception training has been found to improve balance-related gait disorders; however, the relationship between ankle proprioception and specific gait patterns in older adults with and without impaired balance has not been systematically examined.

METHODS

This study characterizes gait patterns of 230 older adults age 60-95 yr evaluated in the Baltimore Longitudinal Study of Aging gait laboratory with (n = 82) and without impaired balance (inability to successfully complete a narrow walk) and examines ankle proprioception performance.

RESULTS

Participants with impaired balance had a higher angle threshold for perceiving ankle movement than those without impaired balance even after controlling for the substantial age difference between groups (P = 0.017). Gait speed, stride length, hip and ankle range of motion, and mechanical work expenditure from the knee and ankle were associated with ankle proprioception performance (P < 0.050 for all) in the full sample, but these associations were evident only in participants with impaired balance in stratified analysis.

CONCLUSION

Ankle proprioception in older persons with balance impairment may play a role in balance-related gait disorders and should be targeted for intervention.

Reliability and Validity of the Computerized Dynamic Posturography Sensory Organization Test in People with Multiple Sclerosis

BACKGROUND

People with multiple sclerosis (MS) frequently have impaired postural control (balance). Psychometric properties of clinical tests of balance for individuals with MS, including the computerized dynamic posturography sensory organization test (CDP-SOT), are poorly understood. This study aimed to determine the reliability and discriminant validity of the CDP-SOT in people with MS.

METHODS

The CDP-SOT was performed on 30 participants with MS. A 2-week-interval, repeated-measures (sessions 1 and 2) design was implemented to investigate test-retest reliability of the CDP-SOT and the ability of the CDP-SOT to discriminate between participants with lower versus higher disability. Self-reported disability level was based on Patient-Determined Disease Steps (PDDS) scale scores: lower (PDDS scale score, 0-3; n = 17) and higher (PDDS scale score, 4-6; n = 13).

RESULTS

All six conditions of the CDP-SOT had good-to-excellent reliability (interclass correlation coefficients, 0.70-0.90) and excellent reliability for composite scores (0.90). Composite scores were significantly greater in the lower-disability group versus the higher-disability group at session 1 (70.89 vs. 48.60, P = .001) and session 2 (74.82 vs. 48.85, P = .002).

CONCLUSIONS

The CDP-SOT is a reliable measure of balance and accurately differentiates disability status in people with MS. Collectively, the results support clinical application of the CDP-SOT as a reliable and valid measure of disease-related progression of impaired balance related to sensory integration and its utility in determining changes in balance in response to treatment.

Adherence of older people with instability in vestibular rehabilitation programmes: prediction criteria

OBJECTIVE

To determine whether demographic characteristics or balance examination findings can predict the adherence of older people with instability to a vestibular rehabilitation programme.

METHODS

A prospective case-control study was conducted of 120 patients aged 65 years or more (mean age, 77.3 ± 6.33 years). Two groups were classified according to patients' adherence with the follow-up post-rehabilitation protocol. Analysed variables included: age, sex, body mass index, Timed Up and Go test findings, computerised dynamic posturography, Dizziness Handicap Inventory scores and Short Falls Efficacy Scale - International questionnaire results, number of falls, and type of vestibular rehabilitation.

RESULTS

Two groups were established: adherents (99 individuals) and non-adherents (21 individuals). There were differences between the groups regarding: sex (female-to-male ratio of 4.8:1 in adherents and 1.63:1 in non-adherents), age (higher in non-adherents) and voluntary movement posturographic test results (non-adherents had poorer scores).

CONCLUSION

The patients most likely to abandon a vestibular rehabilitation programme are very elderly males with low scores for centre of gravity balancing and limits of stability.

Balance Disorders in the Elderly: Does Instability Increase Over Time?

OBJECTIVES

To analyze the equilibriometric differences between 2 populations of elderly patients (young elderly and very elderly) with instability induced solely by age.

METHODS

Cross-sectional study, with 2 study groups classified according to patient age (cut-points in twenty-fifth and seventy-fifth percentiles of the age of the sample).

POPULATION

64 patients aged 65 years or more. Two groups of 32 subjects were established: group A (people 65 years of age or older but less than 72.6, twenty-fifth percentile) and group B (patients 82.5 years, seventh-fifth percentile, or older). Main analyzed variables: timed up-and-go test, sensory organization test of the computerized dynamic posturography, Dizziness Handicap Inventory (DHI), and Short Falls Efficacy Scale-International (FES-I) questionnaires. Student's t test or the Mann-Whitney test were used.

RESULTS

The older patients obtain poorer scores in the equilibriometric tests but not in all of them. In the sensory organization test, the older patients make poorer use of visual and vestibular information; they also require more time and steps for the timed up-and-go. With regards to the questionnaires, fear of falling is greater (higher Short FES-I scores) but not subjective perception of disability (DHI scores without differences).

CONCLUSIONS

There is a need to establish aged subgroups of elderly patients with instability, adapting therapeutic strategies.

Vertigo and Dizziness in the Elderly

The prevalence of vertigo and dizziness in people aged more than 60 years reaches 30%, and due to aging of world population, the number of patients is rapidly increasing. The presence of dizziness in the elderly is a strong predictor of falls, which is the leading cause of accidental death in people older than 65 years. Balance disorders in the elderly constitute a major public health problem, and require an adequate diagnosis and management by trained physicians. In the elderly, common causes of vertigo may manifest differently, as patients tend to report less rotatory vertigo and more non-specific dizziness and instability than younger patients, making diagnosis more complex. In this mini review, age-related degenerative processes that affect balance are presented. Diagnostic and therapeutic approaches oriented to the specific impaired system, including visual, proprioceptive, and vestibular pathways, are proposed. In addition, presbystasis – the loss of vestibular and balance functions associated with aging – benign paroxysmal positional vertigo, and stroke (in acute syndromes) should always be considered.