Falls and Parkinson's Disease: Evidence from Video Recordings of Actual Fall Events

Comparison of factors influencing fall recurrence in the young-old and old-old: a cross-sectional nationwide study in South Korea

Background

Recurrent falls are a concerning problem in the elderly. Elderly people aged > 65 years who are prone to fall often require medical treatment for severe fall-related injuries, which is associated with a substantial financial burden. Therefore, this study aimed to identify factors related to recurrent falls in the community-dwelling young-old (65–74 years old) and old-old (≥ 75 years) in South Korea.

Methods

This study used a cross-sectional, correlation design. Data from the 2017 National Survey of Older Koreans were used, and 5,838 young-old and 4,205 old-old elderly people were included in the analysis. The questionnaire included general characteristics, fall experience, physical status, mental status, and presence of chronic diseases. The data were analyzed using the chi-square test, one-way analysis of variance, and logistic regression analysis.

Results

In the young-old elderly people, limitations in activities of daily living (p < .001), use of visual aids (p = .002), cognitive function (p < .001), presence of suicidal ideations (p = .005), number of chronic diseases (p < .001), and number of prescribed medications used (p = .006) associated with fall recurrence. In the old-old elderly people, having a spouse (p = .034), being a beneficiary of the National Basic Livelihood Security System (p = .025), less exercise (p = .003), limitations in activities of daily living (p < .001), visual aid use (p = .002), presence of suicidal ideations (p = .015), number of chronic diseases (p < .001), and presence of Parkinson's disease (p < .001) associated with fall recurrence.

Conclusions

This study identified differences in factors related to fall recurrence between the young-old and old-old elderly. The results of this study indicate that it is necessary to implement an intervention program to prevent fall recurrence by age group in consideration of the risk factors for fall recurrence in each elderly people group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03172-7.

Benefits of task-specific movement program on en bloc turning in Parkinson's disease: A randomized controlled trial

INTRODUCTION

En bloc turning highlights a lack of rotational intersegmental coordination, which commonly impacts turning ability in people with Parkinson's disease (PD). Whilst this turning deficit responds fairly well to medical treatment, it may be further mitigated by performing specific exercise training. Thus, the present study aimed to examine the effects of a 4-week exercise program, which focused on task-specific movements (TSM program) on turning ability and clinical outcomes in people with PD.

METHODS

Twenty-two adults (67 ± 6 years) with early-to-mid-stage idiopathic PD were randomly assigned to an experimental group (EG; n = 11) or a control group (CG; n = 11). The exercise group (EG) group received a 60-min per session TSM program for 4 weeks (a total of 15 sessions), while the CG group performed their routine rehabilitation program (a total of 12 sessions). Inertial measurement units were used to measure turning kinematics including; onset latency of body segments and stepping characteristics. Clinical outcomes included the Unified Parkinson's Disease Rating Scale (UPDRS), functional reach test (FRT), and fall efficacy scale international (FES-I). Assessments were conducted at baseline and after 4 weeks.

RESULTS

In the EG, turning kinematics, UPDRS scores, FRT, and FES-I scale, were improved at the end of the 4-week program compared with the CG (all p < 0.05).

IMPACT STATEMENT

A 4-week TSM program could be a promising alternative rehabilitation program for improving "en bloc" turns and clinical outcomes in PD patients.

Repeated Gait Perturbation Training in Parkinson's Disease and Healthy Older Adults: A Systematic Review and Meta-Analysis

Background: Gait impairments are common in healthy older adults (HOA) and people with Parkinson's disease (PwPD), especially when adaptations to the environment are required. Traditional rehabilitation programs do not typically address these adaptive gait demands in contrast to repeated gait perturbation training (RGPT). RGPT is a novel reactive form of gait training with potential for both short and long-term consolidation in HOA and PwPD. The aim of this systematic review with meta-analysis is to determine whether RGPT is more effective than non-RGPT gait training in improving gait and balance in HOA and PwPD in the short and longer term. Methods: This review was conducted according to the PRISMA-guidelines and pre-registered in the PROSPERO database (CRD42020183273). Included studies tested the effects of any form of repeated perturbations during gait in HOA and PwPD on gait speed, step or stride length. Studies using balance scales or sway measures as outcomes were included in a secondary analysis. Effects of randomized controlled trials (RCT) on RGPT were pooled using a meta-analysis of final measures. Results: Of the 4421 studies, eight studies were deemed eligible for review, of which six could be included in the meta-analysis, totaling 209 participants (159 PwPD and 50 HOA). The studies were all of moderate quality. The meta-analysis revealed no significant effects of RGPT over non-RGPT training on gait performance (SMD = 0.16; 95% CI = -0.18, 0.49; Z = 0.92; P = 0.36). Yet, in some individual studies, favorable effects on gait speed, step length and stride length were observed immediately after the intervention as well as after a retention period. Gait variability and asymmetry, signifying more direct outcomes of gait adaptation, also indicated favorable RGPT effects in some individual studies. Conclusion: Despite some promising results, the pooled effects of RGPT on gait and balance were not significantly greater as compared to non-RGPT gait training in PwPD and HOA. However, these findings could have been driven by low statistical power. Therefore, the present review points to the imperative to conduct sufficiently powered RCT's to verify the true effects of RGPT on gait and balance in HOA and PwPD. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php? Identifier: CRD42020183273.

Effects of dual-tasking on time-to-boundary during stance in people with PD: A preliminary study

BACKGROUND

Quiet stance is impacted by Parkinson's disease and dual-tasking. Recently developed outcomes such as the time-to-boundary provide unique insight into balance by integrating center of pressure position with base of support. However, little is known about the effects of Parkinson's disease on time-to-boundary. In particular, the effects of distracting cognitive tasks, and how people with Parkinson's disease prioritize balance and cognitive tasks are poorly understood.

METHODS

14 people with Parkinson's disease and 13 controls completed quiet standing and cognitive Stroop tasks separately (single-task) and together (dual-task). 2-dimentional, medio-lateral, and anterior-posterior time-to-boundary were calculated via force-plate data. Traditional sway outcomes, including sway area and path length, were also calculated. Cognitive performance was measured as the verbal reaction time after auditory stimulus delivery. Prioritization was assessed by taking the difference between cognitive and postural dual-task interference.

FINDINGS

Time-to-boundary was worse in Parkinson's disease compared to controls (2-dimentional: p = .019; anterior-posterior: p = .062; medio-lateral: p = .012). Medio-lateral time-to-boundary, but not anterior-posterior, was significantly worse during dual-tasking than single-tasking (p = .024). Neurotypical adults tended to prioritize cognition over medio-lateral postural outcomes.

INTERPRETATION

People with Parkinson's disease exhibit worse time-to-boundary than their neurotypical peers, and medio-lateral outcomes were sensitive to single to dual-task performance changes. Further, participants generally showed cognitive prioritization, such that cognitive performance was less impacted than medio-lateral postural outcomes by dual-tasking.

Abnormal center of mass feedback responses during balance: A potential biomarker of falls in Parkinson's disease

Although Parkinson disease (PD) causes profound balance impairments, we know very little about how PD impacts the sensorimotor networks we rely on for automatically maintaining balance control. In young healthy people and animals, muscles are activated in a precise temporal and spatial organization when the center of body mass (CoM) is unexpectedly moved that is largely automatic and determined by feedback of CoM motion. Here, we show that PD alters the sensitivity of the sensorimotor feedback transformation. Importantly, sensorimotor feedback transformations for balance in PD remain temporally precise, but become spatially diffuse by recruiting additional muscle activity in antagonist muscles during balance responses. The abnormal antagonist muscle activity remains precisely time-locked to sensorimotor feedback signals encoding undesirable motion of the body in space. Further, among people with PD, the sensitivity of abnormal antagonist muscle activity to CoM motion varies directly with the number of recent falls. Our work shows that in people with PD, sensorimotor feedback transformations for balance are intact but disinhibited in antagonist muscles, likely contributing to balance deficits and falls.

Make a Left Turn: Cortico-Striatal Circuitry Mediating the Attentional Control of Complex Movements

BACKGROUND

In movement disorders such as Parkinson's disease (PD), cholinergic signaling is disrupted by the loss of basal forebrain cholinergic neurons, as well as aberrant activity in striatal cholinergic interneurons (ChIs). Several lines of evidence suggest that gait imbalance, a key disabling symptom of PD, may be driven by alterations in high-level frontal cortical and cortico-striatal processing more typically associated with cognitive dysfunction.

METHODS

Here we describe the corticostriatal circuitry that mediates the cognitive-motor interactions underlying such complex movement control. The ability to navigate dynamic, obstacle-rich environments requires the continuous integration of information about the environment with movement selection and sequencing. The cortical-attentional processing of extero- and interoceptive cues requires modulation by cholinergic activity to guide striatal movement control. Cue-derived information is "transferred" to striatal circuitry primarily via fronto-striatal glutamatergic projections.

RESULT

Evidence from parkinsonian fallers and from a rodent model reproducing the dual cholinergic-dopaminergic losses observed in these patients supports the main hypotheses derived from this neuronal circuitry-guided conceptualization of parkinsonian falls. Furthermore, in the striatum, ChIs constitute a particularly critical node for the integration of cortical with midbrain dopaminergic afferents and thus for cues to control movements.

CONCLUSION

Procholinergic treatments that enhance or rescue cortical and striatal mechanisms may improve complex movement control in parkinsonian fallers and perhaps also in older persons suffering from gait disorders and a propensity for falls. © 2021 International Parkinson and Movement Disorder Society.

Reduction of falls in a rat model of PD falls by the M1 PAM TAK-071

RATIONALE

In addition to the disease-defining motor symptoms, patients with Parkinson's disease (PD) exhibit gait dysfunction, postural instability, and a propensity for falls. These dopamine (DA) replacement-resistant symptoms in part have been attributed to loss of basal forebrain (BF) cholinergic neurons and, in interaction with striatal dopamine (DA) loss, to the resulting disruption of the attentional control of balance and complex movements. Rats with dual cholinergic-DA losses ("DL rats") were previously demonstrated to model PD falls and associated impairments of gait and balance.

OBJECTIVES

We previously found that the muscarinic M1-positive allosteric modulator (PAM) TAK-071 improved the attentional performance of rats with BF cholinergic losses. Here, we tested the hypotheses that TAK-071 reduces fall rates in DL rats.

RESULTS

Prior to DL surgery, female rats were trained to traverse a rotating straight rod as well as a rod with two zigzag segments. DL rats were refamiliarized with such traversals post-surgery and tested over 7 days on increasingly demanding testing conditions. TAK-071 (0.1, 0.3 mg/kg, p.o.) was administered prior to daily test sessions over this 7-day period. As before, DL rats fell more frequently than sham-operated control rats. Treatment of DL rats with TAK-071 reduced falls from the rotating rod and the rotating zigzag rod, specifically when the angled part of the zigzag segment, upon entering, was at a steep, near vertical angle.

CONCLUSIONS

TAK-071 may benefit complex movement control, specifically in situations which disrupt the patterning of forward movement and require the interplay between cognitive and motor functions to modify movement based on information about the state of dynamic surfaces, balance, and gait.

Video-Based Analyses of Parkinson's Disease Severity: A Brief Review

Remote and objective assessment of the motor symptoms of Parkinson's disease is an area of great interest particularly since the COVID-19 crisis emerged. In this paper, we focus on a) the challenges of assessing motor severity via videos and b) the use of emerging video-based Artificial Intelligence (AI)/Machine Learning techniques to quantitate human movement and its potential utility in assessing motor severity in patients with Parkinson's disease. While we conclude that video-based assessment may be an accessible and useful way of monitoring motor severity of Parkinson's disease, the potential of video-based AI to diagnose and quantify disease severity in the clinical context is dependent on research with large, diverse samples, and further validation using carefully considered performance standards.

Backward Protective Stepping During Dual-Task Scenarios in People With Parkinson's Disease: A Pilot Study

Introduction. Reactive movements in response to a loss of balance are altered in people with Parkinson's disease (PD) and are critical for fall prevention. Further, falls are more common while attention is divided. Although divided attention has been shown to impact postural responses in healthy older adults, the impact of dividing attention on reactive balance, and the natural prioritization across postural and cognitive tasks in people with PD is largely unknown. Objectives. To characterize (1) the impact of a secondary cognitive task on reactive postural control and (2) the prioritization across stepping and cognitive tasks in people with PD. Methods. Sixteen people with PD and 14 age-matched controls underwent step-inducing, support-surface perturbations from stance, with and without an auditory Stroop secondary cognitive task. Cognitive, neuromuscular, and protective stepping performance were calculated for single and dual task scenarios. Results. In PD and control participants, cognitive reaction times (P = .001) and muscle onset latency (P = .007), but not protective step outcomes (P > .12 for all) were worse during dual tasking compared with single-task scenarios. Both PD and control groups prioritized the protective stepping task over the cognitive task. Overall, people with PD exhibited worse first-step margin of stability (a measure of protective step performance) than controls (P = .044). Conclusion. This study provides preliminary evidence that people with PD, like age-matched controls, exhibit cognitive and neuromuscular, but not protective step, dual-task interference. The lack of dual-task interference on step performance indicates a postural prioritization for PD and healthy older adults during dual-task protective stepping.

Effect of Holding Objects on the Occurrence of Head Impact in Falls by Older Adults: Evidence From Real-Life Falls in Long-Term Care

BACKGROUND

Falls cause approximately 80% of traumatic brain injuries in older adults, and nearly one third of falls by residents in long-term care (LTC) result in head impact. Holding objects during falls, such as mobility aids, may affect the ability of LTC residents to avoid head impact by arresting the fall with their upper limbs. We examined the prevalence of holding objects and their effect on risk for head impact during real-life falls in older adults living in LTC.

METHODS

We analyzed videos of 1105 real-life falls from standing height by 425 LTC residents, using a validated questionnaire to characterize the occurrence of head impact and whether the resident held objects during descent and impact. We classified objects as either "weight-bearing" (via contact to the fixed environment, eg, chairs and walkers) or "non-weight-bearing" (eg, cups) and tested their effect on odds for head impact with generalized estimating equations.

RESULTS

Residents held objects in more than 60% of falls. The odds for head impact were reduced for falls where weight-bearing objects were held or grasped during descent (odds ratio = 0.52; 95% confidence interval = 0.39-0.70) or maintained throughout the fall (odds ratio = 0.34; 95% confidence interval = 0.23-0.49). The most commonly held objects were chairs/wheelchairs (23% of cases), tables/counters (10% of cases), and walkers/rollators (22% of cases); all reduced the odds of head impact when held during descent. Holding non-weight-bearing objects did not affect the odds of head impact (odds ratio = 1.00; 95% confidence interval = 0.64-1.55).

CONCLUSION

Our results show that older adults in LTC use held, weight-bearing objects to reduce their risk for head impact during falls.

Complex Movement Control in a Rat Model of Parkinsonian Falls: Bidirectional Control by Striatal Cholinergic Interneurons

Older persons and, more severely, persons with Parkinson's disease (PD) exhibit gait dysfunction, postural instability and a propensity for falls. These dopamine (DA) replacement-resistant symptoms are associated with losses of basal forebrain and striatal cholinergic neurons, suggesting that falls reflect disruption of the corticostriatal transfer of movement-related cues and their striatal integration with movement sequencing. To advance a rodent model of the complex movement deficits of Parkinsonian fallers, here we first demonstrated that male and female rats with dual cortical cholinergic and striatal DA losses (DL rats) exhibit cued turning deficits, modeling the turning deficits seen in these patients. As striatal cholinergic interneurons (ChIs) are positioned to integrate movement cues with gait, and as ChI loss has been associated with falls in PD, we next used this task, as well as a previously established task used to reveal heightened fall rates in DL rats, to broadly test the role of ChIs. Chemogenetic inhibition of ChIs in otherwise intact male and female rats caused cued turning deficits and elevated fall rates. Spontaneous turning was unaffected. Furthermore, chemogenetic stimulation of ChIs in DL rats reduced fall rates and restored cued turning performance. Stimulation of ChIs was relatively more effective in rats with viral transfection spaces situated lateral to the DA depletion areas in the dorsomedial striatum. These results indicate that striatal ChIs are essential for the control of complex movements, and they suggest a therapeutic potential of stimulation of ChIs to restore gait and balance, and to prevent falls in PD.SIGNIFICANCE STATEMENT In persons with Parkinson's disease, gait dysfunction and the associated risk for falls do not benefit from dopamine replacement therapy and often result in long-term hospitalization and nursing home placement. Here, we first validated a new task to demonstrate impairments in cued turning behavior in rodents modeling the cholinergic-dopaminergic losses observed in Parkinsonian fallers. We then demonstrated the essential role of striatal cholinergic interneurons for turning behavior as well as for traversing dynamic surfaces and avoiding falls. Stimulation of these interneurons in the rat model rescued turning performance and reduced fall rates. Our findings indicate the feasibility of investigating the neuronal circuitry underling complex movement control in rodents, and that striatal cholinergic interneurons are an essential node of such circuitry.

Variance of the Gait Parameters and Fraction of Double-Support Interval for Determining the Severity of Parkinson’s Disease

The aim of this study was to determine the gait features that are most suitable for the quantified assessment of the severity of Parkinson’s disease (PD). This study computed the mean and variance of the four phases of gait intervals, i.e., stride, swing, stance and double-support intervals, and lateral difference to determine the difference between three groups, i.e., control subjects and PD patients with two severity levels (early and advanced stage) of the disease, PD1 and PD2. Data from 31 subjects were used in the study. The data were obtained from the public database (16 control healthy subjects, 6 Parkinson’s disease patients with early stages, and 9 Parkinson’s disease patients with advanced stages based on the Hoehn and Yahr scale). The main outcome measure of the study was the group difference of the four gait interval parameters and the statistical significance of this difference. The results show that there was a significant increase in the variance of the four gait intervals with the severity of the disease. However, there was no significant difference in the mean values between the three groups. It was also observed that the fraction corresponding to the double-support interval was significantly higher for PD patients. This study has shown that the variance of the gait parameters and the fraction of double-support interval are associated with the severity of PD and may be suitable measures for a quantified evaluation of the disease.

Falls When Standing, Falls When Walking: Different Mechanisms, Different Outcomes in Parkinson Disease

Our retrospective study of falls and resultant trauma in consecutive Parkinson disease (PD) patients seen in one year at the Muhammad Ali Parkinson Clinic found that multiple-fallers could be divided into patients who fell mainly when walking or those who fell mainly when standing. Patients who fell when walking were more likely to visit an emergency room or be admitted to a hospital. Of 455 consecutive patients who were evaluated over a one-year period, 51 were excluded because they had atypical Parkinson disorders, had multiple risk factors for falling, or were demented. Unified Parkinson Disease Rating Scales and Zeno Walkway results were compared among non-fallers, single-fallers, and multiple-fallers. Among multiple-fallers, comparisons were made between patients who fell mainly when standing and those who fell mainly when walking. Most patients (197, 49%) did not fall, 142 (35%) fell once, and 65 (16%) fell more than once. Multiple-fallers differed significantly from single-fallers and non-fallers: they had PD significantly longer (p<0.001), were more severely affected (p<0.001), and took shorter steps (p<0.001). Of 65 multiple-fallers, 26 (40%) fell mainly when standing, 28 (43%) fell mainly when walking, and 11 (17%) fell equally often when standing or walking. Falls when walking resulted in more severe injuries. Patients who fell mainly when standing did not realize they could fall when standing; engaged in inappropriate weight shifting, bending, reaching, and multitasking; and failed to use their assistive devices. Such patients would benefit from being counseled about falling when standing. Patients who fell mainly when walking were aware they could fall, despite using an assisted device, and were more likely to have freezing of gait (FOG). They were more likely to sustain a severe injury, and were more likely to be admitted to an emergency room or hospital. Such patients would benefit from reducing, if possible, FOG.

Co-treatment with rivastigmine and idalopirdine reduces the propensity for falls in a rat model of falls in Parkinson's disease

RATIONALE

Falls in patients with Parkinson's disease (PD) are associated with cognitive, specifically attentional impairments and with losses in cholinergic projection systems. We previously established an animal model of the combined basal forebrain cholinergic-striatal dopaminergic losses of PD fallers (Dual Lesioned, DL, rats) and demonstrated that treating DL rats with an acetylcholinesterase inhibitor (AChEI), donepezil, together with a 5HT₆ receptor antagonist, idalopirdine, reduced fall frequency and improved associated aspects of the performance of DL rats traversing rotating rods.

OBJECTIVES

Here, we employed a longer and more taxing rotating beam apparatus to determine the potential therapeutic efficacy of idalopirdine when combined with the pseudo-irreversible, and thus relatively long-acting, AChE- and butyrylcholinesterase- (BuChE) inhibitor rivastigmine.

RESULTS

As before, vehicle-treated DL rats fell more frequently, committed more slips, and exhibited more movement stoppages than intact control rats. Repeated intermittent administration of rivastigmine and idalopirdine significantly improved the performance of DL rats. Rivastigmine alone also produced strong trends for reducing falls and slips. The combination treatment was more effective than rivastigmine alone in reducing stoppages and stoppage-associated falls. As before, idalopirdine treatment alone was ineffective.

CONCLUSIONS

These results extend the prediction that the combined treatment with idalopirdine and an AChEI improves complex movement control and reduces the propensity for falls in patients with movement disorders. Because of the importance of finding better treatments for gait and balance deficits in PD, the present results may further motivate a clinical exploration of the usefulness of this combination treatment.

Age at the time of hip fracture in patients with rheumatoid arthritis is 4 years greater than it was 10 years before, but is still younger than that of the general population

Objective: To investigate the characteristics of hip fractures in patients with rheumatoid arthritis (RA).Methods: Between 2012 and 2015, 789 hip fractures were treated at our hospital. Patients with RA were checked and their characteristics were compared with data recorded 10 years before, and with the general population.Results: There were 11 patients with RA, who were all female, and the mean age was 76 ± 7.0 years. The age at the time of hip fracture was 4 years older than that recorded 10 years before (72 ± 4.5 years, p < .05), but was younger than that of the general population (84 ± 8.0 years, p < .001). The mean prednisolone dose of 2.5 ± 2.6 mg/day was lower than that recorded 10 years before (4.8 ± 2.9 mg/day, p < .05). The rate of patients treated with anti-osteoporotic medications at fracture (73%) was higher than 10 years before (42%); however, the difference was not significant. The incidence of secondary fracture was not high compared to the general population. No mortality was recorded at 1 year, and no infective complications occurred.Conclusion: The age at the time of hip fracture in RA patients is increasing, but is still younger than that of the general population.

Relating Anticipatory Postural Adjustments to Step Outcomes During Loss of Balance in People With Parkinson's Disease

BACKGROUND

Effective protective steps are critical for fall prevention, and anticipatory postural adjustments (APAs) after a perturbation but prior to protective steps affect step performance. Although APAs prior to protective steps are altered in people with Parkinson's disease (PD), whether these changes affect subsequent step performance is poorly understood.

OBJECTIVE

Characterize the relationship between mediolateral APA size and protective step outcomes in response to anteroposterior balance perturbations in people with PD.

METHODS

Twenty-eight individuals with PD completed 25 forward and 25 backward protective steps in response to support surface translations. Multilevel linear models related mediolateral APA size to protective step outcomes.

RESULTS

During forward protective stepping, larger mediolateral APAs were associated with delayed ( P < .001) and larger ( P = .004) steps. Larger APAs were also associated with smaller mediolateral ( P < .001) but larger anterior-posterior center of mass movement at foot off ( P < .001). During backward stepping, larger APAs were associated with later steps ( P < .001) and smaller anterior-posterior margin of stability at first foot contact ( P < .001). During backward stepping, larger APAs were also associated with worse clinical (ie, UPDRS [Unified Parkinson's Disease Rating Scale]; P = .005) and balance (ie, MiniBEST [Mini-Balance Evaluation Systems Test]; P = .021) outcomes.

CONCLUSIONS

During forward protective stepping, larger APAs were associated with larger and later steps, suggesting APA size may have mixed effects on the subsequent step. During backward stepping, larger APAs were associated with worse stepping outcomes (ie, later steps, smaller anterior-posterior margin of stability, worse clinical outcomes). Interventions aimed at improving APAs in PD should monitor spatial and temporal protective step outcomes to ensure treatment does not negatively affect protective steps, particularly for forward stepping.

Turn Around Freezing: Community-Living Turning Behavior in People with Parkinson's Disease

Difficulty in turning while walking is common among patients with Parkinson’s disease (PD). This difficulty often leads to significant disability, falls, and loss of function; moreover, turning is a common trigger for freezing of gait (FoG). We hypothesized that the quantity and quality of turning mobility while walking during daily life would be different among subjects with PD with and without FoG. Here, we investigated, for the first time, the turning quality during daily life as it relates to FoG in people with PD using a single inertial sensor. Ninety-four subjects with PD (among whom 25 had FoG) wore an inertial sensor attached by a belt on the lower back during normal daily activity consecutively for 3 days. An algorithm identified periods of walking and calculated the number and quality metrics of turning. Quality, but not the quantity, of turning at home was different in freezers compared to the non-freezers. The number of turns (19.3 ± 9.2/30 min in freezers, 22.4 ± 12.9/30 min non-freezers; p = 0.194) was similar in the two groups. Some aspects of quality of turns, specifically mean jerkiness, mean and variability of medio-lateral jerkiness were significantly higher (p < 0.05) in the freezers, compared to non-freezers. Interestingly, subjects with FoG showed specific turning differences in the turns with larger angles compared to those without FoG. These findings suggest that turning during daily activities among patients with PD is impaired in subjects with FoG, compared to subject without freezing. As such, clinical decision-making and rehabilitation assessment may benefit from measuring the quality of turning mobility during daily activities in PD.

Falls in Parkinson's disease: A complex and evolving picture

Falls are a major determinant of poor quality of life, immobilization, and reduced life expectancy in people affected by Parkinson's disease (PD) and in older adults more generally. Although many questions remain, recent research has advanced the understanding of this complex problem. The goal of this review is to condense new knowledge of falls in PD from prodromal to advanced disease, taking into account risk factors, assessment, and classification as well as treatment. The fundamental steps of clinical and research-based approaches to falls are described, namely, the identification of fall risk factors, clinical and instrumental methods to evaluate and classify fall risk, and the latest evidence to reduce or delay falls in PD. We summarize recent developments, the direction in which the field should be heading, and what can be recommended at this stage. We also provide a practical algorithm for clinicians.© 2017 International Parkinson and Movement Disorder Society.

Reduction in Fall Rate in Dementia Managed Care Through Video Incident Review: Pilot Study

Background

Falls of individuals with dementia are frequent, dangerous, and costly. Early detection and access to the history of a fall is crucial for efficient care and secondary prevention in cognitively impaired individuals. However, most falls remain unwitnessed events. Furthermore, understanding why and how a fall occurred is a challenge. Video capture and secure transmission of real-world falls thus stands as a promising assistive tool.

Objective

The objective of this study was to analyze how continuous video monitoring and review of falls of individuals with dementia can support better quality of care.

Methods

A pilot observational study (July-September 2016) was carried out in a Californian memory care facility. Falls were video-captured (24×7), thanks to 43 wall-mounted cameras (deployed in all common areas and in 10 out of 40 private bedrooms of consenting residents and families). Video review was provided to facility staff, thanks to a customized mobile device app. The outcome measures were the count of residents’ falls happening in the video-covered areas, the acceptability of video recording, the analysis of video review, and video replay possibilities for care practice.

Results

Over 3 months, 16 falls were video-captured. A drop in fall rate was observed in the last month of the study. Acceptability was good. Video review enabled screening for the severity of falls and fall-related injuries. Video replay enabled identifying cognitive-behavioral deficiencies and environmental circumstances contributing to the fall. This allowed for secondary prevention in high-risk multi-faller individuals and for updated facility care policies regarding a safer living environment for all residents.

Conclusions

Video monitoring offers high potential to support conventional care in memory care facilities.

Reverse Total Shoulder Arthroplasty as Treatment for Rotator Cuff-Tear Arthropathy and Shoulder Dislocations in an Elderly Male with Parkinson's Disease

We report the case of a 70-year-old male with Parkinson's disease (PD) and recurrent traumatic left shoulder dislocations. This case is rare because (1) he had a massive irreparable rotator cuff tear and end-stage arthritis (i.e., rotator cuff-tear arthropathy) of the same shoulder and (2) his shoulder was ultimately reconstructed with a reverse total shoulder arthroplasty (RTSA). His first dislocation occurred after a fall. Recurrent shoulder dislocations occurred despite successful closed reduction and physical therapy. Initial surgical treatment included an open capsular-labral reconstruction; RTSA was not an ideal option because of the presumed risk of failure from PD-related dyskinesias. However, the capsular-labral reconstruction failed after he lost balance and stumbled but did not fall. A RTSA was then done which restored the patient's shoulder stability and greatly improved his pain. At final follow-up two years later, he reported pain relief and improved function. This was partially attributed to the fact that he had moved to an assisted living center. He also began using an electric wheelchair one year after the RTSA. We report this case because of the unusual set of conditions and circumstances, namely, the implantation of a RTSA in a patient with PD and shoulder instability.

Disparate effects of training on brain activation in Parkinson disease

OBJECTIVE

To compare the effects of 2 forms of exercise, i.e., a 6-week trial of treadmill training with virtual reality (TT + VR) that targets motor and cognitive aspects of safe ambulation and a 6-week trial of treadmill training alone (TT), on brain activation in patients with Parkinson disease (PD).

METHODS

As part of a randomized controlled trial, patients were randomly assigned to 6 weeks of TT (n = 17, mean age 71.5 ± 1.5 years, disease duration 11.6 ± 1.6 years; 70% men) or TT + VR (n = 17, mean age 71.2 ± 1.7 years, disease duration 7.9 ± 1.4 years; 65% men). A previously validated fMRI imagery paradigm assessed changes in neural activation pretraining and post-training. Participants imagined themselves walking in 2 virtual scenes projected in the fMRI: (1) a clear path and (2) a path with virtual obstacles. Whole brain and region of interest analyses were performed.

RESULTS

Brain activation patterns were similar between training arms before the interventions. After training, participants in the TT + VR arm had lower activation than the TT arm in Brodmann area 10 and the inferior frontal gyrus (cluster level familywise error-corrected [FWEcorr] p < 0.012), while the TT arm had lower activation than TT + VR in the cerebellum and middle temporal gyrus (cluster level FWEcorr p < 0.001). Changes in fall frequency and brain activation were correlated in the TT + VR arm.

CONCLUSIONS

Exercise modifies brain activation patterns in patients with PD in a mode-specific manner. Motor-cognitive training decreased the reliance on frontal regions, which apparently resulted in improved function, perhaps reflecting increased brain efficiency.

The Influence of Parkinson Disease on Lumbar Decompression Surgery: A Retrospective Case Control Study

BACKGROUND

Parkinson disease (PD) is a major risk factor during spine surgery, and its frequency is increasing as the population ages. The study aim was to examine the influence of PD specifically on lumbar decompression surgery.

METHODS

A retrospective review was performed of all patients with PD who underwent elective lumbar decompression surgery at 2 university hospital departments between December 2003 and July 2016. For each patient, 2 controls without PD were selected randomly among those who were matched for sex and age and had a similar year of surgery (±3) and comorbidity profile. The main outcomes were complications and reoperation rate.

RESULTS

The mean follow up was 1.2 ± 1.6 years in the PD group (n = 36) and 1.4 ± 2.1 years in the control group (n = 72). The overall complication rate was 47.2% in the PD group and 19.4% in the control group (P < 0.01). The reoperation rate was 27.8% in the PD group and 9.7% in the control group (P = 0.02).

CONCLUSIONS

There is a significantly greater rate of perioperative complications in patients with PD undergoing elective decompression surgery. Although the difference in major complication rates was minimal, minor complications were more frequent in patients with PD.

Falling Direction can Predict the Mechanism of Recurrent Falls in Advanced Parkinson's Disease

Falls are a common and disabling symptom in patients with Parkinson’s disease (PD). For prevention, it is important to understand the pathophysiology of falls in PD patients, but the predictors for the possible mechanisms underlying such falls have not been clearly elucidated. In this prospective observational study, we investigated the implications of falling direction to predict the mechanisms of recurrent falls in PD patients. We enrolled 62 recurrent fallers with PD and divided them into two groups according to the main falling directions: 45 PD fallers who fell forward (forward fallers), and 17 PD fallers who fell in the other directions (non-forward fallers). Although there was no difference in demographic data, parkinsonism, or frontal lobe function, forward fallers showed more severe falls and tended to fall during walking or turning, while non-forward fallers usually fell during sitting/standing or turning. Additionally, forward fallers revealed higher score on a freezing of gait (FOG) questionnaire. Logistic regression analysis demonstrated that FOG was associated with falling forward, while balance impairment, akinetic-rigid subtype, and neuropsychiatric symptoms were associated with falling into the other directions. Our results indicate that FOG and balance impairment are two major mechanisms for recurrent falling in PD patients, and falling direction is an important predictor for these mechanisms.

Objective characterization of daily living transitions in patients with Parkinson's disease using a single body-fixed sensor

Body-fixed sensors (BFS), e.g., accelerometers worn for several days, can be used to augment the traditional clinical assessment. Long-term recordings obtained with BFS have been applied to study tremor, postural control, freezing of gait, turning abilities, motor response fluctuations and fall risk among older adults and patients with Parkinson's disease (PD). We aimed to test whether BFS-derived measures of transitions differ between patients with PD and healthy controls, and to evaluate whether there are differences among patients with mild PD, compared to more severe patients, and to controls. We also explored the added value of the metrics extracted from the sensor as compared to traditional testing in the lab. Ninety-nine patients with PD and 38 healthy older adults (HOA) participated in this study and wore a body-fixed sensor for 3 days. Walk-to-sit (n = 3286) and Sit-to-walk (n = 2858) transitions were analyzed and a machine learning algorithm was applied to distinguish between the groups. Significant differences in transitions were observed between PD patients and HOA, between mild and severe PD, and between mild PD and HOA, both in temporal and distribution features. The machine learning algorithm discriminated patients from HOA (accuracy = 92.3 %), mild from severe patients (accuracy = 89.8 %), and mild patients from HOA (accuracy = 85.9 %). These initial results suggest that body-fixed sensor-derived metrics of everyday transitions can characterize disease severity and differentiate mild PD patients from healthy older adults. Perhaps this approach can help with the integration of BFS into clinical care and the tracking of disease progression and the response to therapy.