Preventing falls in multiple sclerosis: a qualitative study on user requirements for a self-management programme.

PURPOSE: To explore perspectives of ambulatory and non-ambulatory people with MS (PwMS) and health care professionals (HCPs) on falls and falls management to gain a deeper understanding of how a self-management programme can be designed to fit the needs of end users. MATERIALS AND METHODS: Twelve PwMS and seven HCPs participated in three four-hour workshops based on Design Thinking. Collected data were field notes and digital post-it notes gathered at the workshops. Data were analyzed using qualitative content analysis with an inductive approach. RESULTS: Two main categories, "Managing the complexity of fall-risk behaviour" and "Embracing diversity to establish group engagement", comprising a total of seven categories were constructed from the analysis. The first main category reflects the challenges PwMS face in managing fall risk in their daily lives, and the support needed to address these challenges. The second main category highlights how engaging in peer learning activities can fulfil individual needs and improve learning outcomes for PwMS. CONCLUSION: A self-management fall prevention programme that is relevant to PwMS regardless of ambulation level should include the development of self-tailored behavioural strategies to prevent falls along with interactive learning activities with other PwMS.

A self-management fall prevention programme should be customized to individual fall prevention needs and circumstances in daily life.A self-management fall prevention programme conducted online can enable accessibility for ambulatory and non-ambulatory people with multiple sclerosis (PwMS).Peer learning in groups with other PwMS can facilitate the development of self-tailored fall prevention strategies and provide positive reinforcement to support behavioral change.

Self-management of falls in people with multiple sclerosis: A scoping review.

OBJECTIVE: Falls are common in people with multiple sclerosis. There is rising interest in how the multifactorial and chronic nature of fall risk among people with multiple sclerosis can be addressed through self-management. Thus, the aims were to investigate the extent and the scope of publications on self-management of falls in people with multiple sclerosis, and to identify how the concept of self-management was defined and used. DATA SOURCES: A systematic literature search in Medline, Cochrane, Web of Science and PsycInfo was conducted to identify publications until July 2022. REVIEW METHODS: Published methodological guidance was followed. Articles targeting: (1) people with multiple sclerosis, (2) falls, and (3) self-management were selected. Of 1656 records, 203 publications were assessed for eligibility, of which 173 did not meet the inclusion criteria, and 16 publications did not contain empirical data. The type of publication, study focus, and study design was extracted. If applicable, key findings, self-management tasks and skills, and the definition of self-management were extracted. RESULTS: Fourteen original articles met all inclusion criteria. Ten articles represented six different fall prevention interventions. Three publications were randomized controlled trials. Self-management content was variable and not comprehensive in nature. None of the 14 publications included a self-management definition. CONCLUSION: The limited number of original articles and the even fewer intervention studies show that the research on self-management of falls in people with multiple sclerosis is in its infancy. To progress in the research area of self-management of falls, a more robust, consensus-based description of self-management frameworks and activities is needed.

Online self-management fall prevention intervention for people with multiple sclerosis: a feasibility study protocol of a parallel group randomised trial.

INTRODUCTION: Falls among people with multiple sclerosis (PwMS) are common and associated with injuries, fear of falling and low health-related quality of life. Considerations of behavioural, environmental, psychological and physical influences (including ambulation status) are needed to meet fall prevention needs for PwMS. Thus, using a codesign process involving key stakeholders a novel online self-management fall prevention intervention was created specifically for ambulatory and non-ambulatory PwMS. The feasibility, acceptability, fidelity and outcome of this complex intervention will be explored. Findings will inform a future full-scale randomised controlled trial. METHODS AND ANALYSIS: A mixed-method design will be used. Forty-eight PwMS, stratified for ambulation level, will be randomised to control (n=24) or intervention (n=24). Both groups will receive a brochure about fall risk factors and fall prevention. The intervention is group-based (eight PwMS in each group); will be delivered online; and involve six, 2-hour weekly sessions and a booster session 8 weeks after the sixth session. Each intervention group will be led by a trained facilitator. Data collection will be performed at baseline, and after seven and 18 weeks. Outcome measures will capture data on fall prevention behaviours, fear of falling, falls self-efficacy, social and everyday activities, perceived impact of MS and number of falls. Feasibility of recruitment process, data collection procedures, outcome measures, and delivery, and intervention acceptability, fidelity and outcomes will be evaluated. Both quantitative and qualitative methods will be used. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Swedish Ethical Review Authority (registration number 2021-04817). Results will be disseminated in peer-review journals, at conferences, research meetings, in social media and through the patient organisation Neuro Sweden. TRIAL REGISTRATION NUMBER: NCT04317716.

What Predicts Falls, and what are the Circumstances and Consequences of Falls in Community-Dwelling Older Adults Who Need Walking Aids or Home Help Service.

The objective was to analyze predictive variables for falls in older community-dwelling adults who needed walking aids or home help service, to describe the circumstances and consequences of falls and fall injuries, and to describe the activities preceding falls, n = 175, mean age 83 years. Falls were self-reported monthly in a fall calendar and were followed up by a telephone interview. A logistic regression analysis was performed to investigate predictive baseline variables for falls. Injuries were reported in 82 of the 185 fall events. Previous falls and a high level of education had a significant association with falls odds ratios 1.9 (95% CI 1.3-2.7), and 2.7 (95% CI 1.4-5.3). Activities preceding the falls were classified according to the International Classification of Functioning (ICF). Falls and fall injuries were most common while moving around within the home and rising from sitting to standing.

The Otago Exercise Program With or Without Motivational Interviewing for Community-Dwelling Older Adults: A 12-Month Follow-Up of a Randomized, Controlled Trial.

The aim of this randomized controlled trial was to examine the 12-month effects of the home-based Otago Exercise Program (OEP) with or without the support of motivational interviewing (MI) on community-dwelling people 75 years and older who needed walking aids and/or home help service. In total, 175 participants were randomized into three groups: OEP (n = 61), OEP with MI (n = 58), and a control group (n = 56) (M age = 83 years). Measures were physical performance, physical activity level, balance, grip strength, fall-related self-efficacy, fall rate, and fall injury rate. The OEP with and the OEP without MI, with the support of a physical therapist (six home visits and three phone calls), demonstrated no benefits in any of the measures compared with a control group. In this subgroup of pre-frail older adults, more frequent support by personnel may be required to secure efficient intensity and progression in the exercises performed on your own at home.

Fall Prevention Exercises With or Without Behavior Change Support for Community-Dwelling Older Adults: A Two-Year Follow-Up of a Randomized Controlled Trial.

This study investigates the effectiveness of two fall prevention exercise interventions targeting physical performance, activity level, fall-related self-efficacy, health-related quality of life, and falls: the Otago Exercise Programme (OEP) with and the OEP without behavior change support. In this randomized controlled trial (RCT), 175 participants were randomised into two intervention groups and one control group. A total of 124 community-dwelling older adults over the age of 75 who needed walking aids or home support participated in the two-year follow-up. The OEP with and the OEP without support for behavior change displayed no long-term benefits on physical performance, fall-related self-efficacy, health-related quality of life, and falls compared to a control group. Although no significant differences were detected between the groups, the results implied the control group's physical activity level decreased compared to the intervention groups at two-year follow up.

Older Adults' Opinions on Fall Prevention in Relation to Physical Activity Level.

The purpose of this study was to explore and describe older adults' opinions regarding actions to prevent falls and to analyze differences in the opinions of highly versus less physically active older adults. An open-ended question was answered by 262 individuals aged 75 to 98 years living in the community. The answers were analyzed using qualitative content analysis, and differences in the categories were compared between highly and less physically active persons. Physical activity was measured according to a five-level scale. The content analysis resulted in eight categories: assistive devices, avoiding hazards, behavioral adaptive strategies, being physically active, healthy lifestyle, indoor modifications, outdoor modifications, and seeking assistance. Behavioral adaptive strategies were mentioned to a greater extent by highly active people, and indoor modifications were more often mentioned by less active older adults. Support for active self-directed behavioral strategies might be important for fall prevention among less physically active older adults.

A feasibility study of a randomised controlled trial comparing fall prevention using exercise with or without the support of motivational interviewing.

OBJECTIVE: The aim of this investigation was to study the feasibility of a randomised controlled trial (RCT) based on a multicentre fall prevention intervention including exercise with or without motivational interviewing compared to standard care in community-living people 75 years and older. METHOD: The feasibility of a three-armed, randomised controlled trial was evaluated according to the following: process, resources, management by questionnaire, and treatment outcomes. The outcome measures were fall frequency, physical performance and falls self-efficacy evaluated after three months. Twelve physiotherapists conducted the measurements and treatments and responded to the questionnaire. The first 45 participants recruited to the ongoing RCT were included: 16 individuals in the Otago Exercise Program group (OEP), 16 individuals in the OEP combined with motivational interviewing group (MI), and 13 individuals in the control group. The study was conducted from November 2012 to December 2013. RESULTS: The feasibility of the study process, resources and management reached the set goals in most aspects; however, the set goal regarding the MI guide and planned exercise for the participating older people was not completely reached. No significant differences were found between the groups regarding the outcome measures. CONCLUSION: This study confirmed the acceptable feasibility for the study protocol in the ongoing RCT.

Abnormal functional connectivity of the medial cortex in euthymic bipolar II disorder.

This project utilized functional MRI (fMRI) and a motor activation paradigm to investigate neural circuitry in euthymic bipolar II disorder. We hypothesized that circuitry involving the cortical midline structures (CMS) would demonstrate abnormal functional connectivity. Nineteen subjects with recurrent bipolar disorder and 18 controls were studied using fMRI and a motor activation paradigm. We used functional connectivity analyses to identify circuits with aberrant connectivity. We found increased functional connectivity among bipolar subjects compared to healthy controls in two CMS circuits. One circuit included the medial aspect of the left superior frontal gyrus and the dorsolateral region of the left superior frontal gyrus. The other included the medial aspect of the right superior frontal gyrus, the dorsolateral region of the left superior frontal gyrus and the right medial frontal gyrus and surrounding region. Our results indicate that CMS circuit dysfunction persists in the euthymic state and thus may represent trait pathology. Future studies should address whether these circuits contribute to relapse of illness. Our results also suggest the possibility that aberrations of superior frontal circuitry may impact default mode network and cognitive processes.

Striatal circuit function is associated with prior self-harm in remitted major depression.

The neural processes underlying suicide risk are incompletely characterized. This project utilized functional MRI (fMRI) to determine whether a history of self-harm was associated with striatal circuit function in recurrent major depression in remission. Twenty unmedicated subjects with recurrent major depression and 21 controls were studied using fMRI and a motor activation paradigm. We used functional connectivity analyses to identify circuits with aberrant connectivity. We also used correlational analyses to determine whether functional connectivity was associated with a history of self-harm. There was a significant association between history of self-harm and functional connectivity of a striatal-motor circuit. Additionally, striatal and cortical midline circuits exhibited decreased functional connectivity in remitted unipolar depression as compared to controls. Our previous study of individuals experiencing an episode of depression indicated an association between striatal circuitry and a history of self-harm. That study, along with the results reported herein suggests striatal circuit function may play a key role in the neurobiology of suicide and self-harm risk in recurrent major depression. Our results also indicate that both striatal and CMS circuit dysfunction persists in the euthymic state of recurrent major depression and thus may represent trait pathology.

Differences in functional connectivity in major depression versus bipolar II depression.

BACKGROUND: Objective methods of differentiating unipolar versus bipolar depression would enhance our ability to treat these disorders by providing more accurate diagnoses. One first step towards developing diagnostic methodology is determining whether brain function as assessed by functional MRI (fMRI) and functional connectivity analyses might differentiate the two disorders. METHODS: Fourteen subjects with bipolar II depression and 26 subjects with recurrent unipolar depression were studied using fMRI and functional connectivity analyses. RESULTS: The first key finding of this study was that functional connectivity of the right posterior cingulate cortex differentiates bipolar II and unipolar depression. Additionally, results suggest that functional connectivity of this region is associated with suicidal ideation and depression severity in unipolar but not bipolar II depression. LIMITATIONS: The primary limitation is the relatively small sample size, particularly for the correlational analyses. CONCLUSIONS: The functional connectivity of right posterior cingulate cortex may differential unipolar from bipolar II depression. Further, connectivity of this region may be associated with depression severity and suicide risk in unipolar but not bipolar depression.

Functional architecture of the cortico-basal ganglia circuitry during motor task execution: correlations of strength of functional connectivity with neuropsychological task performance among female subjects.

The primary aim of this study was to enhance our understanding of the functional architecture of the cortico-basal ganglia circuitry during motor task execution. Twenty right-handed female subjects without any history of neuropsychiatric illness underwent fMRI at 3 T. The activation paradigm was a complex motor task completed with the nondominant hand. Analyses of functional connectivity strength were conducted for pairs of structures in input, intrinsic, and output segments of the circuitry. Next, connectivity strengths were correlated with results of neurocognitive testing conducted outside of the scanner, which provided information about both motor and cognitive processes. For input pathways, results indicate that SMA-striatum interactions are particularly relevant for motor behavior and disruptions may impact both motor and cognitive functions. For intrinsic pathways, results indicate that thalamus (VA nucleus) to striatum feedback pathway appears to have an important role during task execution and carries information relevant for motor planning. Together, these findings add to accumulating evidence that the GPe may play a role in higher order basal ganglia processing. A potentially controversial finding was that strong functional connectivity appears to occur across intrinsic inhibitory pathways. Finally, output (thalamus to cortex) feedback was only correlated with motor planning. This result suggests circuit processes may be more relevant for future behaviors than the execution of the current task.

Aberrant functional connectivity of cortico-basal ganglia circuits in major depression.

There is considerable evidence of functional abnormalities of the cortico-basal ganglia circuitry in affective disorders. However, it has been unknown whether this represented primary pathology within these circuits or altered activation as a result of aberrant input from other brain regions. The aim of this study was to test the hypothesis that cortico-basal ganglia circuit dysfunction represents primary pathology in unipolar depression. Eighteen male subjects with recurrent unipolar depression and eighteen controls without psychiatric illness were studied using functional MRI and functional connectivity analyses. All unipolar subjects were unmedicated and without current psychiatric comorbidity. Compared to controls, unipolar subjects exhibited altered connectivity between bilateral subcortical components of the circuitry (putamen-thalamus) and left hemisphere input and output components. Results provided evidence that functional abnormalities of these circuits represent primary pathology. Further, we found that age of onset but not duration of illness impacts circuit function. These findings suggest that the cortico-basal ganglia circuitry is likely one of several loci of primary pathology in major depression. Additionally, early age of onset is associated with greater circuit abnormality and as such may impact clinical characteristics and/or treatment response through a mechanism of decreasing functional connectivity of some circuit segments. Finally, altered cortico-basal ganglia circuit connectivity with cortical regions (anterior cingulate, inferior frontal gyrus and sensorimotor) may contribute to the emotional dysregulation, impaired emotional recognition and psychomotor symptoms associated with unipolar illness.

Striatal and cortical midline circuits in major depression: implications for suicide and symptom expression.

BACKGROUND: In major depression, the neural mechanisms underlying suicide related thoughts and behaviors as well as the expression of other depressive symptoms are incompletely characterized. Evidence indicates that both the striatum and cortical midline structures (CMS) may be involved with both suicide and emotional dysregulation in unipolar illness. The aim of this study was to identify striatal-CMS circuits associated with current depression severity and suicidal ideation (SI) as well as a history of self-harm. METHODS: Twenty-two male subjects with recurrent unipolar depression were studied using functional MRI. All subjects were unmedicated and without current psychiatric comorbidity. Correlational analyses were used to determine whether striatal-CMS functional connectivity was associated with any of the three clinical variables. RESULTS: A network involving the bilateral striatum and anterior CMS was found to be associated with depressive symptom severity. Current SI was associated with a similar but less extensive circuit in the left hemisphere. A distinct striatal motor/sensory network was associated with self-harm behaviors, but not current SI or depression severity. CONCLUSIONS: The striatal-anterior CMS circuit likely plays a significant role in the expression of depressive symptoms and SI. In contrast, a striatum-motor/sensory cortex network may be a trait marker of suicide-related behaviors. If replicated, this result might eventually lead to the development of a biomarker that would be useful for studies of pharmacologic and/or psychotherapeutic suicide prevention interventions.

Aberrant emotional processing in posterior cortical midline structures in bipolar II depression.

Bipolar II depression is a serious and disabling illness associated with significant impairment and high rates of suicide attempts. However, mechanisms underlying emotional dysregulation in this condition are poorly characterized. The goal of this work was to investigate one component of emotional processing in this disorder, brain activation associated with exposure to emotional faces. Functional MRI was used to study 16 unmedicated male subjects with bipolar II depression and 19 healthy male controls. The activation paradigm exposed subjects to happy, fearful and neutral faces. The two key findings of this study were as follows. First, bipolar subjects demonstrated significantly decreased activation in response to happy facial expression in the left posterior cortical midline structures (CMS) and frontal cortex. Second, depression severity was positively correlated with activation of the posterior CMS and other regions. Our results suggest that mechanisms involving CMS dysfunction may play a role in the neurobiology of bipolar II depression as has been demonstrated for unipolar illness. Further investigations of CMS function in bipolar spectrum disorders are warranted.

Striatal and cortical midline activation and connectivity associated with suicidal ideation and depression in bipolar II disorder.

BACKGROUND: Considerable evidence implicates dysfunction of striatal and cortical midline structure (CMS) circuitry in mood disorders. Whether such aberrations exist in bipolar II depression is unknown. METHODS: Sixteen unmedicated subjects with bipolar II depression and 19 healthy controls were studied using functional MRI and a motor activation paradigm. Analyses of both activation and functional connectivity were conducted. RESULTS: A history of suicidal ideation (SI) was negatively correlated with activation of the left putamen while depression severity was positively correlated with activation of the left thalamus. The superior bilateral putamen was simultaneously correlated with depression severity and anti-correlated with SI. Striatal functional connectivity was altered with the bilateral CMS and right inferior parietal lobule. Depression severity was correlated with strength of connectivity between the bilateral striatum and the right lingual gyrus and left cerebellum. LIMITATIONS: Only males experiencing an episode of major depression were studied. CONCLUSIONS: Striatal and CMS circuit abnormalities likely contribute to the neurobiology of bipolar II depression. Altered connectivity of the striatum may directly impact depression severity. Further, dissociable components of activation associated with depression severity and suicidal ideation may exist. Finally, the motor activation paradigm used in this study appears to be a useful probe of some neural processes underlying bipolar II depression.

Age-related changes of the functional architecture of the cortico-basal ganglia circuitry during motor task execution.

Normal human aging is associated with declining motor control and function. It is thought that dysfunction of the cortico-basal ganglia circuitry may contribute to age-related sensorimotor impairment, however the underlying mechanisms are poorly characterized. The aim of this study was to enhance our understanding of age-related changes in the functional architecture of these circuits. Fifty-nine subjects, consisting of a young, middle and old group, were studied using functional MRI and a motor activation paradigm. Functional connectivity analyses and examination of correlations of connectivity strength with performance on the activation task as well as neurocognitive tasks completed outside of magnet were conducted. Results indicated that increasing age is associated with changes in the functional architecture of the cortico-basal ganglia circuitry. Connectivity strength increased between subcortical nuclei and cortical motor and sensory regions but no changes were found between subcortical components of the circuitry. Further, increased connectivity was correlated with poorer performance on a neurocognitive task independently of age. This result suggests that increased connectivity reflects a decline in brain function rather than a compensatory process. These findings advance our understanding of the normal aging process. Further, the methods employed will likely be useful for future studies aimed at disambiguating age-related versus illness progression changes associated with neuropsychiatric disorders that involve the cortico-basal ganglia circuitry.