Fall risk in people with MS: A Physiological Profile Assessment study.

INTRODUCTION: The Physiological Profile Assessment (PPA) is used in research and clinical practice for assessing fall risk. We compared PPA test performance between people with multiple sclerosis (MS) and healthy controls, determined the fall-risk profile for people with MS and developed a reference database for people with MS. METHODS: For this study, 416 ambulant people with MS (51.5 ± 12.0 years) and 352 controls (52.8 ± 12.2 years) underwent the PPA (tests of contrast sensitivity, proprioception, quadriceps strength, reaction time and sway) with composite fall-risk scores computed from these measures. MS participants were followed prospectively for falls for 3 months. RESULTS: The MS participants performed significantly worse than controls in each PPA test. The average composite fall-risk score was also significantly elevated, indicating a "marked" fall risk when compared with controls. In total, 155 MS participants (37.3%) reported 2 + falls in the follow-up period. Frequent fallers performed significantly worse than non-frequent fallers in the contrast sensitivity, reaction time and sway tests and had higher PPA composite scores. CONCLUSIONS: In line with poor PPA test performances, falls incidence in people with MS was high. This study provides comprehensive reference data for the PPA measures for people with MS that could be used to inform future research and clinical practice.

Developing networks between residential aged care facilities as a result of engagement in a falls prevention project: an action research study.

BACKGROUND: Residential aged care facility (RACF) staff often operate in isolation. Research is lacking on networking between facilities. AIMS: To explore outcomes associated with network formation between two RACFs as part of an action research approach to reducing falls. DESIGN: Action research approach with qualitative data collected. METHODS: Twelve RACF staff from two facilities in regional Tasmania, Australia, formed a falls prevention action research group. Thematic analysis was undertaken of 22 audio-recorded fortnightly group meetings. RESULTS: This was the first opportunity for participants to meet colleagues from another facility in a professional context. The formation of an inter-facility network enabled the sharing of ideas and systems related to evidence-based falls prevention activities and other issues and galvanised a collaborative focus for action. CONCLUSIONS: An action research process can be used to create an inter-facility network. Such networks can decrease staff isolation and facilitate best resident care.

Demographics and discharge outcomes of dysvascular and non-vascular lower limb amputees at a subacute rehabilitation unit: a 7-year series.

OBJECTIVE: To examine personal and social demographics, and rehabilitation discharge outcomes of dysvascular and non-vascular lower limb amputees. METHODS: In total, 425 lower limb amputation inpatient rehabilitation admissions (335 individuals) from 2005 to 2011 were examined. Admission and discharge descriptive statistics (frequency, percentages) were calculated and compared by aetiology. RESULTS: Participants were male (74%), aged 65 years (s.d. 14), born in Australia (72%), had predominantly dysvascular aetiology (80%) and a median length of stay 48 days (interquartile range (IQR): 25-76). Following amputation, 56% received prostheses for mobility, 21% (n = 89) changed residence and 28% (n = 116) required community services. Dysvascular amputees were older (mean 67 years, s.d. 12 vs 54 years, s.d. 16; P < 0.001) and recorded lower functional independence measure--motor scores at admission (z = 3.61, P < 0.001) and discharge (z = 4.52, P < 0.001). More non-vascular amputees worked before amputation (43% vs 11%; P < 0.001), were prescribed a prosthesis by discharge (73% vs 52%; P < 0.001) and had a shorter length of stay (7 days, 95% confidence interval: -3 to 17), although this was not statistically significant. CONCLUSIONS: Differences exist in social and demographic outcomes between dysvascular and non-vascular lower limb amputees.

Predictors of discharge destination in a geriatric population after undergoing rehabilitation.

BACKGROUND AND PURPOSE: Patients undertaking inpatient rehabilitation comprise a diverse group, including patients with stroke and other neurological conditions, patients who have fallen with or without a resulting fracture, and patients with joint replacements, general debility, or various cardiopulmonary conditions. It is not clear whether diagnosis has an impact on discharge destination in a heterogeneous patient group. The purpose of this study was to determine whether diagnostic category matters or whether it is rehabilitation length of stay (LOS), ability on the 10-Meter Walk Test (10MWT), or Balance Outcome Measure for Elder Rehabilitation (BOOMER) at discharge that predicts discharge destination in elderly patients undergoing rehabilitation who had previously lived at home. METHODS: A retrospective audit was undertaken at a single rehabilitation facility in South East Queensland, Australia, that serviced 4 local short-term care hospitals. Participants were admitted consecutively to the facility between June 2010 and March 2012 who met inclusion criteria. These included a primary diagnosis category of orthopedic conditions, debility, stroke, and other neurological conditions according to the Australasian Rehabilitation Outcomes Centre and older than 60 years (n = 248). Interventions while being a rehabilitation inpatient comprised usual care physiotherapy individually tailored and incorporating elements of balance, strengthening, and functional exercise. Main outcome measures were discharge to residential aged care facility (RACF) versus home, differences between diagnostic categories in terms of discharge destination, LOS, and performance on outcome measures. Prediction of discharge destination by LOS, 10MWT, and BOOMER performance at discharge was explored. RESULTS: A total of 28 patients (12.3%) were discharged to RACF. Diagnosis was not correlated with discharge destination (Pearson χ2 = 1.26, P = .74). The variables rehabilitation LOS, an inability to perform the 10MWT at discharge, and discharge BOOMER score of less than 4 can predict discharge destination with 86.4% accuracy (P = .002). This model had a sensitivity of 71.4% (discharge to RACF) and specificity of 93.3% (discharge home). DISCUSSION: To return home after rehabilitation, patients need to be able to walk at least 10 m and undertake tasks such as moving from sitting to standing, turning around, as well as managing steps. The study revealed that a standardized suite of measures of functional ability and balance may not be appropriate for patients in all diagnostic categories undergoing rehabilitation. Therefore, just as intervention needs to be tailored for the individual patient, the measure of their progress also should be unique.

Effects of balance strategy training in myasthenia gravis: a case study series.

INTRODUCTION: Studies of exercise in patients with myasthenia gravis (MG) are sparse. Balance strategy training (BST) multimodal exercise has proven efficacy in adults for enhancing balance and functional mobility. This prospective study aims to determine if BST improves functional ability and balance in people with MG. METHODS: Seven individuals with MG participated in a 16-session workstation intervention. Repeated measures (pre/post-intervention and 4-week follow-up) consisting of quantitative myasthenia gravis score (QMG), 6-minute walk test (6MWT), timed up and go (TUG) with dual task (TUG(manual) and TUG(cognitive)), and standing stability on foam with eyes closed (foamEC) were assessed. RESULTS: Most measurements showed sustained improvement at follow-up. QMG, TUG(cognitive), and foam EC achieved clinically significant improvements (>15%). No adverse effects were reported. CONCLUSIONS: BST was effective in improving balance and QMG scores in subjects with MG. A multimodal BST approach is thus suggested to target different aspects of balance and functional mobility.

Impact of inaccessible spaces on community participation of people with mobility limitations in Zambia.

BACKGROUND: The study investigated the perspective of people with mobility limitations (PWML) in Zambia, firstly of their accessibility to public buildings and spaces, and secondly of how their capacity to participate in a preferred lifestyle has been affected. OBJECTIVES: Firstly to provide insight into the participation experiences of PWML in the social, cultural, economic, political and civic life areas and the relationship of these with disability in Zambia. Secondly to establish how the Zambian disability context shape the experiences of participation by PWML. METHOD: A qualitative design was used to gather data from 75 PWML in five of the nine provinces of Zambia. Focus group discussions and personal interviews were used to examine the accessibility of the built environment and how this impacted on the whole family's participation experiences. The nominal group technique was utilised to rank inaccessible buildings and facilities which posed barriers to opportunities in life areas and how this interfered with the whole family's lifestyle. RESULTS: Inaccessibility of education institutions, workplaces and spaces have contributed to reduced participation with negative implications for personal, family, social and economic aspects of the lives of participants. Government buildings, service buildings, and transportation were universally identified as most important but least accessible. CONCLUSION: Zambians with mobility limitations have been disadvantaged in accessing services and facilities provided to the public, depriving them and their dependants of full and equitable life participation because of reduced economic capacity. This study will assist in informing government of the need to improve environmental access to enable equal rights for all citizens.

Impact of inaccessible spaces on community participation of people with mobility limitations in Zambia

Background: The study investigated the perspective of people with mobility limitations (PWML) in Zambia, firstly of their accessibility to public buildings and spaces, and secondly of how their capacity to participate in a preferred lifestyle has been affected. Objectives: Firstly to provide insight into the participation experiences of PWML in the social, cultural, economic, political and civic life areas and the relationship of these with disability in Zambia. Secondly to establish how the Zambian disability context shape the experiences of participation by PWML. Method: A qualitative design was used to gather data from 75 PWML in five of the nine provinces of Zambia. Focus group discussions and personal interviews were used to examine the accessibility of the built environment and how this impacted on the whole family's participation experiences. The nominal group technique was utilised to rank inaccessible buildings and facilities which posed barriers to opportunities in life areas and how this interfered with the whole family's lifestyle. Results: Inaccessibility of education institutions; workplaces and spaces have contributed to reduced participation with negative implications for personal, family, social and economic aspects of the lives of participants. Government buildings, service buildings, and transportation were universally identified as most important but least accessible. Conclusion: Zambians with mobility limitations have been disadvantaged in accessing services and facilities provided to the public; depriving them and their dependants of full and equitable life participation because of reduced economic capacity. This study will assist in informing government of the need to improve environmental access to enable equal rights for all citizens

Instrumented measurement of balance and postural control in individuals with lower limb amputation: a critical review.

Measurement of balance and postural performance that underpins activities of daily living is important in the rehabilitation of individuals with a lower limb amputation (LLA), and there are a number of methods and strategies available for this purpose. To provide an evidence-based choice of approach, this review aims to critically review the tasks and outcome measures utilized in studies investigating static and dynamic balance using instrumented measurement devices in individuals with a LLA. A systematic search was conducted on multiple databases using keyword or subject headings appropriate to the respective database. Articles investigating static or dynamic balance in adults with LLA by means of instrumented measures were considered for the review. A total of 21 articles were included in the review. The static balance ability of individuals with an LLA has been investigated thoroughly, but their dynamic balance attributes remain relatively unexplored. Although the individual studies do provide valuable information on balance ability in the LLA, the heterogeneity in study designs and measures did not allow an overall analysis of the tasks and the outcome measures used. On the basis of these findings, this review provides an insight into the measurement of balance in amputees to inform novice researchers and clinicians working with individuals with an LLA.

Beyond the 'tick and flick': facilitating best practice falls prevention through an action research approach.

AIMS AND OBJECTIVES: To examine residential aged care facility staff views on using falls risk assessment tools and the implications for developing falls prevention practices in the context of an action research project. BACKGROUND: Falls risk assessments play an important role in care planning by identifying and monitoring aged care facility residents most at risk of falls. Yet while such assessments are recommended in falls prevention best practice guidelines, there is little published research that examines staff procedures and views related to conducting falls risk assessments. DESIGN: Falls risk assessments were undertaken in the context of an action research project. METHOD: Twelve staff members from two residential aged care facilities (RACFs) in Tasmania formed a single Falls Action Research Group, which met 22 times over a year, providing the study's qualitative data. During this time, key group members assessed 178 residents using a new falls risk assessment tool (FROP-Resi). RESULTS: According to group members, facilities evolved from a 'tick-and-flick' approach to falls risk assessment to a more individualised, face-to-face assessment process. Group members perceived the process to be more meaningful and enjoyable for staff involved in the assessment process resulting in higher quality of assessments and leading to improved levels of falls awareness among staff, residents and family caregivers. CONCLUSIONS: An action research process is useful for facilitating a new approach to falls risk assessments, engaging aged care facility staff with falls prevention and prompting improvements in falls prevention practices. RELEVANCE TO CLINICAL PRACTICE: RACFs need to provide opportunities for staff to meet regularly to discuss practice, identify issues and take action. By doing so, staff can engage meaningfully with best practice activities such as optimising falls risk assessment processes.

Mobility has a non-linear association with falls risk among people in residential aged care: an observational study.

QUESTIONS: What is the association between mobility and falls risk for people living in residential aged care? Can the Physical Mobility Scale discriminate between residents at risk of falling and those not at risk? DESIGN: Prospective longitudinal observational study. SETTING: Six residential aged care facilities in Australia. PARTICIPANTS: Eighty-seven high- and low-level care permanent residents. OUTCOME MEASURES: The primary outcome measure was the number of falls in the six months after the initial mobility assessment. Mobility of all participants was assessed using the Physical Mobility Scale, which includes nine mobility items assessed on a 0-5 scale yielding a total score out of 45. RESULTS: During the six-month study period, 131 falls were reported. Residents with mild mobility impairment (Physical Mobility Scale total score 28-36) had the highest fall risk (hazard ratio = 1.98, 95% CI 1.30 to 3.03). Residents with fully dependent mobility (Physical Mobility Scale total score 0-9) had the lowest risk for falls (HR=0.05, 95% CI 0.01 to 0.32). CONCLUSION: Aged care residents with mild mobility impairment are at increased risk of falls and are an appropriate target for falls prevention strategies. Although improving the mobility of residents with moderate to severe mobility impairment may enhance their independence and reduce their burden on staff, paradoxically this may also increase their risk of falls. When these residents improve enough to progress into a higher category of mobility, physiotherapists should be aware that this may increase the risk of falls and should consider instituting appropriate falls prevention strategies.

Reducing staff isolation and developing evidence-informed practice in the aged care environment through an action research approach to falls prevention.

This study aimed to examine whether an action research approach was effective in reducing the isolation of staff in 2 residential aged care facilities, within the context of an evidence-informed falls prevention program. A Falls Action Research Group comprising 12 nursing/nonnursing staff across 2 residential aged care facilities was established and engaged in critical dialogue and action over 12 months to improve their fall prevention activities. Through the group members' engagement, a research community was established that diminished staff isolation by engaging members in a sustained process of collaboration around falls prevention, which worked to disrupt occupational silos and challenge traditional staff hierarchies.

Outcomes from the implementation of a facility-specific evidence-based falls prevention intervention program in residential aged care.

For residents in long-term care facilities, falling is a major concern requiring preventive intervention. A prospective cohort study measured the impact of falls reduction following the implementation of evidence-based fall prevention interventions in 9 Australian residential care facilities. An external project team provided a comprehensive audit of current practice. Facilitated by an action research approach, interventions were individualized to be facility- and patient-specific and included the following: environmental modifications such as low beds and height-adjustable chairs, movement alarms, hazard removal, and hip protectors. Participants included 670 residents and 650 staff from 9 facilities across 3 states. A significant reduction of falls were observed per site in the proportion of fallers (P = .044) and single fallers (P = .04). However, overall the number of falls was confounded by multiple falls in residents. Reduction in fallers was sustained in the 6-month follow-up phase. Positive outcomes from interventions varied between facilities. Further research is necessary to target frequent fallers.

Participation-based environment accessibility assessment tool (P-BEAAT) in the Zambian context.

PURPOSE: The purpose of this study was to describe the preliminary development and validation of a potential measure for assessing the accessibility of the built environment in Zambia. It was designed to identify environmental features that present barriers to participation for people with mobility limitations (PWML) using mobility devices such as wheelchairs or crutches. METHOD: The Participation-Based Environment Accessibility Assessment Tool (P-BEAAT) was developed through focus group discussions and personal interviews with 88 PWML from five provinces of Zambia regarding the accessibility of their built environment. The content validity of the P-BEAAT checklist was accomplished through three phases of development with data gathered from 11 focus groups and nine personal interviews. RESULTS: Participants described accessibility barriers which affect their participation in daily life. This information generated the P-BEAAT with 66 items describing eight environmental features with potential for identifying environmental barriers. The P-BEAAT has shown good homogeneity with Cronbach's α score of 0.91. CONCLUSION: The P-BEAAT was constructed grounded in the reality of people's experiences in Zambia for use in assessing environmental features important in the participation of daily life of PWML pertinent to developing countries. Further clinimetric testing of the properties of the P-BEAAT to establish reliability should be conducted next.

In vivo trial results of a novel ultrasonic cough stimulator.

The aims of these double-blind in-vivo trials of a prototype ultrasonic cough stimulator (CoughStim™) were to establish (1) whether ultrasound (US) stimulation can be safely used to stimulate a cough, (2) the most efficient US frequency and power parameters to reliably stimulate a cough, (3) whether single- or dual-sided stimulation is more effective, and (4) whether a cough can be stimulated in adults unable to cough on demand. Fifteen nondisabled volunteers (18-59 yr) and seven volunteers unable to cough on demand (85-102 yr) were recruited. Stimulation was applied to the neck unilaterally at eight frequencies and two power levels and bilaterally at two frequencies and three power levels. Vital signs were monitored during testing with no adverse responses. CoughStim stimulated a cough in all nondisabled subjects, 80% of subjects at 0.58 MHz and 9 W unilaterally and 75% of subjects at 0.58 MHz and 6 W bilaterally. Of the subjects unable to cough, 71 percent responded to bilateral stimuli (0.54 MHz and 6 W) with a strong cough. The CoughStim regularly and safely produced a moderately strong cough response in subjects with or without ability to cough and produced this effect without causing undue discomfort.

The state of physical environments in Australian residential aged care facilities.

OBJECTIVE: This paper examines the quality and safety of the physical environment in Australian residential aged care facilities (RACFs). DESIGN: Cross-sectional study. One assessor completed environmental audits to identify areas of the physical environment that needed to be addressed to improve the wellbeing and safety of residents. SETTING: Nine RACFs participating in a broader falls prevention project were audited. RACFs were located in Queensland, Tasmania or Victoria and were chosen by convenience to represent high level, low level, dementia and psychogeriatric care, regional and metropolitan facilities, small and large facilities and a culturally specific facility. Main outcome measure. An environmental audit tool was adapted from a tool designed to foster older person friendly hospital environments. The tool consisted of 147 items. Results. Across all sites 450 items (34%) required action. This ranged from 21 to 44% across sites. The audit domains most commonly requiring action included signage, visual perception and lighting, and outdoor areas. CONCLUSIONS: Although not representative of all residential facilities in Australia, this audit process has identified common environmental problems across a diverse mix of residential care facilities. Results highlight the need for further investigation into the quality of physical environments, and interventions to improve physical environments in Australian RACFs.

Enhancing functional balance and mobility among older people living in long-term care facilities.

This study of long-term care residents investigated whether a balance strategy training program (BSTP) developed for older people living in the community is effective in improving functional mobility and reducing falls when adapted to resident functional abilities. The BSTP was delivered twice weekly over 12 weeks. Outcome measures compared pre- and postintervention measured Timed Up and Go, Functional Reach, timed 5 sit-to-stand movements, and number of falls in 12 weeks before intervention with 12-week follow-up period. Forty-seven residents participated, 26 of whom were cognitively impaired. There was a significant improvement in all functional balance and mobility measures, but this was clinically significant only in 5 sit-to-stand time. There was no reduction in falls, although this outcome was confounded by all fallers being acutely ill at the time of falling. These results suggest participation in a BSTP by residents of long-term care improves resident functional mobility and balance.

Age-related changes in musculoskeletal function, balance and mobility measures in men aged 30-80 years.

OBJECTIVES: This study aimed to establish age-related changes in musculoskeletal function, balance and mobility measures in men. DESIGN: An observational, cross-sectional cohort study was undertaken. METHODS: One hundred six healthy, community-ambulant men (30-80 years) participated in this study. Recruitment of a convenience sample continued until a minimum of 20 men represented each decade between 30 and 80 years. Demographics (age, height, weight), health and current activity level were recorded. Balance and mobility were measured using the timed up and go test, the step test, functional and lateral reach. Reaction time was determined from limits of stability test. Leg muscle strength was measured with a spring gauge (kg), and ankle flexibility was measured using goniometry. RESULTS: Balance, mobility and most strength measures were reduced by the 60s while ankle flexibility declined by the 70s (p < 0.01). Reaction times increased by the 60s (p < 0.01). CONCLUSION: This study of men demonstrated reduced musculoskeletal function, balance and mobility generally by the 60s. These results provide health professionals with normal performance levels to use as therapeutic goals as well as identify musculoskeletal factors associated with reducing balance and mobility. Hence, these results inform clinicians and policy makers for the establishment of pre-emptive interventions to promote healthier ageing.

Sensory system function and postural stability in men aged 30-80 years.

OBJECTIVE: To examine age-related changes in postural stability and sensory system functioning in men aged 30-80 years. DESIGN: Observational, cross-sectional study. METHODS: One hundred six healthy men aged 30-80 years participated. Personal characteristics were recorded and outcome measures included: velocity of sway during bilateral stance on a firm and foam surface (eyes open (EO) and eyes closed (EC)), balancing on one leg (EO and EC), lower limb somatosensation (tactile acuity, vibration threshold and joint position error), high-contrast visual acuity (HCVA) and low-contrast visual acuity (LCVA), edge contrast sensitivity and vestibular-ocular reflex (VOR) control. RESULTS: Men in their 60s and 70s were found to be less stable than the younger age decades when standing on a firm or foam surface. Reduced stability was evident from the 40s to 50s for one-leg-stance (EC). Lower limb somatosensation and HCVA and LCVA were significantly reduced by the 60s but edge contrast sensitivity reduced by the 50s. Age-related changes in VOR control did not emerge until the 70s in this study cohort. CONCLUSIONS: The results show reduction in postural stability and sensory system functioning in men by the 60s supporting pre-emptive assessment of workers in industries where falls are frequent.

A protocol for an individualised, facilitated and sustainable approach to implementing current evidence in preventing falls in residential aged care facilities.

BACKGROUND: Falls are common adverse events in residential care facilities. Commonly reported figures indicate that at least 50% of residents fall in a 12 month period, and that this figure is substantially higher for residents with dementia. This paper reports the protocol of a project which aims to implement evidence based falls prevention strategies in nine residential aged care facilities (RACFs) in Australia. The facilities in the study include high and low care, small and large facilities, metropolitan and regional, facilities with a specific cultural focus, and target groups recognised as being more challenging to successful implementation of falls prevention practice (e.g. residents with dementia). METHODS: The project will be conducted from November 2007-November 2009. The project will involve baseline scoping of existing falls rates and falls prevention activities in each facility, an action research process, interactive falls prevention training, individual falls risk assessments, provision of equipment and modifications, organisation based steering committees, and an economic evaluation. In each RACF, staff will be invited to join an action research group that will lead the process of developing and implementing interventions designed to facilitate an evidence based approach to falls management in their facility. In all RACFs a pre/post design will be adopted with a range of standardised measures utilised to determine the impact of the interventions. DISCUSSION: The care gap in residential aged care that will be addressed through this project relates to the challenges in implementing best practice falls prevention actions despite the availability of best practice guidelines. There are numerous factors that may limit the uptake of best practice falls prevention guidelines in residential aged care facilities. A multi-factorial individualised (to the specific requirements of each facility) approach will be used to develop and implement an action plan in each participating facility based on the best available evidence.

A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of inpatient aquatic physiotherapy in addition to usual ward physiotherapy on the recovery of strength, function, and gait speed after total hip or knee replacement surgery. DESIGN: Pragmatic randomized controlled trial with blinded 6-month follow-up. SETTING: Acute-care private hospital. PARTICIPANTS: People (n=65) undergoing primary hip or knee arthroplasty (average age, 69.6+/-8.2y; 30 men). INTERVENTIONS: Participants were randomly assigned to receive supplementary inpatient physiotherapy, beginning on day 4: aquatic physiotherapy, nonspecific water exercise, or additional ward physiotherapy. MAIN OUTCOME MEASURES: Strength, gait speed, and functional ability at day 14. RESULTS: At day 14, hip abductor strength was significantly greater after aquatic physiotherapy intervention than additional ward treatment (P=.001) or water exercise (P=.011). No other outcome measures were significantly different at any time point in the trial, but relative differences favored the aquatic physiotherapy intervention at day 14. No adverse events occurred with early aquatic intervention. CONCLUSIONS: A specific inpatient aquatic physiotherapy program has a positive effect on early recovery of hip strength after joint replacement surgery. Further studies are required to confirm these findings. Our research indicates that aquatic physiotherapy can be safely considered in this early postoperative phase.