Multiple Sclerosis and Postural Control: The Role of Spasticity

Sosnoff JJ, Shin S, Motl RW. Multiple sclerosis and postural control: the role of spasticity.

Objectives

To examine the association between spasticity and postural control in subjects with multiple sclerosis (MS).

Design

Cross-sectional.

Setting

Motor control laboratory.

Participants

Subjects with MS (n=16, 2 male) and age and sex-matched subjects (n=16) participated in the investigation. All subjects with MS had Expanded Disability Status Scale scores between 0 and 4.5 and modified Ashworth scale scores between 1 and 3.

Interventions

Not applicable.

Main Outcome Measures

Postural control was measured with a force platform that quantifies ground reaction forces and moments in mediolateral and anteroposterior directions. Postural control was indexed with anterior-posterior sway range, medial-lateral sway range, 95% elliptical area of the deviations of center of pressure (COP), velocity of COP sway, and the frequency at which 95% of spectral profile was contained. Participants with MS further underwent assessment of the soleus Hoffman reflex (H-reflex) as an index of spasticity.

Results

Cluster analysis on H-reflex data identified groups of MS participants with high spasticity (n=7) and low spasticity (n=9). There were no differences in age, duration of MS, and disease severity between MS groups. There were no differences in anterior-posterior sway range between any of the groups. The high spasticity group had greater COP area, velocity, and mediolateral sway compared with the low spasticity and control group, and the low spasticity group had postural control values between the high spasticity and control groups.

Conclusions

The pattern of results suggests that spasticity contributes to postural deficits observed in MS.     

The interaction between executive attention and postural control in dual-task conditions: children with cerebral palsy

Reilly DS, Woollacott MH, van Donkelaar P, Saavedra S. The interaction between executive attention and postural control in dual-task conditions: children with cerebral palsy.

Objective

To investigate the interference between a secondary task and a postural task in children with cerebral palsy (CP).

Design

In this exploratory study, a dual-task paradigm was used in which children stood in either a wide or a narrow stance position while simultaneously performing a visual working memory task calibrated to be of equitable attentional demand between groups.

Setting

Study data were gathered in a university motor control laboratory.

Participants

Children with CP (n=8; age range, 10−14y) were compared with typically developing older children (n=6; age range, 7−12y), and typically developing young children (n=5; age range, 4−6y).

Interventions

Not applicable.

Main Outcome Measures

Proficiency in postural control was measured by the range and root mean square of the velocity of center of pressure displacement in the mediolateral and anteroposterior directions, calculated from forceplate data. Accuracy of response was used as a measure of cognitive task performance. Capacity of the executive attention system was determined by assessing visual working memory capacity.

Results

Children with CP, like the typically developing young children, were more unstable and had less executive attention capacity compared with older children, and like the typically developing young children, experienced dual-task interference in postural control in both stance positions. Children with ataxic CP also experienced decreased cognitive task performance in narrow stance.

Conclusions

In designing therapeutic interventions for children with CP, it would be beneficial for clinicians to assess postural control in both single- and dual-task environments.     

Reliability of Center of Pressure Measures for Assessing the Development of Sitting Postural Control in Infants With or at Risk of Cerebral Palsy

Kyvelidou A, Harbourne RT, Shostrom VK, Stergiou N. Reliability of center of pressure measures for assessing the development of sitting postural control in infants with or at risk of cerebral palsy.

Objective

To establish the test-retest reliability of linear and nonlinear measures, including intra- and intersession reliability, when used to analyze the center of pressure (COP) time series during the development of infant sitting postural control in infants with or at risk for cerebral palsy (CP).

Design

Longitudinal study.

Setting

University hospital laboratory.

Participants

Infants with or at risk for CP (N=18; mean age ± SD at entry into the study, 13.7±3.6mo).

Interventions

Not applicable.

Main Outcome Measures

Infant sitting COP data were recorded for 3 trials at each session (2 sessions for each month within 1 week) for 4 consecutive months. The linear COP parameters of the root mean square, the range of sway for both the anterior-posterior and the medial-lateral directions, and the sway path were calculated. In addition, the nonlinear parameters of approximate entropy, Lyapunov exponent (LyE), and the correlation dimension for both directions were also calculated. Intra- and intersession reliability was computed by the intraclass correlation coefficient (ICC).

Results

Regarding nonlinear measures, LyE showed high intra- and intersession ICC values in comparison with all other parameters evaluated. Intrasession and intersession reliability increased overall in the last 2 months of data collection and as sitting posture improved.

Conclusions

Our results suggested that the methodology presented is a reliable way of examining the development of sitting postural control in infants with or at risk for CP, and the reliability results generally parallel values found in sitting postural behavior in typical infants. Therefore, this methodology may be helpful in examining efficacy of therapy protocols directed at advancing sitting postural control in infants with motor developmental delays.     

Evaluation of pushrim-activated power-assisted wheelchairs using ANSI/RESNA standards

Karmarkar A, Cooper RA, Liu H, Connor S, Puhlman J. Evaluation of pushrim-activated power-assisted wheelchairs using ANSI/RESNA standards.

Objective

To determine and compare performance of pushrim-activated power-assisted wheelchairs (PAPAW) (iGLIDE, e-motion, Xtender) on national standards.

Design

Engineering performance and safety evaluation.

Setting

A Veteran Affairs and university-based research center.

Specimens

Nine PAPAWs.

Interventions

Not applicable.

Main Outcome Measures

Static, dynamic stability, brake effectiveness, maximum speed, acceleration, retardation, energy consumption, static, impact, and fatigue strength.

Results

There was no significant difference among the 3 models in forward stability. The iGLIDE was the most stable, whereas the e-motion was the least stable model in the rearward stability tests. All PAPAWs performed equally on the slopes of 3° and 6° in the forward and rearward directions. Braking distance was the highest for e-motion (5.64±0.28m) and the lowest (1.13±0.03m) for the iGLIDE in forward direction. The average equivalent cycles of all PAPAWs were 318,292±112,776.6 cycles (n=8) on the fatigue tests. All PAPAWs passed the impact and static strength tests.

Conclusions

The standards of the American National Standards Institute and the Rehabilitation Engineering and Assistive Technology Society of North America could act as quality assurance tool for wheelchairs. The standards for wheelchairs were first approved in 1990; after 17 years, exceeding the minimum values in the standards would be a reasonable expectation.     

A Comparison of Balance Performance: Computerized Dynamic Posturography and a Random Motion Platform

Broglio SP, Sosnoff JJ, Rosengren KS, McShane K. A comparison of balance performance: computerized dynamic posturography and a random motion platform.

Objective

To establish the clinical utility of the PROPRIO 5000 as a balance assessment device by establishing convergent validity with the NeuroCom sensory organization test (SOT).

Design

Cross-sectional.

Setting

Balance research laboratory.

Participants

Young adults (N=40; 21.1±1.4y).

Interventions

Not applicable.

Main Outcome Measures

Performance on each of the 6 NeuroCom SOT testing conditions and PROPRIO 5000 dynamic motion analysis score.

Results

Correlational analyses between output variables yielded significant relationships between the dynamic motion analysis score from the 0 to 10 second (r=−.38), 10 to 20 second (r=−.34), and 20 to 30 second (r=−.35) intervals and the SOT composite balance score.

Conclusions

The initial stages of the PROPRIO 5000 and the NeuroCom SOT battery may evaluate similar aspects of postural control. However, as the magnitude of PROPRIO perturbations increased, the relationship between the devices diverged and the complete PROPRIO assessment is not thought to pair with the SOT assessment. Differences between the 2 devices may be associated with varying degrees of test difficulty and the necessary postural control strategies involved in responding to continual balance perturbations (PROPRIO 5000) or to different sensory inputs (SOT).     

The effects of scale display of visual feedback on postural control during quiet standing in healthy elderly subjects

Pinsault N, Vuillerme N. The effects of scale display of visual feedback on postural control during quiet standing in healthy elderly subjects.

Objective

To assess the effects of scale display of visual feedback (VFB) on postural control during quiet standing in healthy elderly subjects.

Design

Before and after intervention trials.

Setting

Medical university bioengineering laboratory.

Participants

Twelve healthy elderly subjects (mean age, 70.2±2.8y; mean body weight, 65.5±4.1kg; mean height, 163.4±6.5cm).

Intervention

Participants were asked to stand upright as immobile as possible in an eyes-open condition and 3 VFB conditions involving increasing scale displays: 2 to 1 (VFB₂), 5 to 1 (VFB₅), and 10 to 1 (VFB₁₀). These latter conditions correspond to the ratio between the real displacements of the center of pressure (COP), as measured by the force platform, and their visualization on the monitor screen.

Main Outcome Measure

COP displacements were recorded using a force platform.

Results

VFB had different effects on the COP displacements depending on the scale display; no significant difference was observed between the VFB₂ and the eyes-open conditions, whereas the VFB₅ and VFB₁₀ conditions yielded decreased COP displacements relative to the eyes-open condition.

Conclusions

The effectiveness of the VFB system in improving postural control during quiet standing in elderly subjects depends on the scale display. These findings could have implications in clinical and rehabilitative areas.     

Metabolic and Mechanical Energy Costs of Reducing Vertical Center of Mass Movement During Gait

Gordon KE, Ferris DP, Kuo AD. Metabolic and mechanical energy costs of reducing vertical center of mass movement during gait.

Objectives

To test the hypothesis that reducing vertical center of mass (COM) displacement will lower the metabolic cost of human walking. To examine changes in joint work associated with increasing and decreasing vertical COM movement during gait.

Design

Randomized repeated measures.

Setting

Human Neuromechanics Laboratory, University of Michigan.

Participants

Able-bodied subjects (N=10).

Interventions

Subjects walked at 1.2m/s on a treadmill and overground. Subjects manipulated vertical COM displacement either by adjusting stride length or by using visual feedback to reduce COM movement.

Main Outcome Measures

We measured kinematic and kinetic data to calculate vertical and lateral COM displacements, joint torques, and work. In addition, we collected oxygen consumption to calculated metabolic power.

Results

Increasing and decreasing vertical COM displacement beyond subjects' preferred range resulted in increases in the metabolic cost of walking. When vertical COM displacement was reduced, corresponding increases in positive ankle and hip work and negative knee work were observed.

Conclusions

Humans are capable of walking in a manner that will reduce COM displacement from normal. Decreasing vertical COM movement results in increases in metabolic energy costs because of greater mechanical work performed at the hip, knee, and ankle joints. Thus, reducing vertical COM movement is not a successful strategy for improving either metabolic or mechanical energy economy during normal walking by able-bodied subjects.     

The association between nursing diagnoses, resource utilisation and patient and caregiver outcomes in a nurse-led home care service: longitudinal study

Background

The information generated by nurses through standardised nursing languages is insufficiently evaluated and exploited, mainly in home care services, as is its potential impact on outcomes.

Objectives

To find out how often nursing diagnoses are made during nursing home care visits, and to explore their relation with use of resources, mortality, institutionalisation and satisfaction.

Design

Observational, longitudinal follow-up study.

Settings

Home care services delivered by Primary Healthcare Districts in Málaga, Costa del Sol, Almería and Granada, in Spain.

Participants

Patients and caregivers who initiated the Home Care Programme.

Methods

The accumulated incidence of nursing diagnosis was analysed over 34 months of follow-up. Diagnoses were made by nurse case managers in their daily practice. Several regression models were devised to analyse their linkage with the use of resources, mortality, institutionalisation and satisfaction.

Results

Two hundred and forty-seven subjects were included (129 patients and 118 caregivers). 93.8 had been diagnosed (2.8 diagnoses per subject). Risk of caregiver strain and mobility impairment accounted for 40% of total home visits (p = 0.033). Significant differences were observed in the use of physiotherapy and rehabilitation services. The home visits for caregivers were, in 78% of cases, due to the recipient’s baseline functional status. No relation was detected for institutionalisation or for patient satisfaction. There was a higher rate of anxiety diagnosed in the caregiver when the recipient was at greater risk for mortality (RR: 2.08 CI 95%: 1.26-3.42) (p = 0.012).

Conclusions

These data confirm results from other studies which find nursing diagnoses to be sound predictors of resources use. Their synergy with other case-mix systems in home care should be investigated.     

Comparison of Trunk Proprioception Between Patients With Low Back Pain and Healthy Controls

Lee AS, Cholewicki J, Reeves NP, Zazulak BT, Mysliwiec LW. Comparison of trunk proprioception between patients with low back pain and healthy controls.

Objective

To determine whether proprioceptive impairments exist in patients with low back pain (LBP). We hypothesized that patients with LBP would exhibit larger trunk proprioception errors than healthy controls.

Design

Case-control study.

Setting

University laboratory.

Participants

24 patients with nonspecific LBP and 24 age-matched healthy controls.

Interventions

Not applicable.

Main Outcome Measures

We measured trunk proprioception in all 3 anatomical planes using motion perception threshold, active repositioning, and passive repositioning tests.

Results

LBP patients had significantly greater motion perception threshold than controls (P<.001) (1.3±0.9° vs 0.8±0.6°). Furthermore, all subjects had the largest motion perception threshold in the transverse plane (P<.001) (1.2±0.7° vs 1.0±0.8° for all other planes averaged). There was no significant difference between LBP and healthy control groups in the repositioning tasks. Errors in the active repositioning test were significantly smaller than in the passive repositioning test (P=.032) (1.9±1.2° vs 2.3±1.4°).

Conclusions

These findings suggest that impairments in proprioception may be detected in patients with LBP when assessed with a motion perception threshold measure.     

Effects of vision and arm position on amplitude of arm postural tremor in patients with multiple sclerosis

Feys P, Helsen WF, Liu X, Lavrysen A, Nuttin B, Ketelaer P. Effects of vision and arm position on amplitude of arm postural tremor in patients with multiple sclerosis. Arch Phys Med Rehabil 2004;85:1031-3.

Objectives

To quantify the effects of vision and arm position on arm postural tremor, comparisons were made between flexed and extended arm positions performed with the eyes open and closed.

Design

Case-control study.

Setting

National multiple sclerosis (MS) center in Belgium.

Participants

Sixteen patients (32 arms) with MS who had intention tremor and 16 healthy controls (32 arms).

Interventions

Not applicable.

Main outcome measure

The amplitude of postural tremor was assessed by a magnetic position sensor attached to the index finger.

Results

The amplitude of postural tremor was not influenced by changes in visual condition or different arm positions. Both healthy controls and MS patients made more directional changes in the flexed, compared with the extended arm position.

Conclusions

The amplitude of the arm postural tremor in MS is independent of vision and arm position. Selecting 1 arm position is sufficient to assess postural tremor amplitude.     

Lateral stepping for postural correction in Parkinson's disease

King LA, Horak FB. Lateral stepping for postural correction in Parkinson’s disease.

Objective

To characterize the lateral stepping strategies for postural correction in patients with Parkinson’s disease (PD) and the effect of their anti-parkinson medication.

Design

Observational study.

Setting

Outpatient neuroscience laboratory.

Participants

Thirteen participants with idiopathic PD in their on (PD on) and off (PD off) levodopa state and 14 healthy elderly controls.

Interventions

Movable platform with lateral translations of 12cm at 14.6cm/s ramp velocity.

Main Outcome Measures

The incidence and characteristics of 3 postural strategies were observed: lateral side-step, crossover step, or no step. Corrective stepping was characterized by latency to step after perturbation onset, step velocity, and step length and presence of an anticipatory postural adjustment (APA). Additionally, percentages of trials resulting in falls were identified for each group.

Results

Whereas elderly control participants never fell, PD participants fell in 24% and 35% of trials in the on and off medication states, respectively. Both PD and control participants most often used a lateral side-step strategy; 70% (control), 67% (PD off), and 73% (PD on) of all trials, respectively. PD participants fell most often when using a crossover strategy (75% of all crossover trials) or no-step strategy (100% of all no-step trials). In the off medication state, PD participants’ lateral stepping strategies were initiated later than controls (370±37ms vs 280±10ms, P<.01), and steps were smaller (254±20mm vs 357±17mm, P<.01) and slower (0.99±0.08m/s vs 1.20±0.07m/s, P<.05). No differences were found between the PD off versus PD on state in the corrective stepping characteristics. Unlike control participants, PD participants often (56% of side-step strategy trials) failed to activate an APA before stepping, although their APAs, when present, were of similar latency and magnitude as for control participants. Levodopa on or off state did not significantly affect falls, APAs, or lateral step latency, velocity, or amplitude (P>.05).

Conclusions

PD participants showed significantly more postural instability and falls than age-matched controls when stepping was required for postural correction in response to lateral disequilibrium. Although PD participants usually used a similar lateral stepping strategy as controls in response to lateral translations, lack of an anticipatory lateral weight shift, and bradykinetic characteristics of the stepping responses help explain the greater rate of falls in participants with PD. Differences were not found between the levodopa on and off states. The results suggest that rehabilitation aimed at improving lateral stability in PD should include facilitating APAs before a lateral side-stepping strategy with faster and larger steps to recover equilibrium.     

Neutral functional realignment orthosis prevents hand pain in patients with subacute stroke: a randomized trial

Bürge E, Kupper D, Finckh A, Ryerson S, Schnider A, Leemann B. Neutral functional realignment orthosis prevents hand pain in patients with subacute stroke: a randomized trial.

Objective

To quantify the preventive effect of a neutral functional realignment orthosis on pain, mobility, and edema of the hand in subacute hemiparetic poststroke patients with severe motor deficits.

Design

Randomized trial.

Setting

Rehabilitation center.

Participants

Poststroke patients (N=30) with subacute hemiparesis and severe deficits of the upper limb were enrolled. Fifteen patients were randomized to a standard rehabilitation program without orthosis and 15 patients received an experimental orthosis in addition to their standard rehabilitation program.

Intervention

The orthosis group wore the neutral functional realignment orthosis for at least 6 hours daily.

Main Outcome Measures

Hand pain at rest (visual analog scale), wrist range of motion (Fugl-Meyer Assessment subscale), and edema of hand and wrist (circumferences). Outcome measures were assessed at time of randomization and after 13 weeks between groups.

Results

At baseline, 2 patients in each group complained about a painful hand. After 13 weeks, 8 subjects in the control group and 1 subject in the orthosis group complained of hand pain (P=.004). Mobility and edema evolved similarly in both groups.

Conclusions

Neutral functional realignment orthoses have a preventive effect on poststroke hand pain, but not on mobility and edema in the subacute phase of recovery.     

Effects of a 12-Week Tai Chi Chuan Program Versus a Balance Training Program on Postural Control and Walking Ability in Older People

Lelard T, Doutrellot P-L, David P, Ahmaidi S. Effects of a 12-week Tai Chi Chuan program versus a balance training program on postural control and walking ability in older people.

Objective

To compare the respective effects of 2 balance training programs: a Tai Chi (TC) program and a balance training program on static postural control and walking ability.

Design

Randomized controlled trial.

Setting

General community.

Participants

Older subjects (N=28) participated in the study.

Interventions

The TC group (n=14; mean age ± SD, 76.8±5.1y) and the balance training group (n=14; 77.0±4.5y) were both trained for 12 weeks.

Main Outcome Measures

Static postural control was assessed via measurement of center of pressure sway under eyes open (EO) and eyes closed (EC) conditions. Walking speed over a 10-meter course was also assessed.

Results

After the 12-week training period, there were no significant differences in walking speed or postural parameters in either the EO or EC conditions for the TC and balance training groups. Performance in the EC condition was lower than in the EO condition in pretest and posttest for the balance training and TC groups. The Romberg quotient (EO/EC ratio) was significantly higher after the balance training program than the TC program (P<.05).

Conclusions

We cannot conclude that the balance training program has better effects than the TC program on postural control or walking ability. None of the outcome measures showed significant change posttraining in either the TC or the balance training groups. However, the differences described in the Romberg quotient after the training period between the TC and the balance training groups suggest that TC should be helpful to limit the deleterious effects of eye closure on postural balance.     

Prospective analysis of lipid profiles in persons with a spinal cord injury during and 1 year after inpatient rehabilitation

de Groot S, Dallmeijer AJ, Post MW, Angenot EL, van den Berg-Emons RJ, van der Woude LH. Prospective analysis of lipid profiles in persons with a spinal cord injury during and 1 year after inpatient rehabilitation.

Objectives

To investigate the course of lipid profiles during and 1 year after inpatient rehabilitation of persons with spinal cord injury, and to determine which personal, lesion, and lifestyle characteristics influence the changes in lipid profiles over time and among subjects.

Design

Multilevel regression analysis of measurement points during and after rehabilitation.

Setting

Eight rehabilitation centers in The Netherlands.

Participants

People with complete and incomplete paraplegia and tetraplegia (N=180).

Interventions

Not applicable.

Main Outcome Measures

Total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), and the TC/HDL ratio.

Results

We found a significant decrease in TG and TC/HDL during inpatient rehabilitation and a significant increase in HDL during and after inpatient rehabilitation. TC and LDL, however, showed unfavorable increases after clinical discharge. The changes in HDL and LDL over time differed between lesion groups. An increase in the body mass index (BMI) led to an unfavorable change in all lipid profiles. Older participants showed higher TC, LDL, and HDL concentrations. Women and participants who consumed some alcohol, or who were more active 1 year after discharge, had more favorable HDL levels.

Conclusions

Lipid profiles improved during inpatient rehabilitation but deteriorated somewhat after clinical discharge. Controlling one’s BMI seems important in diminishing the risk for unfavorable lipid profiles.     

Implanted Electrical Stimulation of the Trunk for Seated Postural Stability and Function After Cervical Spinal Cord Injury: A Single Case Study

Triolo RJ, Boggs L, Miller ME, Nemunaitis G, Nagy J, Bailey SN. Implanted electrical stimulation of the trunk for seated postural stability and function after cervical spinal cord injury: a single case study.

Objectives

To explore and quantify the physical and functional effects of stabilizing the torso with electrical stimulation of the paralyzed hip and trunk musculature after motor complete tetraplegia.

Design

Single-subject case study with repeated measures and concurrent controls.

Setting

Academic outpatient rehabilitation center.

Participants

Forty-four-year-old man with C4 American Spinal Injury Association grade A tetraplegia 20 years postspinal cord injury.

Intervention

A surgically implanted multichannel pulse generator and intramuscular stimulating electrodes to activate lumbar erector spinae, quadratus lumborum, and gluteus maximus muscles bilaterally.

Main Outcome Measures

Outcomes assessed with and without stimulation included (1) spinal alignment and pelvic orientation, (2) pulmonary function and ventilatory volumes, (3) forward bimanual reaching distance, (4) seated stability and resistance to externally applied disturbances, (5) maximal force and speed of rowing-like movements, and the ability to (6) independently return to an erect seated position from full forward or lateral flexion and (7) roll in bed without assistance.

Results

Stimulation improved spinal convexity and kyphosis by 26° and 21°, reduced posterior pelvic tilt by 11°, increased forced expiratory volume and vital capacity by 10% and 22%, and improved forward reach by more than 7cm. Average resistance to sagittal disturbances increased by more than 40% (P<.002), and mean force exerted during underhanded pulling more than doubled (P=.014) with stimulation. Restoration of upright sitting in both sagittal and coronal planes and bed turning was made possible through appropriately timed activation of the hip and trunk muscles.

Conclusions

A neuroprosthesis for controlling the paralyzed torso can positively impact spinal alignment, seated posture, pulmonary function, trunk stability, and reach. Stimulation of hip and trunk muscles can improve performance of activities of daily living as well as enable independent wheelchair and bed mobility.     

Ankle positioning and knee perturbation affect temporal recruitment of the vasti muscles in people with patellofemoral pain

Objectives

To compare the temporal recruitment of the vastus medialis obliquus (VMO) and vastus lateralis (VL) during voluntary ankle movements and perturbed standing in people with patellofemoral pain, and to determine the effects of different reflex and voluntary postural exercise tasks on VMO facilitation.

Design

Repeated-measures design.

Participants

Twenty-three subjects with patellofemoral pain.

Interventions

Quadriceps reflex contraction in response to postero-anterior knee perturbations was measured with three crural muscle contraction conditions and three postural exercises (semi-squatting, tip-toeing and heel standing).

Main outcome measures

The electromyographic (EMG) onset time of the VMO and VL during each task was measured and compared across the different tasks.

Results

The mean EMG onset time of the VMO was later than that of the VL in the voluntary tasks such as tip-toeing (VMO 95.3 ms vs VL 36.4 ms, mean difference 58.9 ms, 95% confidence interval −33.7 to 151.5 ms), whereas earlier VMO activation was found in the perturbation tests such as toe standing (VMO 17.6 ms vs VL 22.9 ms, mean difference −5.3 ms, 95% confidence interval −25.3 to 14.7 ms).

Conclusion

These findings suggest the potential benefits of unexpected perturbation activities for facilitating VMO activation. The clinical applications of perturbation tasks in rehabilitation exercise programmes and the underlying mechanisms warrant further investigation.     

Association of endothelial protein C receptor haplotypes, factor V Leiden and recurrent first trimester pregnancy loss

Objectives

We evaluated whether the endothelial protein C receptor (EPCR) haplotypes A1 and A3 exert effects on the development of recurrent pregnancy loss (RPL) in association with factor V Leiden.

Design and methods

We determined the EPCR haplotypes A1 and A3 and factor V Leiden in 49 women with a history of RPL and 48 parous controls.

Results

In carriers of factor V Leiden the A1 haplotype decreased the relative risk for RPL from 2.2 to 1.0.

Conclusions

The EPCR A1 haplotype tends to modulate the risk for RPL in carriers of factor V Leiden.     

Work motivation of nurses: a literature review

Objectives

The aim of this review is to describe nurses’ work motivation from the perspective of staff nurses. This information would be useful for the development of motivation strategies and further research into nurses’ work motivation.

Design

A thorough review of the research literature.

Data sources

The literature search was performed using four databases: CINAHL, PubMed, PsychINFO, and SocINDEX. Only studies that met the following criteria were selected for review: (1) were published between 1990 and 2009, (2) were written in English, (3) dealt with work motivation, (4) concerned working staff nurses, (5) involved empirical research, (6) clearly and explicitly provided the research results about the factors affecting nurses’ work motivation. Altogether 24 studies met these criteria and were included in this review.

Review methods

Inductive content analysis was carried out to analyse and categorise the data.

Results

Nursing research has neither clear understanding nor consensus about the concept of work motivation; nor has a universal definition been adopted. Despite limited empirical evidence it may be concluded that staff nurses appear to be motivated. Five categories of factors affecting their work motivation were identified: (1) work-place characteristics, (2) working conditions, (3) personal characteristics, (4) individual priorities, and (5) internal psychological states.

Conclusions

Further research is needed to gain a more comprehensive insight into nurses’ work motivation and the factors affecting it. This can be achieved by defining the concept of work motivation as precisely as possible, working out a pertinent research methodology, and subsequently developing and testing a theoretical model of nurses’ work motivation.     

The efficacy of a multidisciplinary falls prevention clinic with an extended step-down community program

Sze P-C, Cheung W-H, Lam P-S, Lo HS-D, Leung K-S, Chan T. The efficacy of a multidisciplinary falls prevention clinic with an extended step-down community program.

Objective

To investigate the efficacy of a falls prevention clinic and a community step-down program in reducing the number of falls among community-dwelling elderly at high risk of fall.

Design

Prospective cohort.

Setting

Community.

Participants

Community-dwelling elderly (N=200) were screened for risk of fall; 60 were identified as being at high risk and were referred to the intervention program.

Intervention

Twelve sessions of a once-a-week falls prevention clinic, including fall evaluation, balance training, home hazard management program, and medical referrals, were provided in the first 3 months. The community step-down program, including falls prevention education, a weekly exercise class, and 2 home visitations, was provided in the following 9 months.

Main Outcome Measures

Fall rate, injurious fall, and its associated medical consultation were recorded during the intervention period and the year before intervention. Balance tests included the Berg Balance Scale (BBS), Sensory Organization Test, and limits of stability test; fear of falling, as evaluated using the Activities-specific Balance Confidence (ABC) scale, was measured at baseline and after the training in the falls prevention clinic.

Results

Significant reductions in fall rate (74%), injurious falls (43%), and fall-associated medical consultation (47%) were noted. Significant improvement in balance scores (BBS, P<.001; endpoint excursion in limits of stability test, P=.004) and fear of falling (ABC scale, P=.001) was shown.

Conclusions

The programs in the falls prevention clinic were effective in reducing the number of falls and injurious falls. The community step-down programs were crucial in maintaining the intervention effects of the falls prevention clinic.