The risk of being fearful or fearless of falls in older people: An empirical validation

Purpose.?To investigate the risk of being fearful or fearless of falls in older people.

Methods.?Using a force plate, postural control in different sensory and rhythmic conditions was measured in 263 community-dwelling older people. Other assessments included fear of falling, and handgrip strength. Fall incidence was assessed at baseline and during a one-year follow-up period.

Results.?Logistic regression analysis revealed that increased lateral sway in near-tandem stance with eyes open (OR = 5.33; p < 0.01) and a worse performance on anteroposterior rhythmic weight shifts (OR = 0.65; p < 0.05) were related to falls. Univariate analyses revealed that older people with inappropriate high fear of falling according to their fall incidence had worse balance capacities on the rhythmic weight shifts (p < 0.05) but had similar static balance and physical capacities. Older people with inappropriate low fear of falling had a better hand grip (p < 0.05) but equally worse balance capacities than the comparison group.

Conclusions.?The results indicate the importance of lateral stability in relation to falls. They also suggest a substantial impact of inappropriate fear of falling on physical performance. Inappropriate high fear of falling may result in worse performance during dynamic balance tests, whereas older people with inappropriate low fear seem to overrate their capacities because of higher strength.     

Development of an objective balance assessment method for purposes of telemonitoring and telerehabilitation in elderly population

Purpose.?Reliable assessment of balance abilities and determination of the likelihood of falling in the elderly requires a skilled clinician to guide and assist the individual throughout the scoring of a suitable balance assessment method. The most widely used clinical instrument is the Berg Balance Scale (BBS). The aim of this study was to develop an objective balance assessment measure that would correlate well with BBS and could thus be used to test balancing abilities remotely.

Methods.?Twenty elderly individuals were divided into two groups: fallers and non-fallers based on their falling records. Balance abilities were assessed by means of BBS as well as through analysis of peak amplitude of center-of-pressure (COP) responses that followed induced-sway, provoked by a moveable standing frame in the medio-lateral plane. An independent t-test was used to compare BBS scores and COP based measures between both groups. Additionally, correlation between both tests was determined by use of the Pearson correlation coefficient.

Results.?Fallers exhibited significantly lower BBS scores as well as significantly lower peak values of COP responses. The coefficient of correlation between both tests was relatively high (0.68) and statistically significant.

Conclusion.?The high degree of correlation between both tests implies that the proposed objective balance testing apparatus and methods could be used for remote assessment of balance abilities in the elderly, which has implications for the development of home-based mobility training programs.     

Factors associated with quality of life and caregiver strain amongst frail older adults referred to a community rehabilitation service: implications for service delivery

Purpose.?To identify factors contributing to reduced quality of life and increased caregiver strain in an older population referred to a community rehabilitation team and to recommend service delivery models.

Methods.?Analytical cross-sectional study arising from baseline assessments from 107 subjects drawn from a randomised controlled trial of community rehabilitation service delivery models.

Setting.?A community rehabilitation team based in Brisbane, Queensland, Australia.

Measures.?Primary outcome variables include quality of life (EQ-5D & VAS) and Carer Strain Index. Predictor variables include participation in functional activities, history of falls, number of medications, number of co-morbidities, depression, environmental hazards, physical function and nutrition. Association between variables assessed using linear regression.

Results.?Major factors contributing to reduced quality of life were having reduced participation in daily activities, depression, and having poor vision. Having poor nutrition and no longer driving also contributed to poor quality of life. The major factor contributing to increased caregiver strain was reduced participation in daily activities by the older person.

Conclusions.?Community rehabilitation services working with older populations must adopt models of care that screen for and address a wide range of factors that contribute to poor quality of life and caregiver strain.     

Rehabilitation outcome following hip fracture surgery in elderly diabetics: A prospective cohort study of 224 patients

Purpose.?To characterize the course and outcome of rehabilitation following hip fracture (HF) in elderly diabetic patients.

Method.?A non-interventional prospective cohort study of 224 elderly diabetic patients who were hospitalized for rehabilitation, compared to 738 non-diabetic patients. Stepwise multiple regression was used to assess the relative contribution of the variables to the variance of the rehabilitation outcome.

Results.?The absolute efficacy of rehabilitation was lower in diabetics vs. non-diabetics (28.8 ± 20.0 vs. 31.8 ± 18.4, respectively, p = 0.04). This difference was caused by a significantly lower pre-event Functional Independence Measure (FIM?) (112 ± 17 vs. 115 ± 14, p = 0.002) and a significantly higher rate of prior stroke with motor impairment (16% vs. 7%, p < 0.0001). No significant difference was found between the study groups for various rehabilitation-related complications, including mortality. None of the 12 specific variables associated with diabetes or its complications was significantly and independently associated with the outcome of rehabilitation among diabetics.

Conclusions.?The outcome of rehabilitation in elderly diabetic patients following HF is significantly worse than in non-diabetics. This result stems from the poor pre-event functional state of these patients. The results of this study can help to predict the outcome of rehabilitation in elderly diabetic patients who are candidates for rehabilitation following surgical repair of HF.     

Vestibular rehabilitation with computerised dynamic posturography in patients with Parkinson's disease: Improving balance impairment

Purpose.?In patients with Parkinson's disease (PD), balance impairment involves considerable morbi-mortality from the numerous falls that may result. In an earlier postural study, we detected that a deteriorated processing of vestibular input is implicated. The aim of the present study is to assess the effectiveness of vestibular rehabilitation in improving overall stability in patients with PD.

Method.?Out of an initial group of 45 patients with PD, we chose those presenting a high risk of falls, based on their score on the timed up and go test (TUG). Rehabilitation was performed on 10 patients using computerised dynamic posturography (CDP). Improvement was assessed using the dizziness handicap inventory (DHI), the TUG and the CDP.

Results.?We found statistically significant improvement in the sensorial organisation test (SOT) and the limits of stability and rhythmic weight shift tests measured by the CDP, the DHI and the TUG. These improvements continue to be statistically significant 1 year post-treatment.

Conclusion.?Vestibular rehabilitation in PD has shown to be effective in improving the activities of daily life, gait velocity and balance, as well as in reducing the risk of falls. Moreover, these benefits persist over time.     

Effects of dance on balance and gait in severe Parkinson disease: A case study

Purpose.?Dance may improve functional mobility in individuals with mild-to-moderate Parkinson disease (PD), yet dance effects in severe PD remain unexamined. This study's purpose was to evaluate the feasibility and effects of partnered tango classes on balance, endurance and quality of life in an individual with severe PD.

Design.?Over 10 weeks, the participant attended 20, 1-h tango classes for individuals with PD. Balance, walking, and quality of life were evaluated before and after the intervention and at a 1-month follow-up in this single case design. Caregiver burden was also assessed at all time points.

Results.?The participant improved on the Berg Balance Scale, 6-min walk test, and functional reach. He reported increased balance confidence and improved quality of life as measured by the Parkinson Disease Questionnaire-39 summary index. Gains were maintained at the 1-month follow-up. Caregiver burden increased from baseline immediately post-intervention and at follow-up.

Conclusion.?Twenty partnered tango lessons improved balance, endurance, balance confidence, and quality of life in a participant with severe PD. This is the first report of the use of dance as rehabilitation for an individual with advanced disease who primarily used a wheelchair for transportation.     

Activity-related pain in patients with chronic musculoskeletal disorders

Purpose.?Activity-related pain may be a barrier to rehabilitation in patients with chronic musculoskeletal disorders. This study investigated patients' reports of increased pain during activity, and the association between such pain and psychological factors and pain variables.

Method.?Questionnaires from 232 adults with chronic musculoskeletal pain measured pain intensity, spread of pain and pain duration. Pain during activity was assessed both on a 11-point Numeric Rating Scale (NRS), and operationalised as a dichotomous measure, where responders defined if they experienced pain during general activity and exercise. Psychological factors were measured by the Hopkins symptom check list 25, the Tampa Scale for Kinesiophobia and a subscale of the Arthritis Self-efficacy Scale. Multiple and logistic regression were used to analyse associations between increased pain during activity and associated variables.

Results.?Increased pain during activity was reported by 69% of participants. Fear of movement was a significant factor for reporting increased pain during activity, both general activity and exercise also in a subsample with low psychological distress. Other significant factors were spread of pain and a low sense of self-efficacy.

Conclusion.?Patients with high fear of movement, large spread of pain and low self-efficacy were more likely to report increased pain during activity even in the absence of psychological distress.     

Participation of the elderly after vision loss

Purpose.?To assess the degree of participation of the visually impaired elderly and to make a comparison with population-based reference data.

Method.?This cross-sectional study included visually impaired elderly persons (≥55 years; n?=?173) who were referred to a low-vision rehabilitation centre. Based on the International Classification of Functioning, Disability and Health (ICF) participation in: (1) domestic life, (2) interpersonal interactions and relationships, (3) major life areas, and (4) community, social and civic life was assessed by means of telephone interviews. In addition, we assessed perceived participation restrictions.

Results.?Comparison with reference data of the elderly showed that visually impaired elderly persons participated less in heavy household activities, recreational activities and sports activities. No differences were found for the interpersonal interactions and relationships domain. Participants experienced restrictions in household activities (84%), socializing (53%), paid or voluntary work (92%), and leisure activities (88%).

Conclusions.?Visually impaired elderly persons participate in society, but they participate less than their peers. They experience restrictions as a result of vision loss. These findings are relevant, since participation is an indicator for successful aging and has a positive influence on health and subjective well-being.     

Contribution of subjective balance confidence on functional mobility in subjects with chronic stroke

Purpose.?To examine the contribution of subjective balance confidence, balance ability, motor impairments and muscle strength to the timed ‘Up & Go’ (TUG) scores of 78 subjects with chronic stroke using cross-sectional design.

Methods.?Functional mobility was measured in terms of TUG scores. Balance ability and subjective balance confidence were assessed with the Berg Balance Scale (BBS) and the activities-specific balance confidence (ABC) scale, respectively. Stroke-specific motor impairment and muscle strength of lower extremity were measured using the Fugl-Meyer Motor Assessment lower extremity (FMA-LE) scores and hand-held dynamometer.

Results.?We found that the TUG scores had the highest negative correlation with subjective balance confidence. After controlling for use of walking aids, significant partial correlations were identified between the TUG scores and subjective balance confidence and balance ability. Applying linear regression model, the TUG scores showed association with subjective balance confidence and balance ability, independently. The motor impairments and muscle strength, however, were not significant predictors of TUG scores. The whole model could explain 63.0%% of the variance in the TUG scores.

Conclusions.?Our results support that improving both subjective balance confidence, in addition to functional balance training could be crucial in promoting functional mobility of community-dwelling stroke survivors.     

Health behavior change models and theories: contributions to rehabilitation

Purpose.?This article highlights the importance of health behavior change (HBC) theory, and its relevance to rehabilitation research and practice.

Method.?An extensive review of HBC-related literature pertinent to rehabilitation was conducted, focusing on the potential impact of these theories and models in enhancing long-term results of rehabilitation with regard to lifestyle change and health promotion, and outlining the benefits of incorporating HBC themes into rehabilitation practice. For our purposes, the HBC concept is based on initiation and maintenance of health behaviors, functioning, wellness, and self-management of chronic conditions or disabilities within an environmental context. While comparing and contrasting three widely known theories of HBC, the contributions of these theories to rehabilitation research and practice are discussed.

Results.?Three propositions are put forward: (1) HBC variables should regularly be used as outcome measures in evidence-based rehabilitation research; (2) there should be a better understanding of the role of the rehabilitation provider as a facilitator in eliciting healthy behaviors; and (3) there is a need to expand the HBC concept into a more comprehensive view encompassing a person's functioning within the environmental context.

Conclusions.?A conceptual merger between HBC theories and rehabilitation practice can have major implications for individuals with disabilities, their functioning, health, and well-being.     

An analysis of disability models and the application of the ICF to obesity

Purpose.?Given the significant increase in obesity rates and associated health risks, understanding obesity treatment in the context of disability is important to rehabilitation practitioners.

Method.?Published literature in the area of obesity research and clinical practice was reviewed within the medical, social and biopsychosocial conceptual models of disability.

Results.?There is universal agreement that disability is experienced by obese persons. However, interventions for rehabilitation practitioners are not articulated clearly in the literature. No specific conceptual model to underpin rehabilitation treatment is recommended.

Conclusions.?This article provides a rationale for rehabilitation practitioners to use a biopsychosocial model (the International Classification of Functioning, Disability and Health) as a universal framework to classify disability related to the condition of obesity.     

Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool

Purpose.?To evaluate the role of pain perception on admission to geriatric rehabilitation on the functional recovery after rehabilitation treatment in elderly patients with hip fracture and on the length of stay.

Method.?One hundred and sixty-five community dwelling elderly 65-year-old and over (mean age of 78 years), following recent operated traumatic hip fracture without clinical evidence for another acute medical or surgical condition were assessed regarding age, sex, chronic medical conditions, pre-fracture functional status, type of fracture and of operation, pain perception, and cognitive status. Pain was measured using the Visual Analogue Score (VAS). Functional status was measured using the Functional Independence Measurement (FIM). Activities of Daily Living (ADL) were assessed using the Katz index.

Results.?The average VAS score on admission was 7.38 ± 1.20 and on discharge 3.67 ± 1.18. Pain on admission inversely correlated to family support, function prior to fracture and cognitive status on admission, and correlated positively with depressed mood. With every increase of one point in VAS on admission above 4 points, the FIM on discharge decreased by 8.77 and the length of stay increased by 4.76 days.

Conclusions.?Pain intensity may add a valuable dimension for the prognostic evaluation of the patients with hip fractures. Inadequate early patient assessment and associated treatment impact on the patients' functional outcome, prolonged duration of rehabilitation treatment, and therefore, in addition to socio-economic effect, increase the cost to the local health care setting.     

Intra- and inter-rater reliability and validity of the Ottawa Sitting Scale: a new tool to characterise sitting balance in acute care patients

Purpose.?We present the new Ottawa Sitting Scale (OSS) developed to characterise sitting balance in the acute care setting with slow to recover patients. We provide intra- and inter-rater reliability measures of the OSS as well as a factor analysis of scale items.

Method.?Seventy-one subjects aged 21–92 years participated in this study. Original scores were compared to scores from videotaped original sessions. Performance on the OSS was compared to performance on the Berg Balance Scale (BBS) and the Physiotherapy Functional Mobility Profile (PFMP).

Results.?The intra-class correlation coefficient (ICC) obtained for intra-rater reliability was excellent at 0.99 with individual item ICCs ranging from 0.746 to 0.997. Similarly, the ICCs for inter-rater reliability were also excellent at 0.96 to 0.98 with individual item ICCs ranging from 0.723 to 0.985. In the factor analysis, two main factors accounted for 77.8% of the total item variance and could be reasonably identified as movement within base of support (BOS) and movement outside BOS. The BBS and the PFMP had floor effects for the subjects with the lowest OSS scores while there was an OSS ceiling effect corresponding to those with BBS scores of approximately 10 or more.

Conclusions.?The OSS discriminates between those subjects with low levels of sitting balance. Further studies will determine responsiveness to change, and compare the OSS with other postural control measures to identify the unique application of the OSS through the stages of recovery and rehabilitation.     

The system for medical rehabilitation in Croatia

Purpose.?To describe the framework for medical rehabilitation in Croatia and to discuss its influence on the practice of the specialty.

Methods.?Collection, analysis and interpretation of data pertaining to the need for medical rehabilitation in the country and to its elements of structure, process and outcome of care.

Results.?The practice of medical rehabilitation in Croatia has evolved without strategic planning on the national level and therefore without a designed system. This lack in the present framework causes shortcomings in all three elements of rehabilitation care and impedes the advancement of the specialty.

Conclusion.?Medical rehabilitation in Croatia needs a national strategic plan for a three-level system that incorporates inpatient, outpatient and community-based rehabilitation.     

High scores on the Western Aphasia Battery correlate with good functional communication skills (as measured with the Communicative Effectiveness Index) in aphasic stroke patients

Objective.?To examine the correlation between an impairment-level and a functional-level assessment scale of aphasia.

Design.?Prospective, longitudinal study.

Setting.?A stroke rehabilitation unit.

Subjects.?Sixty-seven aphasic acute stroke patients who were undergoing a multi-disciplinary rehabilitation programme, including conventional speech and language therapy (SLT).

Intervention.?Patients were assessed on study entry and 4, 8, 12 and 24 weeks after the start of SLT. The language impairment was assessed with the Western Aphasia Battery (WAB) and the communicative functional limitation associated with aphasia was measured with the Communicative Effectiveness Index (CETI).

Results.?There was a statistically significant correlation between the two scales for all assessment periods (Pearson's r?=?0.71; P?<?0.01).

Conclusion.?The study suggests that in the acute and subacute stages of stroke the scores of WAB and CETI can be surmised from one another.     

Dignity,rights and capabilities in clinical rehabilitation

Purpose.?The purpose of this article is to explore three concepts namely dignity, human rights and capabilities and to argue for their relevance in advancing the theory and practice of rehabilitation.

Method.?A narrative review of selected academic writing on the three constructs is considered with respect to the rehabilitation literature.

Results.?Each concept is defined and technical terms are explained for readers unfamiliar with these topics. Salient aspects of academic or scientific writing on each of these three topics is summarised and attempts are made to integrate these with rehabilitation.

Conclusions.?Dignity, rights and capabilities are three concepts that have the potential to enhance theory development in rehabilitation.     

Employment maintenance and the factors that impact it after vocational rehabilitation and return to work

Purpose.?To determine post-return-to-work disability and functioning amongst occupationally injured workers and to test the extent to which demographic and other variables relate to employment maintenance. In addition, the project sought to document what workers believe determined their work continuation.

Method.?Semi-structured in-depth interviews were conducted to inquire about participant's (N?=?150) post-vocational rehabilitation return-to-work experiences. Results were interpreted using the health and health-related domains from the International Classification of Functioning, Disability and Health.

Results.?Although most participants were working at the time of interview, almost all were experiencing functional- or activity-based restrictions. Factors differentiating those employed from those not, were largely contextual and included relationships with supervisors, economic climate, and working conditions.

Conclusions.?The findings stress the importance of considering environmental strains when planning return to work and indicate ways to assist workers to achieve return-to-work success.     

Effect of multi-sensory balance training for unsteady elderly people: pilot study of the “Reykjavik model”

Abstract

Purpose: To evaluate effects of combined mechano- and proprioceptive, vestibular and fall-prevention training on postural control, functional ability, confidence in activities of daily living (ADL) and frequency of falls among unsteady elderly people. Method: Subjects were 37 elderly outpatients attending physiotherapy because of instability. Treatment consisted of 18 multisensory balance training sessions. Results from Sensory Organization Test, Five-Times-Sit-to-Stand Test, 30-m normal and fast walk with a turn, Ascending–Descending 11 steps and Activities-specific Balance Confidence Scale were compared before and after training. Information was gathered about number of falls 1 year prior to training, during training period and for 6 months after completion of training. Results: Significant improvement was observed in all measured parameters (p?<?0.001). The subjects aged between 70 and 92 years (mean age 80.8 years), had considerable medical history. Thirty four of them reported 159 falls in the year prior to the study. Six subjects reported seven falls during the training period and seven subjects reported 17 falls in the 6 months follow-up period. Conclusions: Combined vestibular, proprioceptive and fall-prevention training improve postural control, functional ability, confidence in ADL and might even decrease the risk of falling among elderly people.

• Implications for Rehabilitation

• Decreased proprioception in the lower limbs and vestibular dysfunction is common among elderly people.

• Stimulation of the sensory systems and training of fall-prevention movements is essential when improving postural control among elderly people.

• Multisensory training increases functional abilities, confidence in activities of daily living and possibly reduces rate of falls among elderly individuals.