An audit of physiotherapists' documentation on physical activity assessment, promotion and prescription to older adults attending out-patient rehabilitation.

PURPOSE: Identify if physiotherapists document the assessment, promotion and prescription of physical activity to older adults attending out-patient rehabilitation and assist them in the transition to an active lifestyle. METHODS: An audit of physiotherapists' documentation in medical records of older adults who attended an out-patient rehabilitation program at a tertiary hospital. RESULTS: Fifty-six medical records were reviewed. Mean age (SD) of participants was 79 (7) years. No documentation was found on the use of validated tools to assess physical activity levels of older adults. Prescription of physical activity was documented in 55/56 (98%) medical records. Seven (12.5%) medical records included documentation on goal setting regarding physical activity participation. Advice on regular physical activity post-discharge from the rehabilitation program was documented in 28/56 (50%) medical records. Formal referral to community-based physical activity programs was documented in 4/56 (7%) medical records. CONCLUSIONS: Evidence-practice gaps were found in physiotherapists' documentation of the promotion of physical activity to older adults attending out-patient rehabilitation, indicating a lack of assistance in the transition to an active lifestyle. These gaps were evident in the lack of; physical activity assessment, implementation of behaviour change strategies and formal referral to physical activity in the community post-discharge from out-patient rehabilitation.Implications for rehabilitationOur findings suggest that physiotherapists are not widely applying evidence-based practice to promote physical activity to older adults attending out-patient rehabilitation nor supporting them in the transition to engage in physical activity in the community post-discharge from rehabilitation program.Incorporating physical activity assessment and behaviour change strategies into usual care may enable physiotherapists to successfully promote physical activity to older adults attending out-patient rehabilitation.Collaboration between the health care system and community-based physical activity programs is imperative to facilitate the sustainability of an active lifestyle after discharge from rehabilitation program.

Center-Based Group and Home-Based Individual Exercise Programs Have Similar Impacts on Gait and Balance in People With Multiple Sclerosis: A Randomized Trial.

BACKGROUND: Group and home-based exercises to improve function in people with multiple sclerosis (MS) are common but have little underpinning evidence. OBJECTIVE: To determine the comparative effectiveness of a center-based group versus home-based individual 8-week exercise program to improve gait and balance in people with MS. DESIGN: Prospective, randomized controlled trial. SETTING: Community center-based and home-based exercise program. PARTICIPANTS: Fifty people with MS were randomized and completed allocated intervention (n = 26 center, n = 24 home), 47 completed post-assessment and 44 follow-up assessment. METHODS: The center- and home-based groups completed an 8-week progressive functional and balance training exercise program. The center-based groups of four to six were supervised by a physiotherapist. The home-based group was provided with telephone support. MAIN OUTCOME MEASUREMENTS: The primary outcome was gait speed (10-meter walk test). Secondary outcomes were gait endurance (6-minute walk test) and balance (Berg Balance Scale). Outcome assessments were conducted at baseline, immediately postintervention and at 8-week follow-up. RESULTS: There was no statistically significant difference between groups in gait speed post training, with a mean difference of 0.01 m/s, 95% CI -0.36 to 0.37. There were no group effects, time effects, or interactions for gait speed, endurance, or balance. In both groups, gait speed improved to a level that met minimal clinically important differences. CONCLUSIONS: Gait speed, endurance, and balance did not statistically improve in either group; however, gait speed changes met minimally important differences.

Sensory retraining of the leg after stroke: systematic review and meta-analysis.

OBJECTIVE: This systematic review aimed to investigate the effects of interventions intended for retraining leg somatosensory function on somatosensory impairment, and secondary outcomes of balance and gait, after stroke. DATA SOURCES: Databases searched from inception to 16 January 2019 included Cochrane Library, PubMed, MEDLINE, CINAHL, EMBASE, PEDro, PsycINFO, and Scopus. Reference lists of relevant publications were also manually searched. REVIEW METHODS: All types of quantitative studies incorporating interventions that intended to improve somatosensory function in the leg post stroke were retrieved. The Quality Assessment Tool for Quantitative Studies was used for quality appraisal. Standardised mean differences were calculated and meta-analyses were performed using preconstructed Microsoft Excel spreadsheets. RESULTS: The search yielded 16 studies, comprising 430 participants, using a diverse range of interventions. In total, 10 of the included studies were rated weak in quality, 6 were rated moderate, and none was rated strong. Study quality was predominantly affected by high risk of selection bias, lack of blinding, and the use of somatosensory measures that have not been psychometrically evaluated. A significant heterogeneous positive summary effect size (SES) was found for somatosensory outcomes (SES: 0.52; 95% confidence interval (CI): 0.04 to 1.01; I2 = 74.48%), which included joint position sense, light touch, and two-point discrimination. There was also a significant heterogeneous positive SES for Berg Balance Scale scores (SES: 0.62; 95% CI: 0.10 to 1.14; I2 = 59.05%). Gait SES, mainly of gait velocity, was not significant. CONCLUSION: This review suggests that interventions used for retraining leg somatosensory impairment after stroke significantly improved somatosensory function and balance but not gait.

Vestibulo-ocular dysfunction in adolescent rugby union players with and without a history of concussion.

OBJECTIVES: Sport-related concussions are common in adolescent contact sports. Vestibulo-ocular dysfunction has been reported in athletes post-concussion. There is a lack of research on vestibulo-ocular function in sporting adolescents, and the influence of previous concussions on the vestibular system in this population. The aim of this study was to investigate vestibulo-ocular function in a cohort of adolescent rugby players with and without a history of concussion during pre-season assessment. DESIGN: Cross-sectional cohort. METHODS: 213 male adolescent (13-18 years old) rugby players were recruited from six schools in Queensland, Australia. Vestibulo-ocular assessments were conducted during the preseason and included clinical assessment of oculomotor function and the vestibulo-ocular reflex (VOR) using the clinical and video-Head Impulse Test (HIT). Players were allocated into two groups: no history of concussion in the last 12 months (n = 165); and concussion in the last 12 months (n = 48). RESULTS: There were no between group differences in vestibulo-ocular function for players with and without a history of concussion (p = 0.65). However, vestibulo-ocular dysfunction was reported in 69 (32.7%) of the players tested, who had either abnormal oculomotor control or VOR function. CONCLUSIONS: The high prevalence of vestibulo-ocular dysfunction in adolescent rugby players suggests that positive clinical findings post-concussion need to be interpreted carefully in the absence of baseline or pre-concussion assessments.

Allied health clinicians using translational research in action to develop a reliable stroke audit tool.

OBJECTIVE: To design and establish reliability of a local stroke audit tool by engaging allied health clinicians within a privately funded hospital. METHODS: Design: Two-stage study involving a modified Delphi process to inform stroke audit tool development and inter-tester reliability. PARTICIPANTS: Allied health clinicians. INTERVENTIONS: A modified Delphi process to select stroke guideline recommendations for inclusion in the audit tool. Reliability study: 1 allied health representative from each discipline audited 10 clinical records with sequential admissions to acute and rehabilitation services. MAIN OUTCOME MEASURES: Recommendations were admitted to the audit tool when 70% agreement was reached, with 50% set as the reserve agreement. Inter-tester reliability was determined using intra-class correlation coefficients (ICCs) across 10 clinical records. RESULTS: Twenty-two participants (92% female, 50% physiotherapists, 17% occupational therapists) completed the modified Delphi process. Across 6 voting rounds, 8 recommendations reached 70% agreement and 2 reached 50% agreement. Two recommendations (nutrition/hydration; goal setting) were added to ensure representation for all disciplines. Substantial consistency across raters was established for the audit tool applied in acute stroke (ICC .71; range .48 to .90) and rehabilitation (ICC.78; range .60 to .93) services. CONCLUSIONS: Allied health clinicians within a privately funded hospital generally agreed in an audit process to develop a reliable stroke audit tool. Allied health clinicians agreed on stroke guideline recommendations to inform a stroke audit tool. The stroke audit tool demonstrated substantial consistency supporting future use for service development. This process, which engages local clinicians, could be adopted by other facilities to design reliable audit tools to identify local service gaps to inform changes to clinical practice.

Can a single session of motor imagery promote motor learning of locomotion in older adults? A randomized controlled trial.

PURPOSE: To investigate the influence of a single session of locomotor-based motor imagery training on motor learning and physical performance. PATIENTS AND METHODS: Thirty independent adults aged >65 years took part in the randomized controlled trial. The study was conducted within an exercise science laboratory. Participants were randomly divided into three groups following baseline locomotor testing: motor imagery training, physical training, and control groups. The motor imagery training group completed 20 imagined repetitions of a locomotor task, the physical training group completed 20 physical repetitions of a locomotor task, and the control group spent 25 minutes playing mentally stimulating games on an iPad. Imagined and physical performance times were measured for each training repetition. Gait speed (preferred and fast), timed-up-and-go, gait variability and the time to complete an obstacle course were completed before and after the single training session. RESULTS: Motor learning occurred in both the motor imagery training and physical training groups. Motor imagery training led to refinements in motor planning resulting in imagined movements better matching the physically performed movement at the end of training. Motor imagery and physical training also promoted improvements in some locomotion outcomes as demonstrated by medium to large effect size improvements after training for fast gait speed and timed-up-and-go. There were no training effects on gait variability. CONCLUSION: A single session of motor imagery training promoted motor learning of locomotion in independent older adults. Motor imagery training of a specific locomotor task also had a positive transfer effect on related physical locomotor performance outcomes.

The patients' perspective of sustaining a fall in hospital: A qualitative study.

AIMS AND OBJECTIVES: To understand the patient's perspective of falling in hospital. BACKGROUND: A fall in hospital can affect a patient physically and psychologically, increasing their hospital length of stay and potentially putting them at risk of further complications. Despite a wealth of literature on falls that focuses on risk assessment, preventive interventions and cost, very little research has focused on the experience of the patient that has fallen, particularly within the acute hospital setting. DESIGN: A qualitative phenomenological design was used to investigate the experience of falling in hospital. METHODS: Twelve hospital inpatients that had recently fallen were interviewed while in hospital using unstructured interviews. The methodology was guided by Van Manen's approach to data collection and analysis. FINDINGS: Three key themes emerged from the analysis: Feeling safe, Realising the risk and Recovering independence and identity. These themes describe a continuum whereby falling was not initially a concern to participants, who trusted staff to keep them safe, and tended to not seek assistance. As participants began to appreciate the reality of their falls risk, they felt disempowered by their loss of independence but were more receptive to receiving assistance. Finally, as participants recovered, their desire to regain independence increased. They wanted others to perceive them as physically competent, rather than as a frail older person, meaning they were more willing to take risks with mobility. CONCLUSION: The participants' perspective of falling describes a continuum of responses with participants positioned at different psychosocial standpoints: from initial denial of their risk of falling to realisation of the importance of their fall and acceptance of its repercussions. RELEVANCE TO CLINICAL PRACTICE: By understanding the patient's perspective of falling, nurses and other health professionals conducting risk assessment can tailor their discussions and interventions to the patient's perceptions and needs.

A systematic review of patient-reported measures associated with vestibular dysfunction.

OBJECTIVES/HYPOTHESIS: Use of clinical questionnaires to assist in the screening of vestibular disorders in the acute hospital setting is needed. The objective is to detail the clinimetric properties and clinical utility of patient-reported questionnaires for quantifying dizziness/vertigo symptoms associated with vestibular dysfunction, and to determine validity and utility for screening dizziness/vertigo in the emergency department. DATA SOURCES: We performed a systematic review of PubMed, CINAHL, Embase, and Web of Science in May 2015. METHODS: Two independent reviewers selected studies reporting clinimetric properties of patient-reported questionnaires that aim to evaluate symptomology of dizziness/vertigo associated with vestibular dysfunction. A third reviewer resolved disparities. Of 1,901 articles initially found in the database search, 58 articles and 9 patient-reported questionnaires were included. RESULTS: Clinimetric properties of content validity, criterion validity, internal consistency, inter-/intrarater reliability, test-retest reliability, and responsiveness to vestibular rehabilitation are reported, and methodological quality is rated using the COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) checklist. Clinical utility is described in terms of target population, purpose, number of items, and whether the questionnaire was validated in the emergency department. CONCLUSIONS: The Vestibular Rehabilitation Benefit Questionnaire, a relatively new tool, scored an "excellent" rating on three COSMIN criteria, and may be the best measure to address treatment outcomes. Questions on respective tools ranged from nine to 36, and no questionnaire was validated in the emergency department. Due to the number of questions and lack of validity, none of the questionnaires was deemed appropriate as a screening tool for dizziness/vertigo in the emergency department. Laryngoscope, 128:971-981, 2018.

Inter- and intra-tester reliability of the acute brain injury physiotherapy assessment (ABIPA) in patients with acquired brain injury.

BACKGROUND: The Acute Brain Injury Physiotherapy Assessment (ABIPA) is a new outcome measure with face validity and sensitivity to change in the early stages of neuromotor recovery after acquired brain injury (ABI). Reliability of physiotherapists using the tool has not been established. OBJECTIVE: Determine inter- and intra-tester reliability of physiotherapists using the ABIPA. METHODS: An observational study using video-recorded assessments of patient performance (n = 7) was undertaken with two cohorts of physiotherapists: those receiving training (n = 23) and those provided with guidelines only (n = 7) to administer the ABIPA. RESULTS: Across all physiotherapists (n = 30), inter-tester reliability was excellent (α ≥ 0.9) for total ABIPA score. All individual items, except trunk alignment in supine (α = 0.5), showed excellent or good internal consistency (α ≥ 0.7). For intra-tester reliability, substantial or perfect agreement was achieved for eight items (weighted Kappa Kw ≥ 0.6), moderate agreement for four items (Kw = 0.4-0.6) and three items achieved fair agreement (alignment head supine: Kw = 0.289; alignment trunk supine: Kw = 0.387 and tone left upper limb: Kw = 0.366). CONCLUSION: Physiotherapists are highly consistent using the ABIPA but several items may need revision to improve intra-tester reliability.

Self-reported Concussion History and Sensorimotor Tests Predict Head/Neck Injuries.

PURPOSE: Sport-related concussion (SRC) is a risk for players involved in high-impact, collision sports. A history of SRC is a risk factor for future concussions, but the mechanisms underlying this are unknown. Despite evidence that most visible signs and symptoms associated with sports concussion resolve within 7-10 d, it has been proposed that subclinical loss of neuromuscular control and impaired motor functioning may persist and be associated with further injury. Alternatively, indicators of poor sensorimotor performance could be independent risk factors. This study investigated if a history of SRC and/or preseason sensorimotor performance predicted season head/neck injuries. METHODS: A total of 190 male rugby league, rugby union, and Australian Football League players participated. Preseason assessments included self-report of SRC within the previous 12 months and a suite of measures of sensorimotor function (balance, vestibular function, cervical proprioception, and trunk muscle function). Head/neck injury data were collected in the playing season. RESULTS: Forty-seven players (25%) reported a history of SRC. A history of concussion was related to changes in size and contraction of trunk muscles. Twenty-two (11.6%) players sustained a head/neck injury during the playing season, of which, 14 (63.6%) players had a history of SRC. Predictors of in-season head/neck injuries included history of SRC, trunk muscle function, and cervical proprioceptive errors. Five risk factors were identified, and players with three or more of these had 14 times greater risk of sustaining a season neck/head injury (sensitivity of 75% and specificity of 82.5%) than did players with two or fewer risk factors. CONCLUSIONS: The modifiable risk factors identified could be used to screen football players in the preseason and guide the development of exercise programs aimed at injury reduction.

Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention: QASC Trial (Quality in Acute Stroke Care) Follow-Up.

BACKGROUND AND PURPOSE: Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005-2010). We now examine long-term all-cause mortality. METHODS: Mortality was ascertained using Australia's National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber-White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates. RESULTS: One thousand and seventy-six participants (intervention n=600; control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival (>20%), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.58-1.07; P=0.13; adjusted HR, 0.77; 95% CI, 0.59-0.99; P=0.045). Older age (75-84 years; HR, 4.9; 95% CI, 2.8-8.7; P<0.001) and increasing stroke severity (HR, 1.5; 95% CI, 1.3-1.9; P<0.001) were associated with increased mortality, while being married (HR, 0.70; 95% CI, 0.49-0.99; P=0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths. CONCLUSIONS: Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care. CLINICAL TRIAL REGISTRATION: URL: http://www.anzctr.org.au. Unique identifier: ACTRN12608000563369.

A prospective investigation of changes in the sensorimotor system following sports concussion. An exploratory study.

BACKGROUND: Sports concussion is a risk for players involved in high impact, collision sports. Post-concussion, the majority of symptoms subside within 7-10 days, but can persist in 10-20% of athletes. Understanding the effects of sports concussion on sensorimotor systems could inform physiotherapy treatment. OBJECTIVE: To explore changes in sensorimotor function in the acute phase following sports concussion. DESIGN: Prospective cohort study. METHODS: Fifty-four players from elite rugby union and league teams were assessed at the start of the playing season. Players who sustained a concussion were assessed three to five days later. Measures included assessments of balance (sway velocity), vestibular system function (vestibular ocular reflex gain; right-left asymmetry), cervical proprioception (joint position error) and trunk muscle size and function. RESULTS: During the playing season, 14 post-concussion assessments were performed within 3-5 days of injury. Significantly decreased sway velocity and increased size/contraction of trunk muscles, were identified. Whilst not significant overall, large inter-individual variation of test results for cervical proprioception and the vestibular system was observed. LIMITATIONS: The number of players who sustained a concussion was not large, but numbers were comparable with other studies in this field. There was missing baseline data for vestibular and cervical proprioception testing for some players. CONCLUSIONS: Preliminary findings post-concussion suggest an altered balance strategy and trunk muscle control with splinting/over-holding requiring consideration as part of the development of appropriate physiotherapy management strategies.

Impacts of small vestibular schwannoma on community ambulation, postural, and ocular control.

OBJECTIVES/HYPOTHESIS: To investigate balance, community mobility, gaze instability, and dizziness handicap and assess falls risk in people who are conservatively managed with small vestibular schwannoma (VS). STUDY DESIGN: Cross-sectional study with controls. METHODS: The study involved 18 people (mean age 58.7 ± 12.2 years) diagnosed with VS (<12 mm) and 22 age-matched controls (mean age 56.9 ± 8.0 years). Measures included standing on firm and foam surfaces with feet apart, then together with eyes open and closed, Timed Up and Go (TUG) test and dual TUG test, Dynamic Gait Index, 6-Minute Walk Test, Halmagyi Impulse Test, Dynamic Visual Acuity Test, and the Dizziness Handicap Inventory. RESULTS: The clinical group failed more trials standing feet together on foam with eyes closed (P < .05); had inferior mobility and walked more slowly with divided attention (P < .05); had more difficulty walking with head movement, negotiating obstacles, and using stairs (P < .01); and walked shorter distances (P < .001) than controls. Reduced gaze stability (P < .01) and higher total (P = .007) and subcategory dizziness handicap scores (P < .05) were revealed compared to age-matched controls. CONCLUSIONS: Although outcomes for the clinical group are inferior to the control group across all measures and the dizziness impact is higher, the results fall in the low-risk category for falls. Preliminary data (level 4 evidence) support using a suite of clinical measures to monitor people with VS during conservative management. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:1147-1152, 2017.

Association between altered motor control of trunk muscles and head and neck injuries in elite footballers - An exploratory study.

BACKGROUND: Head and neck injuries are common in football. Injuries such as concussion can have serious consequences. Previous studies have shown that size and function of trunk muscles are predictive of lower limb injuries in professional Australian Football League (AFL) players. It is unknown whether measurement of trunk muscles can also be used to predict head and neck injuries. OBJECTIVES: To examine whether trunk muscle measurements predict head and neck injuries incurred by professional AFL players. DESIGN: Prospective cohort study. METHOD: Ultrasound imaging of trunk muscles was performed on 165 professional AFL players at the start of the pre-season and 168 players at the start of the playing season. Injury data were obtained from records collected by the AFL club staff during the playing season. RESULTS/FINDINGS: The ability to contract the multifidus (MF) muscle at the L5/S1 vertebral level at the start of pre-season and start of the playing season predicted head and neck injury in the playing season. Sensitivity and specificity of the model were 56.3% and 76.6% for the pre-season and 50.0% and 77.2% for the playing season respectively. CONCLUSIONS: A model with potential clinical utility was developed for prediction of head and neck injuries in AFL players. These predictive values will need to be validated in other teams. Ability to contract MF is modifiable and this information could be incorporated into pre-season injury prevention programs.

Are Changes in Gait and Balance Across the Disease Step Rating Scale in Multiple Sclerosis Statistically Significant and Clinically Meaningful?

OBJECTIVES: To explore differences in gait endurance, speed, and standing balance in people with multiple sclerosis (MS) across the Disease Step Rating Scale, and to determine if differences are statistically significant and clinically meaningful. DESIGN: Observational study. SETTING: Community rehabilitation - primary health care center. PARTICIPANTS: Community-dwelling people with MS (N=222; mean age, 48±12y; 32% men). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were categorized using the Disease Step Rating Scale. Demographics and clinical measures of gait endurance (6-minute walk test [6MWT]), gait speed (10-m walk test [10MWT] and 25-foot walk test [25FWT]), and balance (Berg Balance Scale [BBS]) were recorded in 1 session. Differences in these parameters across categories of the Disease Step Rating Scale were explored, and clinically meaningful differences were identified. RESULTS: The 6MWT showed a greater number of significant differences across adjacent disease steps in those with less disability (P<.001), whereas the 10MWT and 25FWT demonstrated more significant changes in those with greater disability (P<.001). The BBS demonstrated significant differences across the span of the Disease Step Rating Scale categories (P<.001). Differences in gait and balance between adjacent Disease Step Rating Scale categories met most previously established levels of minimally detectable change and all minimally important change scores. CONCLUSIONS: Our findings support the Disease Step Rating Scale is an observational tool that can be used by health professionals to categorize people with MS, with the categories reflective of statistically significant and clinically meaningful differences in gait and balance performance.

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.

Frailty and Mobility.

Frailty represents a state of heightened vulnerability. Mobility impairment contributes to the construct of frailty and channels adverse events. While mobility disorder is universal at a high burden of frailty, neither mobility nor balance dysfunction is sufficient to fully define frailty. Frailty represents proximity to complex system failure, with higher-order disturbance, such as mobility and balance disturbance, as a consequence. Impairment of mobility and balance is a common manifestation of illness in the frail individual and is therefore a sensitive marker of acute disease, putatively also in delirium. Clinical measurement of mobility and balance should be prioritized. Consequently, assessment tools, such as the de Morton Mobility Index and the Hierarchical Assessment of Balance and Mobility, are being explored, with the sensitivity of the latter illustrated in the acute hospital setting. Walking with speed and under dual/multi-task conditions better differentiates healthier and frail ambulant adults, providing a basis for screening older adults for pre-emptive interventions. Specific mobility and balance interventions reduce falls risk. However, patients with dementia walk too fast for their level of frailty, creating an ethical dimension to rehabilitation and risk. Overall, there is no need for reduced mobility to reinforce the frailty stereotype; both are potentially modifiable and amenable to intervention strategies.

Balance self-efficacy in older adults following inpatient rehabilitation.

Older adults discharging from inpatient rehabilitation were investigated to determine change in self-efficacy at 1 month after discharge, the relationship with discharge balance performance and physical function, and the influence of diagnosis. A prospective cohort of 101 adults older than 50 years of age, 43% men, average age 75.84 (SD 9.8) years, were recruited at discharge from inpatient rehabilitation. Balance self-efficacy was assessed using Activities-specific Balance Confidence (ABC) scale at discharge and 1 month following discharge. Balance and physical function were measured at discharge using the Functional Independence Measure, Balance Outcome Measure for Elder Rehabilitation, Modified Elderly Mobility Scale and gait speed. At discharge, balance self-efficacy was moderate (ABC score 62, SD 23) and did not change at follow-up. When grouped by discharge self-efficacy (ABC scores: low<50; moderate 51-80; high>80), significant between-group differences were found for balance (P=0.005) and physical function (P=0.035). At the 1-month follow-up, those with low discharge balance self-efficacy showed improvement (mean-change ABC score 12, 95% confidence interval 2-22) and those with high discharge balance self-efficacy had lower scores (mean-change ABC score 18, 95% confidence interval -8 to -28). Differences in ABC change scores were also found between diagnostic groups (F=3.740, P=0.03), with the orthopaedic group improving (ABC mean change=8) and the general frailty group showing a decrease in confidence (ABC mean change=10). The differences in balance self-efficacy change at 1 month following discharge were related to self-efficacy level at discharge and clinical group requiring rehabilitation. Clinicians need to be aware of these changes as patients are prepared for discharge.

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.

Measuring fall risk and predicting who will fall: clinimetric properties of four fall risk assessment tools for residential aged care.

BACKGROUND: The purpose of this prospective cohort study was to describe the clinimetric evaluation of four fall risk assessment tools (FRATs) recommended in best practice guidelines for use in residential aged care (RAC). METHODS: Eighty-seven residents, mean age 81.59 years (SD +/-10.69), participated. The Falls Assessment Risk and Management Tool (FARAM), Peninsula Health Fall Risk Assessment Tool (PHFRAT), Queensland Fall Risk Assessment Tool (QFRAT), and Melbourne Fall Risk Assessment Tool (MFRAT) were completed at baseline, and 2 and 4 months, and falls occurring in the 6 months after the baseline assessment were recorded. Interrater agreement (kappa), predictive accuracy (survival analysis and Youden Index), and fit to the Rasch model were examined. Twelve-month fall history formed the predictive accuracy reference. RESULTS: Interrater risk classification agreement was high for the PHFRAT (small ka, Cyrillic = .84) and FARAM (small ka, Cyrillic = .81), and low for the QFRAT (small ka, Cyrillic = .51) and MFRAT (small ka, Cyrillic = .21). Survival analysis identified that 43%-66% of risk factors on each tool had no (p > .10) association with falls. No tool had higher predictive accuracy (Youden index) than the question, "has the resident fallen in past 12 months?" (p > .05). All tools did not exhibit fit to the Rasch model, invalidating summing of risk factor scores to provide an overall risk score. CONCLUSION: The studied tools have poor clinimetric properties, casting doubt about their usefulness for identifying fall risk factors for those most at risk for falling and measuring fall risk in RAC.