The European Physiotherapy Guideline for Parkinson's Disease: translation for non-English speaking countries.

BACKGROUND: The use of the European Physiotherapy Guideline for Parkinson's Disease is limited in countries where the official language is not English. OBJECTIVE: To provide practical steps on how to translate the European Physiotherapy Guideline for Parkinson's Disease. METHODS: We used the translation process of the Portuguese version as an example of how to define the recommended steps. A combination of a forward-backward-translation and dual-panel approach was used. RESULTS: Ten recommended translation steps were defined: (1) authorization, (2) translation of sample chapter, (3) physiotherapy expert panel review, (4) backward translation, (5) approval by copyright holders, (6) translation of the remaining sections of the guideline, (7) review of the entire translation by expert panel, (8) review by a user panel, (9) conclude final draft, (10) publication and dissemination. Several adjustments were needed in the Portuguese version. CONCLUSION: The additional adjustments that were required for the Portuguese version justify the need for the detailed and multifaceted translation process that was outlined in this manuscript.

External validation of the recurrent falls risk scale in community-dwelling stroke individuals.

OBJECTIVE: To externally validate the Recurrent Fall Risk Scale (ReFR) in community-dwelling stroke survivors. METHODS: Cohort of stroke survivors with independent gait ability recruited from a reference outpatient stroke clinic. Besides sociodemographic and clinical data, the following scales were used: Modified Barthel Index (mBI), ReFR scale and National Institutes of Health Stroke Scale (NIHSS). Participants were followed up for 12 months to record the incidence of falls. Accuracy of the ReFR scale was measured by the area under the ROC curve. RESULTS: One hundred and thirteen individuals were recruited between April 2016 and November 2016: mean age 54 years (± 14), 55% women, median time since the last stroke 24 months (range 12 -48 months), posterior vascular territory affected in 35% of the sample. Median NIHSS was 3 (range 1 to 6), median mBI 49 (range 46-50), median ReFR 3 (range 2 to 5). During the follow-up period, 32 (33%) subjects had at least one fall and 18 (19%) were recurrent fallers (two or more falls). The accuracy of ReFR scale was 0.67 (95% CI = 0.54-0.79), p = 0.026. CONCLUSION: This study externally validated the ReFR as a tool to predict recurrent falls in individuals after stroke.

Predicting falls in people with Parkinson's disease: impact of methodological approaches on predictors identified.

BACKGROUND: Previous investigations of falls predictors in people with Parkinson's disease (PD) have used various statistical methods and categorization of falls outcomes. The impact of methodological differences on falls predictors has not been investigated. OBJECTIVES: To describe similarities and differences in predictors modelled for fall rates [negative binomial (NB), Poisson Inverse Gaussian (PIG) and quantile regression] and previously-reported predictors of time to second fall (Cox regression), i.e. past falls, motor fluctuations, disability, levodopa dose and balance impairment. To investigate whether predictors from quantile regression vary across subsets of fallers based on fall frequency. METHODS: Participants with PD (n = 229) were followed-up for 12 months. NB and PIG regression were used to determine predictors of fall rates, with the best fitting model reported. Quantile regression was used to determine predictors at higher (62nd, 70th, 80th) percentiles of the falls distribution. Univariate and multivariate analyses were performed. RESULTS: Predictors of fall rates were the same in NB and PIG multivariate models, with the PIG model fitting our data better. Past falls, disability and levodopa dose were associated with fall rates from PIG and quantile regression. Freezing of gait was associated with fall rates from PIG regression. Disease severity predicted less (70th percentile, approximately 2-4) and more (80th percentile, approximately ≥ 5) frequent falls, and anteroposterior stability also predicted less frequent falls (p < 0.05), from quantile regression. CONCLUSIONS: Not all predictors of time to second fall were predictors of fall rates. Quantile regression revealed some divergent predictors depending on the percentile of fall frequency examined.

Anxiety Independently Contributes to Severity of Freezing of Gait in People With Parkinson's Disease.

Freezing of gait is a disabling feature of Parkinson's disease, and it has been shown that nonmotor symptoms, such as anxiety and cognitive impairment, may be involved in the pathophysiology of the phenomenon. However, the association between freezing of gait severity and nonmotor symptoms is yet to be determined. Therefore, the overall aim of this study was to determine factors that contribute to severity of freezing of gait in people with Parkinson's disease. Participants (N=78) were assessed by disease-specific and self-report measures, including the Hospital Anxiety and Depression Scale (HADS), the Montreal Cognitive Assessment, and the Freezing of Gait Questionnaire (FOG-Q). Participants were classified as "freezers" if they scored ≥1 on item 3 of the FOG-Q; the sum of items 3-6 was used to determine freezing of gait severity. Freezers (N=27) showed higher scores on the HADS anxiety (p=0.002) and HADS depression (p=0.006) subscales. A multivariate linear model showed that disease severity (as measured by using the modified Hoehn and Yahr scale) accounted for 31% of the variance in FOG-Q severity scores (p<0.001). The presence of HADS anxiety ≥8 points increased the explained variance to 38% (p=0.010), and the full model (reached by adding the levodopa equivalent dose) explained 42% of the variance in freezing of gait severity (p=0.026). The findings provide additional support for the contribution of anxiety to greater freezing of gait severity, taking into account not only the frequency but the duration of the episodes, and suggest that anxiety should be routinely evaluated in people with Parkinson's disease who present with freezing of gait.

Predictors of Recurrent Falls in People with Parkinson's Disease and Proposal for a Predictive Tool.

BACKGROUND: Falls are a debilitating problem for people with Parkinson's disease (PD). OBJECTIVES: To compare clinical and functional characteristics of non-fallers, single and recurrent fallers (≥2 falls); to determine predictors of time to second fall; and to develop a predictive tool for identifying people with PD at different categories of falls risk. METHODS: Participants (n = 229) were assessed by disease-specific, self-report and balance measures and followed up for 12 months. Area under the receiver operating characteristic curves (AUC), Kaplan-Meier curves and log-rank test were performed. Selected predictors with p < 0.10 in univariate analysis were chosen to be entered into the Cox regression model. RESULTS: Eighty-four (37%) participants had ≥2 falls during the follow-up. Recurrent fallers significantly differed from single fallers. The final Cox model included history of ≥2 falls in the past year (Hazard Ratio [HR] = 3.94; 95% confidence interval [CI] 2.26-6.86), motor fluctuations (HR = 1.91; 95% CI 1.12-3.26), UPDRS activities of daily living (ADL) (HR = 1.10 per 1 point increase; 95% CI 1.06-1.14) and levodopa equivalent dose (LED) (HR = 1.09 per 100 mg increase; 95% CI 1.02-1.16). A 3-predictor tool included history of ≥2 falls in the past year, motor fluctuations and UPDRS ADL >12 points (AUC = 0.84; 95% CI 0.78-0.90). By adding LED >700 mg/day and Berg balance scale ≤49 points, a 5-predictor tool was developed (AUC = 0.86; 95% CI 0.81-0.92). CONCLUSIONS: Two predictive tools with moderate-to-high accuracy may identify people with PD at low, medium and high risk of falling recurrently within the next year. However, future studies to address external validation are required.

Comparison of Self-report and Performance-Based Balance Measures for Predicting Recurrent Falls in People With Parkinson Disease: Cohort Study.

BACKGROUND: Balance confidence and fear of falling are factors associated with recurrent falls in people with Parkinson disease (PD). However, the accuracy for predicting falls on the basis of self-report measures has not been widely investigated. OBJECTIVE: The study objectives were: (1) to compare the accuracy of the Activities-specific Balance Confidence Scale (ABC) and the Falls Efficacy Scale-International (FES-I) with that of the Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Functional Reach Test (FRT), and Timed "Up & Go" Test (TUG) for predicting recurrent falls in people with PD and (2) to explore the ability of combinations of up to 3 tests to predict recurrent falls. DESIGN: This was a prospective cohort study involving 225 people with PD. METHODS: Participants were assessed with the ABC, FES-I, BBS, FRT, TUG, and DGI. Participants who reported 2 or more falls in the 12-month follow-up period were classified as recurrent fallers. Areas under the receiver operating characteristic curves were determined, and the Akaike information criterion was used to select the best predictive model. RESULTS: Eighty-four participants (37.3%) were classified as recurrent fallers. Areas under the receiver operating characteristic curves for the ABC, FES-I, TUG, FRT, DGI, and BBS were 0.73, 0.74, 0.72, 0.74, 0.76, and 0.79, respectively. Two-test models provided additional discriminating ability compared with individual measures and had Akaike information criterion values similar to those of 3-test models, particularly the combination of the BBS with the FES-I. LIMITATIONS: The lack of an external validation sample was a limitation of this study. CONCLUSIONS: The ABC and FES-I demonstrated moderate accuracy in predicting recurrent falls and a predictive ability similar to that of performance-based balance measures, especially the FRT and the TUG. Two-test models showed performance similar to that of 3-test models, suggesting that a combination of 2 measures may improve the ability to predict recurrent falls in people with PD. Specifically, the combination of the BBS with the FES-I may be considered.

Disability is an Independent Predictor of Falls and Recurrent Falls in People with Parkinson's Disease Without a History of Falls: A One-Year Prospective Study.

BACKGROUND: Predictors of falls in people with Parkinson's disease (PD) who have not previously fallen are yet to be identified. OBJECTIVES: We aimed to identify predictors of all falls and recurrent falls in people with PD who had not fallen in the previous year and to explore the timing of falls in a 12-month follow-up period. METHODS: Participants with PD (n = 130) were assessed by disease-specific, self-report and balance measures. Falls were recorded prospectively for 12 months. Univariate and multivariate analyses were performed. Kaplan-Meier survival analysis was used to investigate time to falling. RESULTS: Forty participants (31%) had ≥1 fall during follow-up and 21 (16%) had ≥2 falls. Disability, reduced balance confidence and greater concern about falling were associated with ≥1 fall in univariate analyses. Additionally, PD duration and severity, freezing of gait and impaired balance were associated with ≥2 falls (p <  0.05). Disability (Schwab and England scale, Odds Ratio [OR] = 0.56 per 10 points increase; 95% confidence interval [CI] 0.39-0.80; p = 0.002) was associated with ≥1 fall in the final multivariate model (area under the receiver operating characteristic curve [AUC] = 0.65; 95% CI 0.55-0.76; p = 0.005). Disability (Unified Parkinson's Disease Rating Scale activities of daily living, OR = 1.20; 95% CI 1.07-1.34; p = 0.001) and levodopa equivalent dose (OR = 1.11 per 100 mg increase; 95% CI 0.95-1.30; p = 0.19) were associated with ≥2 falls in the final multivariate model (AUC = 0.72; 95% CI 0.60-0.84; p = 0.001). Recurrent fallers experienced their first fall earlier than single fallers (p <  0.05). CONCLUSIONS: Self-reported disability was the strongest single predictor of all falls and recurrent falls.

Recurrent Falls in People with Parkinson's Disease without Cognitive Impairment: Focusing on Modifiable Risk Factors.

Falls can be considered a disabling feature in Parkinson's disease. We aimed to identify risk factors for falling, testing simultaneously the ability of disease-specific and balance-related measures. We evaluated 171 patients, collecting demographic and clinical data, including standardized assessments with the Unified Parkinson's Disease Rating Scale (UPDRS), activities of daily living (ADL) and motor sections, modified Hoehn and Yahr Scale, Schwab and England, eight-item Parkinson's Disease Questionnaire, Activities-specific Balance Confidence Scale, Falls Efficacy Scale-International (FES-I), Berg Balance Scale, Dynamic Gait Index, Functional Reach, and Timed Up and Go. ROC curves were constructed to determine the cutoff scores for all measures. Variables with P < 0.1 entered a logistic regression model. The prevalence of recurrent falls was 30% (95% CI 24%-38%). In multivariate analysis, independent risk factors for recurrent falls were (P < 0.05) levodopa equivalent dose (OR = 1.283 per 100 mg increase; 95% CI = 1.092-1.507), UPDRS-ADL > 16 points (OR = 10.0; 95% CI = 3.6-28.3), FES-I > 30 points (OR = 6.0; 95% CI = 1.6-22.6), and Berg ≤ 48 points (OR = 3.9; 95% CI = 1.2-12.7).We encourage the utilization of these modifiable risk factors in the screening of fall risk.