Utricular Dysfunction and Hearing Impairment Affect Spatial Navigation in Community-dwelling Healthy Adults: Analysis from the Baltimore Longitudinal Study of Aging.

INTRODUCTION: Spatial navigation, the ability to move through one's environment, is a complex skill utilized in everyday life. The effects of specific vestibular end-organ deficits and hearing impairments on spatial navigation have received little to no attention. We hypothesized that hearing impairment adversely affects spatial navigation and that bi-modal impairments (vestibular and hearing) further impair navigation ability. METHODS: Data from 182 participants in the Baltimore Longitudinal Study of Aging who had interpretable results for the video head impulse test (vHIT), cervical (cVEMP) and ocular (oVEMP) vestibular evoked myogenic potentials, audiometric testing, and the triangle completion test (TCT) were retrospectively analyzed. Multiple linear regression, controlling for age, sex, and cognition, was employed to identify predictors of TCT performance in terms of end-point error, angle deviation, and distance walked. RESULTS: oVEMP abnormalities were associated with larger end-point error (p=0.008) and larger angle deviation (p=0.002) but were not associated with distance walked (p=0.392). Abnormalities on cVEMP and vHIT were not associated with distance walked (p=0.835, p=0.300), end-point error (p=0.256, p=0.808), or angle deviation (p=0.192, p=0.966). Compared with normal hearing adults, hearing impaired adults walked a shorter distance during the TCT (p=0.049) but had similar end-point error (p=0.302) and angle deviation (p=0.466). There was no interaction between vestibular and hearing function for predicting spatial navigation ability. CONCLUSION: In this cohort analysis, utricular dysfunction and hearing impairment were associated with poorer spatial navigation performance. We postulate that hearing impairment negatively affects one's ability to use real-time, intrinsic auditory cues and/or prior experience to guide navigation.

Treatment of Vestibular Disorders (Inner Ear Balance Problems): How Does Your Physical Therapist Treat Dizziness Related to Inner Ear Balance Problems?

Dizziness is very common, but it is never normal. Dizziness can make performing daily activities, work, and walking difficult. Inner ear balance problems can make people dizzy when they turn their head, which can cause problems during walking and make people more likely to fall. Most of the time dizziness is not from a life-threatening disease. Often, dizziness is related to a problem of the vestibular (or inner ear balance) system. Vestibular disorders can be caused by infections in the ear, problems with the immune system, medications that harm the inner ear, and rarely from diabetes or stroke because of a lack of blood flow to the inner ear. Stress, poor sleep, migraine headaches, overdoing some activities, and feeling anxious or sad can increase symptoms of dizziness. Updated guidelines for the treatment of inner ear disorders are published in this issue of the Journal of Neurologic Physical Therapy. The guideline recommends which exercises are best to treat the dizziness and balance problems commonly seen with an inner ear problem.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association.

BACKGROUND: Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises. METHODS: These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence. RESULTS: Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes. DISCUSSION: Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction. LIMITATIONS: The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction. DISCLAIMER: These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369).

Navigating Through a COVID-19 World: Avoiding Obstacles.

Individuals with balance and gait problems encounter additional challenges navigating this post-coronavirus disease-2019 (COVID-19) world. All but the best fitting facemasks partially obscure the lower visual field. Facemask use by individuals with balance and gait problems has the potential to further compromise walking safety. More broadly, as the world reopens for business, balance and gait testing in clinics and research laboratories will also be impacted by facemask use. Here, we highlight some of the challenges faced by patients, clinicians, and researchers as they return to "normal" after COVID-19.Video Abstract is available for insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A328).

Failure on the Foam Eyes Closed Test of Standing Balance Associated With Reduced Semicircular Canal Function in Healthy Older Adults.

OBJECTIVES: Standing on foam with eyes closed (FOEC) has been characterized as a measure of vestibular function; however, the relative contribution of vestibular function and proprioceptive function to the FOEC test has not been well described. In this study, the authors investigate the relationship between peripheral sensory systems (vestibular and proprioception) and performance on the FOEC test in a cohort of healthy adults. DESIGN: A total of 563 community-dwelling healthy adults (mean age, 72.7 [SD, 12.6] years; range, 27 to 93 years) participating in the Baltimore Longitudinal Study of Aging were tested. Proprioceptive threshold (PROP) was evaluated with passive motion detection at the right ankle. Vestibulo-ocular reflex (VOR) gain was measured using video head impulses. Otolith function was measured with cervical and ocular vestibular-evoked myogenic potentials. Participants stood on FOEC for 40 sec while wearing BalanSens (BioSensics, LLC, Watertown, MA) to quantify center of mass sway area. A mixed-model multiple logistic regression was used to examine the odds of passing the FOEC test based on PROP, VOR, cervical vestibular-evoked myogenic potential, and ocular vestibular-evoked myogenic potential function in a multisensory model while controlling for age and gender. RESULTS: The odds of passing the FOEC test decreased by 15% (p < 0.001) for each year of increasing age and by 8% with every 0.1 reduction in VOR gain (p = 0.025). Neither PROP nor otolith function was significantly associated with passing the FOEC test. CONCLUSIONS: Failure to maintain balance during FOEC may serve as a proxy for rotational vestibular contributions to postural control. Semicircular canals are more sensitive to low-frequency motion than otoliths that may explain these relationships because standing sway is dominated by lower frequencies. Lower VOR gain and increased age independently decreased the odds of passing the test.

Psychometrics of inertial heading perception.

BACKGROUND: Inertial self-motion perception is thought to depend primarily on otolith cues. Recent evidence demonstrated that vestibular perceptual thresholds (including inertial heading) are adaptable, suggesting novel clinical approaches for treating perceptual impairments resulting from vestibular disease. OBJECTIVE: Little is known about the psychometric properties of perceptual estimates of inertial heading like test-retest reliability. Here we investigate the psychometric properties of a passive inertial heading perceptual test. METHODS: Forty-seven healthy subjects participated across two visits, performing in an inertial heading discrimination task. The point of subjective equality (PSE) and thresholds for heading discrimination were identified for the same day and across day tests. Paired t-tests determined if the PSE or thresholds significantly changed and a mixed interclass correlation coefficient (ICC) model examined test-retest reliability. Minimum detectable change (MDC) was calculated for PSE and threshold for heading discrimination. RESULTS: Within a testing session, the heading discrimination PSE score test-retest reliability was good (ICC = 0. 80) and did not change (t(1,36) = -1.23, p = 0.23). Heading discrimination thresholds were moderately reliable (ICC = 0.67) and also stable (t(1,36) = 0.10, p = 0.92). Across testing sessions, heading direction PSE scores were moderately correlated (ICC = 0.59) and stable (t(1,46) = -0.44, p = 0.66). Heading direction thresholds had poor reliability (ICC = 0.03) and were significantly smaller at the second visit (t(1,46) = 2.8, p = 0.008). MDC for heading direction PSE ranged from 6-9 degrees across tests. CONCLUSION: The current results indicate moderate reliability for heading perception PSE and provide clinical context for interpreting change in inertial vestibular self-motion perception over time or after an intervention.

Does visual feedback during walking result in similar improvements in trunk control for young and older healthy adults?

BACKGROUND: Most current applications of visual feedback to improve postural control are limited to a fixed base of support and produce mixed results regarding improved postural control and transfer to functional tasks. Currently there are few options available to provide visual feedback regarding trunk motion while walking. We have developed a low cost platform to provide visual feedback of trunk motion during walking. Here we investigated whether augmented visual position feedback would reduce trunk movement variability in both young and older healthy adults. METHODS: The subjects who participated were 10 young and 10 older adults. Subjects walked on a treadmill under conditions of visual position feedback and no feedback. The visual feedback consisted of anterior-posterior (AP) and medial-lateral (ML) position of the subject's trunk during treadmill walking. Fourier transforms of the AP and ML trunk kinematics were used to calculate power spectral densities which were integrated as frequency bins "below the gait cycle" and "gait cycle and above" for analysis purposes. RESULTS: Visual feedback reduced movement power at very low frequencies for lumbar and neck translation but not trunk angle in both age groups. At very low frequencies of body movement, older adults had equivalent levels of movement variability with feedback as young adults without feedback. Lower variability was specific to translational (not angular) trunk movement. Visual feedback did not affect any of the measured lower extremity gait pattern characteristics of either group, suggesting that changes were not invoked by a different gait pattern. CONCLUSIONS: Reduced translational variability while walking on the treadmill reflects more precise control maintaining a central position on the treadmill. Such feedback may provide an important technique to augment rehabilitation to minimize body translation while walking. Individuals with poor balance during walking may benefit from this type of training to enhance path consistency during over-ground locomotion.

Vestibular perceptual testing from lab to clinic: a review.

Not all dizziness presents as vertigo, suggesting other perceptual symptoms for individuals with vestibular disease. These non-specific perceptual complaints of dizziness have led to a recent resurgence in literature examining vestibular perceptual testing with the aim to enhance clinical diagnostics and therapeutics. Recent evidence supports incorporating rehabilitation methods to retrain vestibular perception. This review describes the current field of vestibular perceptual testing from scientific laboratory techniques that may not be clinic friendly to some low-tech options that may be more clinic friendly. Limitations are highlighted suggesting directions for additional research.

Type, dose, and outcomes of physical therapy interventions for unilateral peripheral vestibular hypofunction: protocol for a systematic review.

BACKGROUND: Unilateral peripheral vestibular hypofunction can result in symptoms of dizziness, gaze and gait instability, and impaired navigation and spatial orientation. These impairments and activity limitations may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. However, there is great variability in clinical practice with regard to the type of interventions and only weak evidence to guide optimal exercise dosage. It is important to identify the most appropriate interventions and exercise dosage to optimize and accelerate recovery of function and to decrease distress. The objective of this systematic review is to determine which interventions and which doses are most effective in decreasing dizziness or vertigo, improving postural control, and improving quality of life in adults with unilateral peripheral vestibular hypofunction. METHODS: The literature will be systematically searched using the following online databases: PubMed/MEDLINE, EMBASE, Web of Science (Science and Social Science Citation Index), Cumulative Index for Nursing and Allied Health Literature (CINAHL), and The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register). The review will include randomized controlled trials (RCTs), including cluster RCTs, to assess the beneficial effects of the interventions. Assessment of methodological quality and risk of bias will be performed by two independent, blinded reviewers using the PEDro scale and Cochrane Risk of Bias version 2, respectively. The primary outcome measure will be change in self-perceived handicap related to dizziness from baseline to the end of the study, measured using the Dizziness Handicap Inventory. Other relevant outcome measures will include self-reported change in symptoms (to include severity, frequency, and duration) such as verbal or visual analog scales for dizziness. Tertiary outcome measures will include questionnaires related to disability and/or quality of life. DISCUSSION: This systematic review will identify, evaluate, and integrate the evidence on the effectiveness of physical therapy interventions for unilateral peripheral vestibular hypofunction in an adult population. We anticipate our findings may inform individualized treatment and future research. Clinical recommendations generated from this systematic review may inform vestibular physical therapy treatment of individuals with unilateral peripheral vestibular hypofunction. TRIAL REGISTRATION: In accordance with the guidelines, our systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 06 August 2021 (registration number CRD42021266163 ). In the event of protocol amendments, the date of each amendment will be accompanied by a description of the change and the rationale.

Facemasks Block Lower Visual Field in Youth Ice Hockey.

Wearing a facemask (FM) reduces the spread of COVID-19, but it also blocks a person's lower visual field. Many new public safety rules were created in response to COVID-19, including mandated FM wearing in some youth sports like youth ice hockey. We hypothesized that FM wearing in youth hockey players obstructs the lower field of view and may impact safety. Youth hockey players (n = 33) aged 12.03 (1.6) years button press when they saw an LED on the floor turn on in two conditions (wearing FM or no FM) in random order. An interleaved one-up/one-down two-alternative-forced-choice adaptive staircase design was used. Visual thresholds were calculated for each condition and participant. The visual angle threshold (VAT) was determined using standing eye height and the linear distance from the tip of the skates to the visual threshold. Paired t-tests determined whether mask wearing changed the VAT. We modeled the probability a player could see the puck on their stick in four distinct scenarios to estimate the potential impact of FM wearing during hockey play. The average unmasked VAT (11.4 degrees) was significantly closer to the skates than the masked VAT (20.3 degrees) (p < 0.001). Our model indicated a significant reduction in ability to visualize the puck using peripheral vision when more upright while wearing a FM. FM wearing compromised their lower visual field, suggesting a downward head tilt may be necessary to see the puck. Playing ice hockey while wearing a FM may lead to unsafe on-ice playing conditions due to downward head tilt to see the puck.

Psychometric Tests and Spatial Navigation: Data From the Baltimore Longitudinal Study of Aging.

Spatial cognition is the process by which individuals interact with their spatial environment. Spatial cognition encompasses the specific skills of spatial memory, spatial orientation, and spatial navigation. Prior studies have shown an association between psychometric tests of spatial ability and self-reported or virtual measures of spatial navigation. In this study, we examined whether psychometric spatial cognitive tests predict performance on a dynamic spatial navigation task that involves movement through an environment. We recruited 151 community-dwelling adult participants [mean (SD) age 69.7 (13.6), range 24.6-93.2] from the Baltimore Longitudinal Study of Aging (BLSA). Spatial navigation ability was assessed using the triangle completion task (TCT), and two quantities, the angle and distance of deviation, were computed. Visuospatial cognitive ability was assessed primarily using the Card Rotations Test. Additional tests of executive function, memory, and attention were also administered. In multiple linear regression analyses adjusting for age, sex, race, and education, cognitive tests of visuospatial ability, executive function, and perceptual motor speed and integration were significantly associated with spatial navigation, as determined by performance on the TCT. These findings suggest that dynamic spatial navigation ability is related to spatial memory, executive function, and motor processing speed.

Reliability and Fall Risk Detection for the BESTest and Mini-BESTest in Older Adults.

BACKGROUND & PURPOSE: Test stability and test-retest reliability have not previously been reported for either the Balance Evaluation Systems Test (BESTest) or mini-BESTest (mBEST) in a population of older adults with nonspecific balance limitations. Furthermore, no criterion for identifying change greater than chance has been reported in older adults with nonspecific balance problems using either BESTest or mBEST scores. The purposes of this study were to determine test stability over time, test-retest reliability, to identify minimum detectable change for the BESTest and mBEST in a population of older adults with nonspecific balance problems. In addition, the ability of the BESTest and mBEST to identify past fallers was characterized. METHODS: This was an observational study with 58 adults 65 years or older with a history of falls or self-reported balance problem. The BESTest and mBEST were administered to all participants at the beginning and end of 4 weeks. Test-retest reliability was calculated with intraclass correlations, and minimum detectable change was calculated at the 95% confidence level (MDC95). Receiver operating characteristics were used to characterize the sensitivity and specificity of the BESTest and mBEST to identify older adults who had previously fallen. RESULTS: Balance scores did not significantly change over a 4-week period. Test-retest reliability for the BESTest (0.86) and mBEST (0.84) was good to excellent. MDC95 scores were identified for the BESTest (8.9) and mBEST (4). CONCLUSIONS: The BESTest and mBEST scores were stable and reliable over a period of 4 weeks for a population of older adults with self-reported balance problems or a history of falling. MDC95 scores allow interpretation of change in BESTest and mBEST scores following rehabilitation.

Vestibulo-Ocular Reflex Function in Adolescents With Sport-Related Concussion: Preliminary Results.

BACKGROUND: Oculomotor impairments, dizziness, and imbalance are common after sports-related concussion (SRC) in adolescents and suggest a relationship between SRC and vestibular system dysfunction. However, it is not clear whether the source of these problems is attributable to the peripheral or central vestibular system. HYPOTHESIS: The video Head Impulse Test (vHIT), which assesses peripheral vestibular function, will show differences in gain between adolescents with and without SRC. Furthermore, there will be an association between vHIT and clinical balance and vestibular/oculomotor testing. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 2. METHODS: Twenty-five symptomatic adolescents aged between 12 and 19 years with a recent (within 10 days) SRC and 22 healthy controls aged 13 to 20 years were assessed using the vHIT, Balance Error Scoring System (BESS), and Vestibular Ocular Motor Screening (VOMS) tools. The vestibulo-ocular reflex (VOR) gain was calculated independently for right and left head impulses. Independent-samples t tests or Mann-Whitney U tests for nonnormal distributions were used to compare concussed patients and controls on the measures. Spearman rank-order correlations were used to assess the association of vHIT with BESS and VOMS. RESULTS: VOR gain in all adolescents with SRC was greater than 0.8, which is considered within normal limits. VOR gain and BESS scores were not significantly different between groups. Adolescents with SRC had significantly worse VOMS item scores than adolescents without SRC (P < 0.001). There were no significant correlations among vHIT gain and VOMS or BESS. CONCLUSION: There was no evidence for dysfunction in the peripheral horizontal semicircular canal function at high rotation speeds (ie, vHIT) after SRC, and vHIT was unrelated to balance and vestibular/oculomotor symptoms and dysfunction. However, adolescents with SRC scored worse on vestibular and oculomotor testing than those without SRC. Vestibular dysfunction and symptoms after SRC may be centrally derived. CLINICAL RELEVANCE: We do not recommend the assessment of head impulse function in adolescents with SRC unless more definitive signs of peripheral vestibular injury are present. We recommend using the VOMS to assess symptoms of suspected SRC injury in adolescents.

A Tool to Quantify the Functional Impact of Oscillopsia.

BACKGROUND: Individuals with bilateral vestibular hypofunction (BVH) often report symptoms of oscillopsia during walking. Existing assessments of oscillopsia are limited to descriptions of severity and symptom frequency, neither of which provides a description of functional limitations attributed to oscillopsia. A novel questionnaire, the Oscillopsia Functional Impact scale (OFI) was developed to describe the impact of oscillopsia on daily life activities. Questions on the OFI ask how often individuals are able to execute specific activities considered to depend on gaze stability in an effort to link functional mobility impairments to oscillopsia for individuals with vestibular loss. METHODS: Subjective reports of oscillopsia and balance confidence were recorded for 21 individuals with BVH and 48 healthy controls. Spearman correlation coefficients were calculated to determine the relationship between the OFI and oscillopsia visual analog scale (OS VAS), oscillopsia severity questionnaire (OSQ), and Activities-Specific Balance Confidence scale to demonstrate face validity. Chronbach's α was calculated to determine internal validity for the items of the OFI. A one-way MANOVA was conducted with planned post hoc paired t-tests for group differences on all oscillopsia questionnaires using a corrected α = 0.0125. RESULTS: The OFI was highly correlated with measures of oscillopsia severity (OS VAS; r = 0.69, p < 0.001) and frequency (OSQ; r = 0.84, p < 0.001) and also with the Activities-Specific Balance Confidence scale (r = -0.84, p < 0.001). Cronbach's α for the OFI was 0.97. Individuals with BVH scored worse on all measures of oscillopsia and balance confidence compared to healthy individuals (p's < 0.001). CONCLUSION: The OFI appears to capture the construct of oscillopsia in the context of functional mobility. Combining with oscillopsia metrics that quantify severity and frequency allows for a more complete characterization of the impact of oscillopsia on an individual's daily behavior. The OFI discriminated individuals with BVH from healthy individuals.

Influences of Age, Obesity, and Adverse Drug Effects on Balance and Mobility Testing Scores in Ambulatory Older Adults.

BACKGROUND AND PURPOSE: The adverse effects of drugs may influence results on tests of mobility and balance, but the drug-specific impact is not identified when using these tests. We propose that a quantitative drug index (QDI) will assist in assessing fall risk based on these tests, when combined with other fall risk variables. METHODS: Fifty-seven community-dwelling older adults who could walk independently on a treadmill and had Mini-Mental State Examination (MMSE) scores equal to or greater than 24 participated. Mobility and balance outcome measures included the Balance Evaluation Systems Test (BESTest), Berg Balance Scale (BBS), Timed Up and Go (TUG) and cognitive dual task TUG (TUGc). Fall history, current drug list, and Activity-Specific Balance Confidence (ABC) scale scores were also collected. Body mass index (BMI) was calculated. The QDI was derived from the drug list for each individual, and based on fall-related drug adverse effects. Multiple linear regression analyses were conducted using age, BMI, and QDI as predictor variables for determining mobility and balance test scores, and ABC scale scores. Subsequently, participants were divided into (QDI = 0) low-impact drug group (LIDG) and (QDI > 0) high-impact drug group (HIDG) for Mann-Whitney 2-group comparisons. RESULTS: Age, BMI, and QDI were all significant (P < .001) independent variables in multiple regression analyses for mobility and balance test scores, but not for the ABC scale. Separately, the 2 group comparisons for the BESTest, BBS, TUG, and TUGc demonstrated that HIDG scored significantly (P < .05) worse on these tests compared with the LIDG. Drug counts were also significantly higher for the HIDG than for the LIDG. In contrast, age, BMI, MMSE, and reported falls in the last 12 months were not significantly different between groups. CONCLUSION: Age, BMI, and QDI-all contributed independently to the mobility and balance test scores examined, and may provide health care professionals a screening tool to determine whether additional mobility and balance testing is required. In addition, the QDI is a more precise marker of adverse effects of drugs compared with drug counts, as the latter does not quantitate the influence of drugs on physiologic function.

"Text It" program to track falls in patients with Alzheimer's disease and dementia.

INTRODUCTION: Falls are a significant problem among older adults with Alzheimer's disease, leading to high rates of fracture, hospitalization, and death. Tracking falls in older adults, particularly those with cognitive impairment, is a clinical and research challenge. METHODS: This prospective pilot study evaluated the feasibility of a text message program to track falls among patients with dementia. We also compared this technique with the calendar method of fall data collection. RESULTS: There was a 96% completion rate of text messaging and 100% of calendars; however, the text-gathered data were more accurate. DISCUSSION: A text-messaging platform to track falls shows promise in cognitively impaired individuals.

Visual biofeedback training reduces quantitative drugs index scores associated with fall risk.

OBJECTIVE: Drugs increase fall risk and decrease performance on balance and mobility tests. Conversely, whether biofeedback training to reduce fall risk also decreases scores on a published drug-based fall risk index has not been documented. Forty-eight community-dwelling older adults underwent either treadmill gait training plus visual feedback (+VFB), or walked on a treadmill without feedback. The Quantitative Drug Index (QDI) was derived from each participant's drug list and is based upon all cause drug-associated fall risk. Analysis of covariance assessed changes in the QDI during the study, and data is presented as mean ± standard error of the mean. RESULTS: The QDI scores decreased significantly (p = 0.031) for participants receiving treadmill gait training +VFB (- 0.259 ± 0.207), compared to participants who walked on the treadmill without VFB (0.463 ± 0.246). Changes in participants QDI scores were dependent in part upon their age, which was a significant covariate (p = 0.007). These preliminary results demonstrate that rehabilitation to reduce fall risk may also decrease use of drugs associated with falls. Determination of which drugs or drug classes that contribute to the reduction in QDI scores for participants receiving treadmill gait training +VFB, compared to treadmill walking only, will require a larger participant investigation. Trial Registration ISRNCT01690611, ClinicalTrials.gov #366151-1, initial 9/24/2012, completed 4/21/2016.

Trunk motion visual feedback during walking improves dynamic balance in older adults: Assessor blinded randomized controlled trial.

BACKGROUND: Virtual reality and augmented feedback have become more prevalent as training methods to improve balance. Few reports exist on the benefits of providing trunk motion visual feedback (VFB) during treadmill walking, and most of those reports only describe within session changes. RESEARCH QUESTION: To determine whether trunk motion VFB treadmill walking would improve over-ground balance for older adults with self-reported balance problems. METHODS: 40 adults (75.8 years (SD 6.5)) with self-reported balance difficulties or a history of falling were randomized to a control or experimental group. Everyone walked on a treadmill at a comfortable speed 3×/week for 4 weeks in 2 min bouts separated by a seated rest. The control group was instructed to look at a stationary bulls-eye target while the experimental group also saw a moving cursor superimposed on the stationary bulls-eye that represented VFB of their walking trunk motion. The experimental group was instructed to keep the cursor in the center of the bulls-eye. Somatosensory (monofilaments and joint position testing) and vestibular function (canal specific clinical head impulses) was evaluated prior to intervention. Balance and mobility were tested before and after the intervention using Berg Balance Test, BESTest, mini-BESTest, and Six Minute Walk. RESULTS: There were no significant differences between groups before the intervention. The experimental group significantly improved on the BESTest (p = 0.031) and the mini-BEST (p = 0.019). The control group did not improve significantly on any measure. Individuals with more profound sensory impairments had a larger improvement on dynamic balance subtests of the BESTest. SIGNIFICANCE: Older adults with self-reported balance problems improve their dynamic balance after training using trunk motion VFB treadmill walking. Individuals with worse sensory function may benefit more from trunk motion VFB during walking than individuals with intact sensory function.

Eye Movements Are Correctly Timed During Walking Despite Bilateral Vestibular Hypofunction.

Individuals with bilateral vestibular hypofunction (BVH) often report symptoms of oscillopsia (the perception that the world is bouncing or unstable) during walking. Efference copy/proprioception contributes to locomotion gaze stability in animals, sometimes inhibiting the vestibulo-ocular reflex (VOR). Gaze stability requires both adequate eye velocity and appropriate timing of eye movements. It is unknown whether eye velocity (VOR gain), timing (phase), or both are impaired for individuals with BVH during walking. Identifying the specific mechanism of impaired gaze stability can better inform rehabilitation options. Gaze stability was measured for eight individuals with severe BVH and eight healthy age- and gender-matched controls while performing a gaze fixation task during treadmill walking. Frequency response functions (FRF) were calculated from pitch eye and head velocity. A one-way ANOVA was conducted to determine group differences for each frequency bin of the FRF. Pearson correlation coefficients were calculated to determine the relationship between the real and imaginary parts of the FRF and the Oscillopsia Visual Analog Scale (oVAS) scores. Individuals with BVH demonstrated significantly lower gains than healthy controls above 0.5 Hz, but their phase was ideally compensatory for frequencies below 3 Hz. Higher oVAS scores were correlated with lower gain. Individuals with BVH demonstrated ideal timing for vertical eye movements while walking despite slower than ideal eye velocity when compared to healthy controls. Rehabilitation interventions focusing on enhancing VOR gain during walking should be developed to take advantage of the intact timing reported here. Specifically, training VOR gain while walking may reduce oscillopsia severity and improve quality of life.

Age-Related Imbalance Is Associated With Slower Walking Speed: An Analysis From the National Health and Nutrition Examination Survey.

BACKGROUND AND PURPOSE: Walking speed is an important dimension of gait function and is known to decline with age. Gait function is a process of dynamic balance and motor control that relies on multiple sensory inputs (eg, visual, proprioceptive, and vestibular) and motor outputs. These sensory and motor physiologic systems also play a role in static postural control, which has been shown to decline with age. In this study, we evaluated whether imbalance that occurs as part of healthy aging is associated with slower walking speed in a nationally representative sample of older adults. METHODS: We performed a cross-sectional analysis of the previously collected 1999 to 2002 National Health and Nutrition Examination Survey (NHANES) data to evaluate whether age-related imbalance is associated with slower walking speed in older adults aged 50 to 85 years (n = 2116). Balance was assessed on a pass/fail basis during a challenging postural task-condition 4 of the modified Romberg Test-and walking speed was determined using a 20-ft (6.10 m) timed walk. Multivariable linear regression was used to evaluate the association between imbalance and walking speed, adjusting for demographic and health-related covariates. A structural equation model was developed to estimate the extent to which imbalance mediates the association between age and slower walking speed. RESULTS: In the unadjusted regression model, inability to perform the NHANES balance task was significantly associated with 0.10 m/s slower walking speed (95% confidence interval: -0.13 to -0.07; P < .01). In the multivariable regression analysis, inability to perform the balance task was significantly associated with 0.06 m/s slower walking speed (95% confidence interval: -0.09 to -0.03; P < .01), an effect size equivalent to 12 years of age. The structural equation model estimated that age-related imbalance mediates 12.2% of the association between age and slower walking speed in older adults. CONCLUSIONS: In a nationally representative sample, age-related balance limitation was associated with slower walking speed. Balance impairment may lead to walking speed declines. In addition, reduced static postural control and dynamic walking speed that occur with aging may share common etiologic origins, including the decline in visual, proprioceptive, and vestibular sensory and motor functions.