A custom-built step exergame training programme to prevent falls in people with multiple sclerosis: A multicentre randomised controlled trial.

BACKGROUND: Cognitive-motor step training can improve stepping, balance and mobility in people with multiple sclerosis (MS), but effectiveness in preventing falls has not been demonstrated. OBJECTIVES: This multisite randomised controlled trial aimed to determine whether 6 months of home-based step exergame training could reduce falls and improve associated risk factors compared with usual care in people with MS. METHODS: In total, 461 people with MS aged 22-81 years were randomly allocated to usual care (control) or unsupervised home-based step exergame training (120 minutes/week) for 6 months. The primary outcome was rate of falls over 6 months from randomisation. Secondary outcomes included physical, cognitive and psychosocial function at 6 months and falls over 12 months. RESULTS: Mean (standard deviation (SD)) weekly training duration was 70 (51) minutes over 6 months. Fall rates did not differ between intervention and control groups (incidence rates (95% confidence interval (CI)): 2.13 (1.57-2.69) versus 2.24 (1.35-3.13), respectively, incidence rate ratio: 0.96 (95% CI: 0.69-1.34, p = 0.816)). Intervention participants performed faster in tests of choice-stepping reaction time at 6 months. No serious training-related adverse events were reported. CONCLUSION: The step exergame training programme did not reduce falls among people with MS. However, it significantly improved choice-stepping reaction time which is critical to ambulate safely in daily life environment.

Reduced strength, poor balance and concern about falls mediate the relationship between knee pain and fall risk in older people.

BACKGROUND: Pain is an independent risk factor for falling. One in two older community-dwelling people with musculoskeletal pain fall each year. This study examined physical, psychological and medical factors as potential mediators to explain the relationship between knee pain and falls. METHODS: Three hundred and thirty-three community-dwelling people aged 70+ years (52% women) participated in this cohort study with a 1-year follow-up for falls. Participants completed questionnaires (medical history, general health and concern about falls) and underwent physical performance tests. Participants were classified into 'pain' and 'no pain' groups based on self-reported knee pain. Poisson Regression models were computed to determine the Relative Risk (RR) of having multiple falls and potential mediators for increased fall risk. RESULTS: One hundred and eighteen (36%) participants were categorised as having knee pain. This group took more medications and had more medical conditions (P < 0.01) compared to the no pain group. The pain group had poorer balance, physical function and strength and reported increased concern about falls. Sixty one participants (20%) reported ≥2 falls, with the pain group twice as likely to experience multiple falls over the 12 month follow up (RR = 2.0, 95% confidence interval (CI) = 1.27-3.13). Concern about falls, knee extension torque and postural sway with eyes closed were identified as significant and independent mediators of fall risk, and when combined explained 23% of the relationship between knee pain and falls. CONCLUSION: This study has identified several medical, medication, psychological, sensorimotor, balance and mobility factors to be associated with knee pain, and found the presence of knee pain doubles the risk of multiple falls in older community living people. Alleviating knee pain, as well as addressing associated risk factors may assist in preventing falls in older people with knee pain.

Reducing the burden of dizziness in middle-aged and older people: A multifactorial, tailored, single-blind randomized controlled trial.

BACKGROUND: Dizziness is common among older people and is associated with a cascade of debilitating symptoms, such as reduced quality of life, depression, and falls. The multifactorial aetiology of dizziness is a major barrier to establishing a clear diagnosis and offering effective therapeutic interventions. Only a few multidisciplinary interventions of dizziness have been conducted to date, all of a pilot nature and none tailoring the intervention to the specific causes of dizziness. Here, we aimed to test the hypothesis that a multidisciplinary dizziness assessment followed by a tailored multifaceted intervention would reduce dizziness handicap and self-reported dizziness as well as enhance balance and gait in people aged 50 years and over with dizziness symptoms. METHODS AND FINDINGS: We conducted a 6-month, single-blind, parallel-group randomized controlled trial in community-living people aged 50 years and over who reported dizziness in the past year. We excluded individuals currently receiving treatment for their dizziness, those with degenerative neurological conditions including cognitive impairment, those unable to walk 20 meters, and those identified at baseline assessment with conditions that required urgent treatment. Our team of geriatrician, vestibular neuroscientist, psychologist, exercise physiologist, study coordinator, and baseline assessor held case conferences fortnightly to discuss and recommend appropriate therapy (or therapies) for each participant, based on their multidisciplinary baseline assessments. A total of 305 men and women aged 50 to 92 years (mean [SD] age: 67.8 [8.3] years; 62% women) were randomly assigned to either usual care (control; n = 151) or to a tailored, multifaceted intervention (n = 154) comprising one or more of the following: a physiotherapist-led vestibular rehabilitation programme (35% [n = 54]), an 8-week internet-based cognitive-behavioural therapy (CBT) (19% [n = 29]), a 6-month Otago home-based exercise programme (24% [n = 37]), and/or medical management (40% [n = 62]). We were unable to identify a cause of dizziness in 71 participants (23% of total sample). Primary outcome measures comprised dizziness burden measured with the Dizziness Handicap Inventory (DHI) score, frequency of dizziness episodes recorded with monthly calendars over the 6-month follow-up, choice-stepping reaction time (CSRT), and gait variability. Data from 274 participants (90%; 137 per group) were included in the intention-to-treat analysis. At trial completion, the DHI scores in the intervention group (pre and post mean [SD]: 25.9 [19.2] and 20.4 [17.7], respectively) were significantly reduced compared with the control group (pre and post mean [SD]: 23.0 [15.8] and 21.8 [16.4]), when controlling for baseline scores (mean [95% CI] difference between groups [baseline adjusted]: -3.7 [-6.2 to -1.2]; p = 0.003). There were no significant between-group differences in dizziness episodes (relative risk [RR] [95% CI]: 0.87 [0.65 to 1.17]; p = 0.360), CSRT performance (mean [95% CI] difference between groups [baseline adjusted]: -15 [-40 to 10]; p = 0.246), and step-time variability during gait (mean [95% CI] difference between groups [baseline adjusted]: -0.001 [-0.002 to 0.001]; p = 0.497). No serious intervention-related adverse events occurred. Study limitations included the low initial dizziness severity of the participants and the only fair uptake of the falls clinic (medical management) and the CBT interventions. CONCLUSIONS: A multifactorial tailored approach for treating dizziness was effective in reducing dizziness handicap in community-living people aged 50 years and older. No difference was seen on the other primary outcomes. Our findings therefore support the implementation of individualized, multifaceted evidence-based therapies to reduce self-perceived disability associated with dizziness in middle-aged and older people. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000379819.

Tailored multifactorial intervention to improve dizziness symptoms and quality of life, balance and gait in dizziness sufferers aged over 50 years: protocol for a randomised controlled trial.

BACKGROUND: Dizziness is a frequently reported symptom in older people that can markedly impair quality of life. This manuscript presents the protocol for a randomised controlled trial, which has the main objective of determining the impact of comprehensive assessment followed by a tailored multifaceted intervention in reducing dizziness episodes and symptoms, improving associated impairments to balance and gait and enhancing quality of life in older people with self-reported significant dizziness. METHODS: Three hundred people aged 50 years or older, reporting significant dizziness in the past year will be recruited to participate in the trial. Participants allocated to the intervention group will receive a tailored, multifaceted intervention aimed at treating their dizziness symptoms over a 6 month trial period. Control participants will receive usual care. The primary outcome measures will be the frequency and duration of dizziness episodes, dizziness symptoms assessed with the Dizziness Handicap Inventory, choice-stepping reaction time and step time variability. Secondary outcomes will include health-related quality of life measures, depression and anxiety symptoms, concern about falling, balance and risk of falls assessed with the physiological fall risk assessment. Analyses will be by intention-to-treat. DISCUSSION: The study will determine the effectiveness of comprehensive assessment, combined with a tailored, multifaceted intervention on dizziness episodes and symptoms, balance and gait control and quality of life in older people experiencing dizziness. Clinical implications will be evident for the older population for the diagnosis and treatment of dizziness. TRIAL REGISTRATION: The study is registered with the Australia New Zealand Clinical Trials Registry ACTRN12612000379819 .

Exergame and cognitive training for preventing falls in community-dwelling older people: a randomized controlled trial.

Exergame training, in which video games are used to promote exercise, can be tailored to address cognitive and physical risk factors for falls and is a promising method for fall prevention in older people. Here, we performed a randomized clinical trial using the smart±step gaming system to examine the effectiveness of two home-based computer game interventions, seated cognitive training and step exergame training, for fall prevention in community-dwelling older people, as compared with a minimal-intervention control group. Participants aged 65 years or older (n = 769, 71% female) living independently in the community were randomized to one of three arms: (1) cognitive training using a computerized touchpad while seated, (2) exergame step training on a computerized mat or (3) control (provided with an education booklet on healthy ageing and fall prevention). The rate of falls reported monthly over 12 months-the primary outcome of the trial-was significantly reduced in the exergame training group compared with the control group (incidence rate ratio = 0.74, 95% confidence interval = 0.56-0.98), but was not statistically different between the cognitive training and control groups (incidence rate ratio = 0.86, 95% confidence interval = 0.65-1.12). No beneficial effects of the interventions were found for secondary outcomes of physical and cognitive function, and no serious intervention-related adverse events were reported. The results of this trial support the use of exergame step training for preventing falls in community-dwelling older people. As this intervention can be conducted at home and requires only minimal equipment, it has the potential for scalability as a public health intervention to address the increasing problem of falls and fall-related injuries. Australian and New Zealand Clinical Trial Registry identifier: ACTRN12616001325493 .

Effects of Delayed Surgical Intervention Following Emergency Department Presentation on Stone Surgery Complexity.

Introduction and Objective: Prior literature had demonstrated increased stone burden and higher rates of staged surgery in individuals of lower socioeconomic status (SES). Low SES individuals are more likely to experience delays in definitive stone surgery after initial presentation to the emergency department (ED) for kidney stones. This study aims to investigate the relationship between delays in definitive kidney stone surgery and the subsequent need for percutaneous nephrolithotomy (PNL) and/or staged surgical procedures using a statewide data set. Methods: This retrospective cohort study gathered longitudinal data from 2009 to 2018 using the California Department of Health Care Access and Information data set. Patient demographic characteristics, comorbidities, diagnosis/procedure codes, and distance were analyzed. Complex stone surgery was defined as initial PNL and/or undergoing more than one procedure within 365 days of initial intervention. Results: A total of 1,816,093 billing encounters from 947,798 patients were screened, resulting in 44,835 patients with ED visits for kidney stones followed by a urologic stone procedure. Multivariable analysis revealed that relative to patients who underwent surgery within 1 month of initial ED visit for stone disease, patients were at increased odds of undergoing complex surgery if waiting ≥6 months (odds ratio [OR] 1.18, p = 0.022), ≥1 year (OR 1.29, p < 0.001), and ≥3 years (OR 1.43, p < 0.001). Conclusions: Delays in definitive stone surgery after initial ED encounter for stone disease were associated with increased likelihood of undergoing a complex stone treatment.

Training reactive balance using trips and slips in people with multiple sclerosis: A blinded randomised controlled trial.

BACKGROUND: This study examined the feasibility and efficacy of reactive balance training for improving stepping performance and reducing laboratory-induced falls in people with multiple sclerosis (MS). METHODS: Thirty people diagnosed with MS (18-70 years) participated in a blinded randomized controlled trial (ACTRN12618001436268). The intervention group (n = 14) underwent two 50-minute sessions (total 100 min) that exposed them to a total of 24 trips and 24 slips in mixed order, over one week. The control group (n = 16) received sham training (stepping over foam obstacles) with equivalent dosage. The primary outcome was falls into the harness (defined as >30% body weight) when exposed to trips and slips that were unpredictable in timing, location and type at post-assessment. Physical and psychological measures were also assessed at baseline and post assessments. RESULTS: The intervention and control groups completed 86% and 95% of the training protocols respectively. Incidence rate ratios (95% confidence intervals) of the intervention group relative to the control group were 0.57 (0.25, 1.26) for all falls, 0.80 (0.30, 2.11) for slip falls and 0.20 (0.04, 0.96) for trip falls in the laboratory. Kinematic analyses indicated the intervention participants improved dynamic stability, with higher centre of mass position and reduced trunk sway during recovery steps following a trip, compared to control. There were no significant differences between the intervention and control participants at post-assessment for other secondary outcome measures. CONCLUSIONS: Reactive balance training improved trip-induced dynamic stability, limb support, trunk control and reduced falls in people with MS. More research is required to optimise the training protocol and determine whether the beneficial effects of reactive balance training can be retained long term and generalize to fewer daily-life falls.

Underinsurance And Multiple Surgical Treatments for Kidney Stones.

OBJECTIVE: To further elucidate the relationship between low socioeconomic status (SES) and larger, more complex stones requiring staged surgical interventions. Specifically, we aimed to determine if underinsurance (Medicaid, Medicare, and self-pay insurance types) is associated with multiple surgeries within 1 year. METHODS: We performed a retrospective longitudinal analysis of prospectively collected data from the California statewide Department of Health Care Access and Information (HCAI) dataset. We included adult patients who had their first recorded kidney stone encounter between 2009 and 2018 and underwent at least 1 urologic stone procedure. We followed these patients within the dataset for one year after their initial surgery to assess for factors predicting multiple surgical treatments for stones. RESULTS: A total of 156,319 adults were included in the study. The proportions of individuals in private insurance, Medicaid, Medicare and self-pay/indigent groups differed by the presence or absence of additional surgeries (64.0%, 13.5%, 19.4%, and 0.1%, vs 70.3%, 10.1%, 16.6%, and 0.1%, respectively). Compared to private insurance, Medicaid (1.46 [1.40-1.53] P < .001) and Medicare (1.15 [1.10-1.20] P < .001) insurance types were associated with significantly greater odds of multiple surgeries, whereas no significant association was seen in the self-pay/indigent insurance type (1.35 [0.83-2.19], P = 1.0). CONCLUSION: In a statewide, California database from 2009 to 2018, underinsured adults had higher odds of undergoing a second procedure for kidney stones within 1 year of initial surgical treatment. This study adds to the expanding body of literature linking suboptimal healthcare access and disparate outcomes for kidney stone patients.

Ten-year work burden after prostate cancer treatment.

INTRODUCTION: We aim to characterize the magnitude of the work burden (weeks off from work) associated with prostate cancer (PCa) treatment over a 10-year period after PCa diagnosis and identify those at greatest risk. MATERIALS AND METHODS: We identified men diagnosed with PCa treated with radical prostatectomy, radiation therapy, or active surveillance/watchful waiting within CaPSURE. Patients self-reported work burden and SF36 general health scores via surveys before and 1,3,5, and 10 years after treatment. Using multivariate repeated measures generalized estimating equation modeling we examined the association between primary treatment with risk of any work weeks lost due to care. RESULTS: In total, 6693 men were included. The majority were White (81%, 5% Black, and 14% Other) with CAPRA low- (60%) or intermediate-risk (32%) disease and underwent surgery (62%) compared to 29% radiation and 9% active surveillance. Compared to other treatments, surgical patients were more likely to report greater than 7 days off work in the first year, with relatively less time off over time. Black men (RR 0.64, 95% CI 0.54-0.77) and those undergoing radiation (vs. surgery, RR 0.46, 95% CI 0.41-0.51) were less likely to report time off from work over time. Mean baseline GH score (73 [SD 18]) was similar between race and treatment groups, and stable over time. CONCLUSIONS: The work burden of cancer care continued up to 10 years after treatment and varied across racial groups and primary treatment groups, highlighting the multifactorial nature of this issue and the call to leverage greater resources for those at greatest risk.

Community Income, Healthy Food Access, and Repeat Surgery for Kidney Stones.

OBJECTIVE: To determine if limited food access census tracts and food swamp census tracts are associated with increased risk for repeat kidney stone surgery. And to elucidate the relationship between community-level food retail environment relative to community-level income on repeat stone surgery over time. METHODS: Data were abstracted from the University of California, San Francisco Information Commons. Adult patients were included if they underwent at least one urologic stone procedure. Census tracts from available geographical data were mapped using Food Access Research Atlas data from the United States Department of Agriculture Economic Research Service. Kaplan-Meier curves were employed to illustrate time to a second surgical procedure over 5 years, and log-rank tests were used to test for statistically significant differences. A multivariate Cox regression model was used to generate hazard ratios for undergoing second surgery by group. RESULTS: A total of 1496 patients were included in this analysis. Repeat stone surgery occurred in 324 patients. Kaplan-Meier curves demonstrated a statistically significant difference in curves depicting patients living in low income census tracts (LICTs) vs those not living in LICTs (P <.001). On Cox regression models, patients in LICTs had significantly higher risk of undergoing repeat surgery (P = .011). Patients from limited food access census tracts and food swamp census tracts did not have a significantly higher adjusted risk of undergoing second surgery (P = .11 and P = .88, respectively). CONCLUSION: Income more so than food access associates with increased risk of repeat kidney stone surgery. Further research is needed to explore the interaction between low socioeconomic status and kidney stone outcomes.

Ladder Use in Older People: Type, Frequency, Tasks and Predictors of Risk Behaviours.

Ladder fall and injury risk increases with age. People who present to a hospital after an injurious ladder fall have been surveyed, but little is known about ladder use in the community. The purpose of this study was to: (1) document salient factors related to ladder safety, and (2) determine physical, executive function, psychological and frequency-of-use factors associated with unsafe ladder use in older people. One hundred and two older people (aged 65+ years) were recruited. Participants completed questionnaires on demographics, health, and ladder use (type, frequency, task, behaviours) and underwent assessments of physical and executive function ability. Results showed both older men and women commonly use step ladders (61% monthly, 96% yearly), mostly inside the home for tasks such as changing a lightbulb (70%) and decorating (43%). Older men also commonly use straight ladders (27% monthly, 75% yearly), mostly outside the home for tasks such as clearing gutters (74%) and pruning trees (40%). Unsafe ladder use was more common in males and individuals with greater ladder use frequency, greater quadriceps strength, better upper limb dexterity, better balance, better stepping ability, greater self-reported everyday risk-taking, a lower fear of falling, and fewer health problems compared to their counterparts (all p < 0.05). These findings document ladder use by older people and provide insight into unsafe ladder behaviours that may be amenable to interventions to reduce ladder falls and associated injuries.

Identifying Key Risk Factors for Dizziness Handicap in Middle-Aged and Older People.

OBJECTIVES: More than 10% of people aged 50 years and older report dizziness. Despite available treatments, dizziness remains unresolved for many people due in part to suboptimal assessment. We aimed to identify factors associated with dizziness handicap in middle-aged and older people to identify targets for intervention to address this debilitating problem. A secondary aim was to determine whether factors associated with dizziness differed between middle-aged (<70 years) and older people (≥ 70 years). DESIGN: Secondary analysis of baseline and prospective data from a randomized controlled trial. SETTING AND PARTICIPANTS: In total, 305 individuals aged 50 to 92 years reporting significant dizziness in the past year were recruited from the community. METHODS: Participants were classified as having either mild or no dizziness handicap (score <31) or moderate/severe dizziness handicap (score: 31‒100) based on the Dizziness Handicap Inventory. Participants completed health questionnaires and underwent assessments of psychological well-being, lying and standing blood pressure, vestibular function, strength, vision, proprioception, processing speed, balance, stepping, and gait. Participants reported dizziness episodes in monthly diaries for 6 months following baseline assessment. RESULTS: Dizziness Handicap Inventory scores ranged from 0 to 86 with 95 participants (31%) reporting moderate/severe dizziness handicap. Many vestibular, cardiovascular, psychological, balance-related, and medical/medications measures were significantly associated with dizziness handicap severity and dizziness episode frequency. Binary logistic regression identified a positive Dix Hallpike/head-roll test for benign paroxysmal positional vertigo [odds ratio (OR) 2.09, 95% confidence interval (CI) (1.11‒3.97)], cardiovascular medication use [OR 1.90, 95% CI (1.09‒3.32)], high postural sway when standing on the floor with eyes closed (sway path ≥160 mm) [OR 2.97, 95% CI (1.73‒5.10)], and anxiety (Generalized Anxiety Disorder Scale 7-item Scale score ≥8) [OR 3.08, 95% CI (1.36‒6.94)], as significant and independent predictors of moderate/severe dizziness handicap. Participants aged 70 years and over were significantly more likely to report cardiovascular conditions than those aged less than 70 years old. CONCLUSIONS AND IMPLICATIONS: Assessments of cardiovascular conditions and cardiovascular medication use, benign paroxysmal positional vertigo, anxiety, and postural sway identify middle-aged and older people with significant dizziness handicap. A multifactorial assessment including these factors may assist in tailoring evidence-based therapies to alleviate dizziness handicap in this group.

A pilot study of reactive balance training using trips and slips with increasing unpredictability in young and older adults: Biomechanical mechanisms, falls and clinical feasibility.

BACKGROUND: Exposure to unpredictable trips and slips can improve balance recovery responses but it was not known if older adults can tolerate such high intensity training. The study aim was to determine if reactive balance in both young and older adults could be trained in a single day through exposure to slip and trip hazards hidden in unpredictable walkway locations. METHODS: Ten young (20-40 yr) and ten older adults (65 + yr) completed 32 trials on a 10-meter trip and slip walkway; 14 slip trials, 14 trip trials and 4 no-perturbation trials presented in a pseudo-random order. Participant usual gait speed was regulated using a metronome and stepping tiles at fixed distances. Gait kinematics (Vicon motion capture), falls (> 30% body weight into the harness), anxiety and confidence to avoid falling were assessed. FINDINGS: Margin of stability for balance recovery after slips substantially improved at training completion for older adults (effect size = 1.13, P = 0.019). Falls from slips also decreased: 44.4% to 0% in the young adults; and 28.6% to 14.3% in the older adults. Although confidence to avoid falling did not change, anxiety increased during training with one young and three older participants withdrawing during training. INTERPRETATIONS: The findings indicate exposure to unpredictable perturbations improves reactive balance in young and older adults. However, improvements of balance recovery from trips were not significant. Elevated anxiety levels and a high dropout rate suggest the need for more individualised training over multiple days.

Exposure to trips and slips with increasing unpredictability while walking can improve balance recovery responses with minimum predictive gait alterations.

INTRODUCTION: The primary study aim was to determine if repeated exposure to trips and slips with increasing unpredictability while walking can improve balance recovery responses when predictive gait alterations (e.g. slowing down) are minimised. The secondary aim was to determine if predictive gait alterations acquired through exposure to perturbations at a fixed condition would transfer to highly unpredictable conditions. METHODS: Ten young adults were instructed to step on stepping tiles adjusted to their usual step length and to a metronome adjusted to their usual cadence on a 10-m walkway. Participants were exposed to a total of 12 slips, 12 trips and 6 non-perturbed trials in three conditions: 1) right leg fixed location, 2) left leg fixed location and 3) random leg and location. Kinematics during non-perturbed trials and pre- and post-perturbation steps were analysed. RESULTS: Throughout the three conditions, participants walked with similar gait speed, step length and cadence(p>0.05). Participants' extrapolated centre of mass (XCoM) was anteriorly shifted immediately before slips at the fixed location (p<0.01), but this predictive gait alteration did not transfer to random perturbation locations. Improved balance recovery from trips in the random location was indicated by increased margin of stability and step length during recovery steps (p<0.05). Changes in balance recovery from slips in the random location was shown by reduced backward XCoM displacement and reduced slip speed during recovery steps (p<0.05). CONCLUSIONS: Even in the absence of most predictive gait alterations, balance recovery responses to trips and slips were improved through exposure to repeated unpredictable perturbations. A common predictive gait alteration to lean forward immediately before a slip was not useful when the perturbation location was unpredictable. Training balance recovery with unpredictable perturbations may be beneficial to fall avoidance in everyday life.