Riding waves to improve functioning: a quantitative evaluation of a Surf Week in individuals with chronic phase brain injury with six months follow-up.

PURPOSE: Environmental enrichment seems to enable people in the chronic phase of acquired brain injury (ABI) to experience new functional abilities and motor/coping strategies and consequently to become more adaptable which might prevent/reverse functional decline. This study describes the influence of a five-days Surf Week program on participants on physical function, self-efficacy, functional balance performance and self-perceived recovery. MATERIALS AND METHODS: A multiple-baseline single-case design was used. Adults participating in the Surf Week in chronic phase of ABI were eligible to participate. Participants completed a battery of tests monitoring physical function, self-efficacy, functional balance performance and self-perceived recovery. This battery was repeated 5 times over a 1-year period, two times pre-Surf Week, three times post-Surf Week. Visual data inspection with two non-overlap methods were used to determine if patients showed sustained improvement in outcomes post-intervention. RESULTS: A moderate to strong indication for improvements on physical function, functional balance performance and self-perceived recovery exists till six months follow-up. No indication was observed on self-efficacy till six months follow-up. CONCLUSIONS: A five-days Surf Week is a physically, cognitively and socially intensive stimulating activity that can positively challenge individuals after ABI and seems to improve physical functioning, functional balance performance and self-perceived recovery.

Surf therapy, if appropriate measures are taken, is a safe yet physically, cognitively and socially intensive stimulating intervention that capitalizes on enriched environment principles, and might address the holistic needs in this population.Surf therapy might positively influence physical function, balance and self-perceived recovery in adults with acquired brain injury in the chronic phase.Rehabilitation professionals should experience/explore with their patients with acquired brain injury challenging (group) outdoors activities such as these, aiming to meet patients' needs, interests, or values in the chronic phase of recovery, and so create successfully participation in activities that capitalizes on enriched environment principles.

Exploring the role of attention towards balance in chronic dizziness: Development of the Balance Vigilance Questionnaire.

BACKGROUND AND PURPOSE: Vigilance towards balance has been proposed to underpin various chronic dizziness disorders, including persistent postural-perceptual dizziness (PPPD). The objective of this study was to develop (through patient input) a validated balance-specific measure of vigilance that comprehensively assesses the varied ways in which this construct may manifest. METHODS: We developed the Balance Vigilance Questionnaire (Balance-VQ) through patient and clinician feedback, designed to assess vigilance towards balance. We then validated the questionnaire in 497 participants consisting of patients diagnosed with chronic dizziness disorders (including 97 individuals diagnosed with PPPD) and healthy controls. RESULTS: The final six-item Balance-VQ was shown to be a valid and reliable way to assess vigilance towards balance. Scores were significantly higher in individuals diagnosed with PPPD compared to controls. Although scores were also higher in the PPPD group compared to individuals with diagnosed vestibular disorders other than PPPD, Balance-VQ scores did not discriminate between the two groups when confounding factors (including dizziness severity) were controlled for. Scores did, however, independently discriminate between the PPPD group and individuals who experience dizziness in daily life, but who have not been diagnosed with a neuro-otological disorder. CONCLUSIONS: Our findings confirm that the Balance-VQ is a valid and reliable instrument for assessing vigilance towards balance. As symptom vigilance has been identified as a key risk factor for developing chronic dizziness following acute vestibular symptoms or balance disruption, we recommend using the Balance-VQ as a screening tool in people presenting with such symptoms.

The perceived control model of falling: developing a unified framework to understand and assess maladaptive fear of falling.

BACKGROUND: fear of falling is common in older adults and can have a profound influence on a variety of behaviours that increase fall risk. However, fear of falling can also have potentially positive outcomes for certain individuals. Without progressing our understanding of mechanisms underlying these contrasting outcomes, it is difficult to clinically manage fear of falling. METHODS: this paper first summarises recent findings on the topic of fear of falling, balance and fall risk-including work highlighting the protective effects of fear. Specific focus is placed on describing how fear of falling influences perceptual, cognitive and motor process in ways that might either increase or reduce fall risk. Finally, it reports the development and validation of a new clinical tool that can be used to assess the maladaptive components of fear of falling. RESULTS: we present a new conceptual framework-the Perceived Control Model of Falling-that describes specific mechanisms through which fear of falling can influence fall risk. The key conceptual advance is the identification of perceived control over situations that threaten one's balance as the crucial factor mediating the relationship between fear and increased fall risk. The new 4-item scale that we develop-the Updated Perceived Control over Falling Scale (UP-COF)-is a valid and reliable tool to clinically assess perceived control. CONCLUSION: this new conceptualisation and tool (UP-COF) allows clinicians to identify individuals for whom fear of falling is likely to increase fall risk, and target specific underlying maladaptive processes such as low perceived control.

Frailty, falls and poor functional mobility predict new onset of activity restriction due to concerns about falling in older adults: a prospective 12-month cohort study.

PURPOSE: Concerns about falling are common in older adults and often cause activity restriction. This can lead to physical deconditioning, falls and social isolation. However, not every concerned older adult will restrict their activities. This 12-month longitudinal study investigated the physical and psychosocial factors that predict the new onset of activity restriction due to concerns about falling in older people. METHODS: Participants were 543 older adults (Mage = 80.3 ± 4.4 years, range: 75-98) who did not report activity restriction due to concerns about falling at Timepoint-1 (negative response to the following question: "Do concerns about falling stop you going out-and-about?"). Participants completed a battery of physical and psychological assessments at Timepoint-1. Using binary logistic regression, we then assessed which of these variables predicted whether participants reported having started restricting their activity due to concerns about falling at the 12-month follow-up (Timepoint 2). RESULTS: 10.1% of the sample started to restrict activity due to concerns about falling at Timepoint 2. Three key predictors significantly predicted activity restriction group status at 12-month follow-up: greater frailty at Timepoint-1 (Fried Frailty Index; OR = 1.58, 95% CI 1.09-2.30), experiencing a fall between Timepoint-1 and 2 (OR = 2.22, 95% CI 1.13-4.38) and poorer functional mobility at Timepoint-1 (Timed up and Go; OR = 1.08, 95% CI 1.01-1.15). CONCLUSIONS: Frailty, experiencing a fall and poorer functional mobility all predicted the onset of activity restriction due to concerns about falling. Clinicians working in balance and falls-prevention services should regularly screen for frailty, and patients referred to frailty services should likewise receive tailored treatment to help prevent the development of activity restriction due to concerns about falling.

Weighting for the Beat: Using a Dance Cue to Facilitate Turning in People with Parkinson's Disease and Freezing of Gait.

Freezing of gait (FOG) can severely compromise daily functioning in people with Parkinson's disease. Inability to initiate a step from FOG is likely underpinned, at least in part, by a deficient preparatory weight-shift. Conscious attempts to weight-shift in preparation to step can improve success of initiating forward steps following FOG. However, FOG often occurs during turning, where weight-shifting is more complex and risk of falling is higher. We explored the effectiveness of a dance-based ('cha-cha') weight-shifting strategy to re-initiate stepping following FOG during turning. Results suggest that this simple movement strategy can enhance turning steps following FOG, without compromising safety.

Balance capacity influences the effects of conscious movement processing on postural control in older adults.

Older adults rely increasingly on conscious processes to control balance. While this could be in response to age-related declines in balance capacity, it is unclear whether such strategy is adaptive or not. We investigated whether balance capacity modified the effects of conscious movement processing (CMP) on postural control in older adults. Forty-seven older adults (Mage = 74.8, range = 61-88) completed 60-s, narrow-stance balance trials on a force platform, under conditions designed to increase (high-CMP; through movement-monitoring instructions) or reduce conscious processing (low-CMP; distraction task). Balance capacity was operationalised as a composite score of Berg Balance Scale and Timed-up-and-Go. Balance capacity influenced the effects of the CMP manipulation on mediolateral sway amplitude (p = .023). Specifically, it positively associated with sway amplitude during the high-CMP condition (ß = 0.273), but not low-CMP condition (ß = -0.060). In other words, higher balance capacity was associated with increased sway during high-CMP, confirming our hypothesis that CMP does not uniformly negatively impact balance performance. Rather, CMP was maladaptive for those with better balance. Results also indicated that older adults' balance capacity influenced the degree to which they could engage conscious or automatic postural control processes. Specifically, we found that, overall, participants showed reduced mediolateral sway frequency and complexity for the high-CMP vs. low-CMP condition (p's ≤ 0.018), indicating reduced automaticity of balance (as expected). However, these effects were significantly attenuated as balance capacity reduced (i.e., smaller changes in those with lower balance capacity, p's < 0.010). Hence, the ability to readily shift between conscious and automatic modes of postural control seems more constrained as balance becomes worse. Overall, these findings suggest clinicians need to consider older adults' balance capacity when using providing instructions or feedback likely to influence CMP within rehabilitation settings.

Standing up to threats: Translating the two-system model of fear to balance control in older adults.

The 'two-system' view of fear builds on traditional conceptualisations of emotion; proposing that the mechanisms responsible for behavioural and physiological responses to threat may be distinct from those underpinning the (conscious) emotional experience itself. We empirically tested this notion within a novel, applied context of social and economic importance: fear of falling in older adults. Older adults stood on the edge of a raised platform and were stratified based on whether they reported fear in response to this postural threat. Irrespective of whether participants reported fear, we observed behaviours indicative of postural 'stiffening' during the threat condition. Self-reports indicated that participants cognitively monitored these changes in balance, and fear of falling was experienced in those who interpreted these behaviours to imply that harm was likely to occur. Fearful participants exhibited additional changes in balance (increased movement complexity and altered utilisation of sensory feedback) - behaviours likely influenced by attempts to consciously control balance. Taken together, these findings provide novel insight into the systems that regulate behavioural and emotional responses to postural threats. The novel conceptual framework developed from these findings helps identify specific mechanisms that might be targeted through clinical intervention.

Short-latency inhibition mitigates the relationship between conscious movement processing and overly cautious gait.

BACKGROUND: Overly cautious gait is common in older adults. This is characterised by excessively slow gait, shortened steps, broadened base of support and increased double limb support. The current study sought to (1) evaluate if overly cautious gait is associated with attempts to consciously process walking movements, and (2) explore whether an individual's ability to rapidly inhibit a dominant motor response serves to mitigate this relationship. METHODS: A total of 50 older adults walked at a self-selected pace on an instrumented walkway containing two raised wooden obstacles (height = 23 cm). Trait conscious movement processing was measured with the Movement-Specific Reinvestment Scale. Short-latency inhibitory function was assessed using a validated electronic go/no-go ruler catch protocol. We used linear regressions to explore the relationship between these variables and gait parameters indicative of overly cautious gait. RESULTS: When controlling for general cognitive function (MoCA), and functional balance (Berg Balance Scale), the interaction between trait conscious movement processing and short-latency inhibition capacity significantly predicted gait velocity, step length and double limb support. Specifically, older adults with higher trait conscious movement processing and poorer inhibition were more likely to exhibit gait characteristics indicative of cautious gait (i.e. reduced velocity, shorter step lengths and increased double limb support). Neither conscious movement processing nor inhibition independently predicted gait performance. CONCLUSION: The combination of excessive movement processing tendencies and poor short-latency inhibitory capacity was associated with dysfunctional or 'overly cautious' gait. It is therefore plausible that improvement in either factor may lead to improved gait and reduced fall risk.

Consciously processing balance leads to distorted perceptions of instability in older adults.

BACKGROUND: Persistent dizziness without a clear cause is common in older adults. We explored whether an anxiety-driven preoccupation with consciously processing balance may underpin the distorted perceptions of unsteadiness that characterises 'unexplained' dizziness in older adults. METHODS: We experimentally induced anxiety about losing one's balance (through a postural threat manipulation) in a cohort of asymptomatic older adults and evaluated associated changes in perceived stability, conscious movement processing and postural control. These outcomes were also assessed when performing a distracting cognitive task designed to prevent anxiety-related conscious movement processing, in addition to during baseline conditions (ground level). RESULTS: Despite a lack of increase in postural sway amplitude (p = 0.316), participants reported reductions in perceived stability during postural threat compared to baseline (p < 0.001). A multiple linear regression revealed that anxiety-related conscious movement processing independently predicted perceptions of instability during this condition (p = 0.006). These changes were accompanied by alterations in postural control previously associated with functional dizziness, namely high-frequency postural sway and disrupted interaction between open- and closed-loop postural control (ps < 0.014). While the distraction task successfully reduced conscious processing (p = 0.012), leading to greater perceived stability (p = 0.010), further increases in both postural sway frequency (p = 0.002) and dominance of closed-loop control (p = 0.029) were observed. CONCLUSION: These findings implicate the role of conscious movement processing in the formation of distorted perceptions of unsteadiness, suggesting that such perceptions may be modifiable by reducing an over-reliance on conscious processes to regulate balance.

Conscious Movement Processing, Fall-Related Anxiety, and the Visuomotor Control of Locomotion in Older Adults.

OBJECTIVES: Older adults anxious about falling will often consciously process walking movements in an attempt to avoid falling. They also fixate their gaze on the present step rather than looking ahead to plan future actions. The present work examined whether conscious movement strategies result in such restricted visual planning. METHODS: A total of 18 community-dwelling older adults (agemean = 71.22; SD = 5.75) walked along a path and stepped into two raised targets. Repeated-measures analyses of variance were used to compare gaze behavior and movement kinematics when participants walked: (a) at baseline (ground level); (b) under conditions designed to induce fall-related anxiety (walkway elevated 0.6 m); and (c) in the absence of anxiety (ground level), but with explicit instructions to consciously process movements. RESULTS: Participants reported increased conscious movement processing when walking both on the elevated walkway (fall-related anxiety condition) and at ground level when instructed to consciously process gait. During both conditions, participants altered their gaze behavior, visually prioritizing the immediate walkway 1-2 steps ahead (areas needed for the on-line visual control of individual steps) at the expense of previewing distal areas of the walking path required to plan future steps. These alterations were accompanied by significantly slower gait and increased stance durations prior to target steps. CONCLUSIONS: Consciously processing movement (in the relative absence of anxiety) resulted in gaze behavior comparable to that observed during conditions of fall-related anxiety. As anxious participants also self-reported directing greater attention toward movement, this suggests that fall-related anxiety may disrupt the visual control of gait through increased conscious movement processing.