A highly challenging balance training intervention for people with multiple sclerosis: a feasibility trial.

BACKGROUND: Balance training interventions with a gradual progression of difficulty and highly challenging tasks designed specifically for people with multiple sclerosis (MS) are rare. The objective was to adapt a balance training intervention originally developed for Parkinson's disease through a co-design process and then conduct a pilot trial in MS to evaluate the feasibility of a large, full-scale study. METHODS: Twelve people with MS with mild to moderate overall MS-disability were included in this single-group feasibility trial. Participants received one-hour training sessions twice or three times weekly for 10 weeks. The assessment included tests of physical and cognitive functioning and patient-reported quality of life-related outcomes. Data on feasibility aspects were collected at baseline and follow-up assessments and three times during the intervention period to inform the recruitment process, as well as to monitor retention and inclusion rates, study procedures, intervention delivery, and dynamic changes in the selected potential outcome measures. Progression criteria were used to determine whether to proceed to a full-scale trial. Descriptive statistics were used to present the data. RESULTS: Out of six progression criteria, only retention and attendance at training sessions were not met. Reasons reported for not completing the intervention period mainly depended on external circumstances beyond the control of the study. In contrast, study procedures, intervention delivery, and intervention content (progression, adjustment, and control of challenge level of exercises) were considered feasible for a future, full-scale trial. The Mini-BESTest, which was used for the assessment of balance control, was considered suitable as the primary outcome in a full-scale trial with no ceiling or floor effects. Further, the Mini-BESTest showed a positive trend in outcome response with a median difference of 3.5 points between baseline and follow-up assessments. The power calculation performed suggests a feasible number of participants for recruitment. CONCLUSIONS: Overall trial aspects and intervention delivery were deemed feasible for a full-scale trial, but adjustments are needed to increase retention and attendance.

Experiences of supporting older persons in completion of an exercise and nutrition intervention: an interview study with nursing home staff.

BACKGROUND: The interactions between nursing home (NH) staff and their residents are crucial not only for the atmosphere at the NH but also for achieving care goals. In order to test the potential effects of daily physical activities (sit-to-stand (STS) exercises) combined with oral nutritional supplementation (ONS), a randomized intervention trial (the Older Person's Exercise and Nutrition (OPEN) Study) was performed in NH residents. One aspect of the study was to interview and report the NH staff's experiences of supporting the residents in fulfilling the intervention. METHODS: In this qualitative study, individual and focus group interviews were performed in eight NH facilities with NH staff who had assisted residents in performing the 12-week ONS/STS intervention. An interview guide developed for this study was used to assess staff experiences of the intervention and its feasibility. The transcribed interviews were analyzed inductively following a constant comparative method and with input from experts in the area, described in Grounded Theory as a reliable technique for researchers to form theory and hypothesis in unexplored areas. RESULTS: Three main themes relating to the health-promoting intervention emerged. These included: 1) insights into attitudes towards health in general and NH care specifically; 2) intervention-related challenges, frustrations and needs, and 3) aspects of collaboration and opportunities. The overarching hypothesis derived from the analysis reads: A health-promoting intervention such as the OPEN-concept has great potential for integration into NH life if a combined empathic and encouraging attitude, and a structure to keep it sustainable, are in place. CONCLUSIONS: NH staff experienced the health-promoting intervention as a potentially positive concept, although it was suggested that it works best if introduced as a general routine in the unit and is integrated into the daily planning of care. TRIAL REGISTRATION: ClinicalTrials.govIdentifier: NCT02702037 . Date of trial registration February 26, 2016. The trial was registered prospectively.

Do Malnutrition, Sarcopenia and Frailty Overlap in Nursing-Home Residents?

OBJECTIVES: To study the prevalence and overlap between malnutrition, sarcopenia and frailty in a selected group of nursing home (NH) residents. DESIGN: Cross-sectional descriptive study. SETTING: Nursing homes (NH). PARTICIPANTS: 92 residents taking part in an exercise and oral nutritional supplementation study; >75 years old, able to rise from a seated position, body mass index ≤30 kg/m2 and not receiving protein-rich oral nutritional supplements. MEASUREMENTS: The MNA-SF and Global Leadership Initiative on Malnutrition (GLIM) criteria were used for screening and diagnosis of malnutrition (moderate or severe), respectively. Sarcopenia risk was assessed by the SARC-F Questionnaire (0-10p; ≥4=increased risk), and for diagnosis the European Working Group of Sarcopenia in Older People (EWGSOP2) criteria was used. To screen for frailty the FRAIL Questionnaire (0-5p; 1-2p indicating pre-frailty, and >3p indicating frailty), was employed. RESULTS: Average age was 86 years; 62% were women. MNA-SF showed that 30 (33%) people were at risk or malnourished. The GLIM criteria verified malnutrition in 16 (17%) subjects. One third (n=33) was at risk for sarcopenia by SARC-F. Twenty-seven (29%) subjects displayed confirmed sarcopenic according to EWGSOP2. Around 50% (n=47) was assessed as pre-frail or frail. Six people (7%) suffered from all three conditions. Another five (5%) of the residents were simultaneously malnourished and sarcopenic, but not frail, while frailty coexisted with sarcopenia in 10% (n=9) of non-malnourished residents. Twenty-nine (32%) residents were neither malnourished, sarcopenic nor frail. CONCLUSIONS: In a group of selected NH residents a majority was either (pre)frail (51%), sarcopenic (29%) or malnourished (17%). There were considerable overlaps between the three conditions.

Energy expenditure in people with motor-complete paraplegia.

This corrects the article DOI: 10.1038/ajg.2017.27.

Energy expenditure in people with motor-complete paraplegia.

STUDY DESIGN: The present descriptive clinical and laboratory study is cross-sectional in design. OBJECTIVES: The primary aim is to describe and compare resting energy expenditure (REE) and energy expenditure (EE) during different standardized sedentary, non-exercise and exercise activities in people with motor-complete paraplegia (Th7 to Th12.). A secondary aim was to compare men and women. METHODS: Thirty-eight adults (10 women) with SCI, T7-T12 AIS A-B, were recruited. All the data were collected through indirect calorimetry. REE was measured in supine for 30 min after 8 h of overnight fasting. Activity energy expenditure (AEE) for activities was measured for seven minutes during sedentary, non-exercise physical activity (NEPA) and exercise activities. RESULTS: AEE increased four to eight times when engaging in NEPA compared to that in sedentary activities. Men had significantly higher resting oxygen uptake compared to women, 0.19 vs 0.15 l min-1 (P=0.005), REE per 24 h, 1286 vs 1030 kcal (P=0.003) and EE during weight-bearing activities. However, these became nonsignificant after adjustment for body weight and speed of movement, with a mean resting oxygen uptake of 2.47 ml O2 per kg min-1 for the whole group (women 2.43 and men 2.57 ml O2 kg-1 min-1, P=0.49). CONCLUSIONS: NEPA increases AEE up to eight times compared to sedentary activities. Gender differences in oxygen uptake during both rest and weight-bearing activities were diminished after adjustment for body weight. The mean resting oxygen uptake for the whole group was 2.47 ml O2 kg-1 min-1. These results highlight the importance, especially of NEPA, for increasing total daily EE in the target population.

Investigating the Mini-BESTest's construct validity in elderly with Parkinson's disease.

OBJECTIVES: The Mini-BESTest consists of items relevant to balance deficiencies among people with Parkinson's disease (PwPD). However, the Mini-BESTest's construct validity has been sparsely evaluated in this population. We therefore aimed to investigate the hypotheses that the Mini-BESTest results would be worse among: (i) PwPD compared to healthy controls; (ii) PwPD with moderate compared to mild motor severity; (iii) PwPD with a history of recurrent compared to non-recurrent falls. Moreover, the relationship between the Mini-BESTest and tests of similar and different constructs was expected to be moderate to strong and poor, respectively. MATERIALS AND METHODS: One hundred and five PwPD with mild-to-moderate motor severity and 47 healthy controls were included. PwPD were divided into subgroups based on motor severity and fall history. Main outcome measures were the Mini-BESTest, the timed up and go (TUG), and the original Unified Parkinson's Disease Rating Scale, part II (Activities of Daily Living). Independent t-tests and Spearman's rho were used for the analyses. RESULTS: The Mini-BESTest results were worse among PwPD compared to controls (P<.001), and among people with moderate motor severity compared to those with mild severity (P<.001). However, no differences were found between recurrent and non-recurrent fallers (P=.096). Spearman's rho showed moderate (ρ=-.470) and poor correlations (ρ=-.211) for convergent (TUG) and divergent validity (UPDRS, part II), respectively. CONCLUSIONS: Overall, the Mini-BESTest appears to adequately measure dynamic balance among PwPD with mild-to-moderate severity, although it was unable to distinguish between recurrent and non-recurrent fallers.

Concerns about falling in wheelchair users with spinal cord injury--validation of the Swedish version of the spinal cord injury falls concern scale.

OBJECTIVE: Translation of the Spinal Cord Injury Falls Concern Scale (SCI-FCS); validation and investigation of psychometric properties. DESIGN: Translation, adaptation and validation study. SUBJECTS/PATIENTS: Eighty-seven wheelchair users with chronic SCI attending follow-up at Rehab Station Stockholm/Spinalis, Sweden. METHODS: The SCI-FCS was translated to Swedish and culturally adapted according to guidelines. Construct validity was examined with the Mann-Whitney U-test, and psychometric properties with factor and Rasch analysis. RESULTS: Participants generally reported low levels of concerns about falling. Participants with higher SCI-FCS scores also reported fear of falling, had been injured for a shorter time, reported symptoms of depression, anxiety and fatigue, and were unable to get up from the ground independently. Falls with or without injury the previous year, age, level of injury, sex and sitting balance did not differentiate the level of SCI-FCS score. The median SCI-FCS score was 21 (range 16-64). Cronbachs alpha (0.95), factor and Rasch analysis showed similar results of the Swedish as of the original version. CONCLUSION: The Swedish SCI-FCS showed high internal consistency and similar measurement properties and structure as the original version. It showed discriminant ability for fear of falling, time since injury, symptoms of depression or anxiety, fatigue and ability to get up from the ground but not for age, gender or falls. Persons with shorter time since injury, psychological concerns, fatigue and decreased mobility were more concerned about falling. In a clinical setting, the SCI-FCS might help identifying issues to address to reduce the concerns about falling.

Detection of cardiovascular disease in elite athletes using cardiac magnetic resonance imaging.

PURPOSE: Sudden cardiac death [SCD] in competitive athletes is caused by a diverse set of cardiovascular diseases such as hypertrophic and dilated cardiomyopathy [HCM/DCM], myocarditis, coronary anomalies or even coronary artery disease. In order to identify potential risk factors responsible for SCD, elite athletes underwent cardiac magnetic resonance [CMR] imaging. MATERIALS AND METHODS: 73 male [M] and 22 female [F] athletes (mean age 35.2 ±â€Š11.4 years) underwent CMR imaging. ECG-gated breath-hold cine SSFP sequences were used for the evaluation of wall motion abnormalities and myocardial hypertrophy as well as for quantitative analysis (left and right ventricular [LV, RV] end-diastolic and end-systolic volume [EDV, ESV], stroke volume [SV], ejection fraction [EF] and myocardial mass [MM]). Furthermore, left and right atrial sizes were assessed by planimetry and delayed enhancement imaging was performed 10 minutes after the application of contrast agent. Coronary arteries were depicted using free-breathing Flash-3 D MR angiography. RESULTS: The quantitative analyses showed eccentric hypertrophy of the left ventricle (remodeling index [MM/LV-EDV]: M 0.75, F 0.665), enlargement of the RV volumes (RV-EDV: M 122.6 ±â€Š19.0 ml/m², F 99.9 ±â€Š7.2 ml/m²) and an increased SV (LV-SV: M 64.7 ±â€Š10.0 ml/m², F 56.5 ±â€Š5.7 ml/m²; RV-SV; M 66.7 ±â€Š10.4 ml/m², F 54.2 ±â€Š7.1 ml/m²). Abnormal findings were detected in 6 athletes (6.3 %) including one benign variant of coronary anomaly and abnormal late gadolinium enhancement in 2 cases. None of the athletes showed wall motion abnormalities or signs of myocardial ischemia. CONCLUSION: CMR imaging of endurance athletes revealed abnormal findings in more than 5 % of the athletes. However, the prognostic significance remains unclear. Thus, cardiac MRI cannot be recommended as a routine examination in the care of athletes.

Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire's convergent validity in elderly women with osteoporosis.

UNLABELLED: The Falls Efficacy Scale-International (FES-I) is a highly reliable questionnaire for assessing fear of falling in elderly individuals with increased fall risk and has low or no convergent validity with balance performance tests and health-related quality of life (HRQL) among elderly women with osteoporosis, which indicates that both measurements should be included as they are measuring different components. INTRODUCTION: Fear of falling is increased in elderly individuals with osteoporosis and FES-I is a widely used questionnaire to assess fear of falling. There is limited evidence of the reliability and convergent validity in elderly with increased risk of falling and osteoporosis. METHODS: Reliability and validity study of the FES-I. Community-dwelling elderly with increased fall risk, 59 subjects, were recruited to the reliability assessment, and 81 women with osteoporosis, in the validity assessment. For the reliability assessment, two postal surveys were used. For the validity assessment, we used baseline data from an on-going study in women with osteoporosis. The FES-I was correlated to a single-item question regarding fear of falling, self-reported history of falls, balance performance tests and health-related quality of life. RESULTS: The FES-I had very good relative reliability (intra-class correlation 0.88) and internal consistency reliability (Cronbach's alpha 0.94). The value for absolute reliability was a standard error of measure 2.9 (10.6 %), smallest real difference 7.9 (29 %). There was "little if any" to "low" correlation between the FES-I and the single-item question regarding fear of falling and self-reported history of falls, HRQL and balance performance tests. CONCLUSION: The FES-I seems to be a highly reliable questionnaire for assessing fear of falling in elderly with increased fall risk but has low relation to/convergent validity with balance performance and HRQL among elderly women with osteoporosis.

[Aortic aneurysm 2012: open, hybrid or total endovascular repair?]. / Aortenaneurysma 2012 - offen, hybrid oder total endovaskulär?

During the past two decades, minimally invasive endovascular procedures have changed therapeutic strategies. Such techniques have now become the method of choice for practically all vascular and aortic pathologies. This development is especially apparent in the treatment of aortic aneurysms. The purpose of this report is to provide a critical review about the current standard of care of abdominal and thoracic aorta based on an electronic Medline literature search. For elective infrarenal aneurysms, endovascular aneurysm repair (EVAR) has become a widely accepted alternative to open repair in cases with appropriate morphology. Currently, fenestrated (FEVAR) or branched endografts offer promising short- and mid-term results in juxtarenal aneurysms, however, these techniques are complex, technically challenging, and expensive. The alternative chimney or sandwich graft technique are becoming more common because they are feasible using standard endografts. Thoracic endovascular aortic repair (TEVAR) is already the gold standard for some descending pathologies. Complex thoracoabdominal aneurysms still require open surgery in centres of excellence, whereby, total endovascular repair or hybrid procedures have proved to be feasible in such specialist centres for selected patients.

Walking in circles: navigation deficits from Parkinson's disease but not from cerebellar ataxia.

Little is known on the role of neuronal structures for spatial navigation. Our goal was to examine how Parkinson's disease (PD) and cerebellar ataxia, as human lesion models of the basal ganglia and cerebellum, affect spatial navigation round a circular walking path, blindfolded. Twelve subjects with idiopathic PD (ON and OFF medication), eight subjects with cerebellar ataxia and a control group of 20 age-matched healthy subjects participated. All groups performed well when walking around the circle with eyes open. In the eyes-closed condition, control subjects overshot the outlined trajectory but returned to their initial position, thus walking a further distance with eyes closed than with eyes open. When OFF medication, PD subjects navigated a larger radius than controls with eyes closed. When ON levodopa, PD subjects walked a similar distance as controls but with even larger errors in endpoint. Surprisingly, cerebellar patients navigated the circular walking task in the eyes closed condition with even more accuracy (i.e. following the outlined circle) than control and PD subjects. We conclude that blindfolded navigation around a previously seen circle requires intact basal ganglia, but not cerebellar input.

Haptic touch reduces sway by increasing axial tone.

It is unclear how haptic touch with a stable surface reduces postural sway. We hypothesized that haptic input enhances postural stability due to alterations in axial postural tone. We measured the influence of heavy and light touch (LT) of the hands on a stable bar on axial postural tone and postural sway during stance in 14 healthy adults. A unique "Twister" device measured hip torque by fixing the upper body in space while oscillating the surface in yaw ±10 at 1 deg/s. Subjects were tested while: (1) standing quietly with their arms at their sides, (2) lightly touching a rigid bar in front of them and (3) firmly gripping the bar. Horizontal and vertical sway was not restricted by the device's yaw fixation, therefore, the subjects remained in a state of active postural control during the three touch conditions. Haptic touch significantly increased hip postural tone by 44% during light touch, from 2.5±0.9 to 3.6±1.0 Nm (P=0.005), and by 40% during firm grip to 3.5±0.8 Nm (P=0.005). Increases in hip postural tone were associated with a reduction in postural sway (r=-0.55, P=0.001). This is the first study showing that axial postural tone can be modified by remote somatosensory input and provides a potential explanation for how light touch improves postural stability. Changes in subjects' perception from trunk to surface rotation when changing from no touch (NT) to haptic touch, suggests that the CNS changes from using a global, to a local, trunk reference frame for control of posture during touch. The increase of hip postural tone during touching and gripping can be explained as a suppression of hip muscle shortening reactions that normally assist axial rotation.

Antitumoral vaccination with granulocyte-macrophage colony-stimulating factor or interleukin-12-expressing DHD/K12 colon adenocarcinoma cells.

Immunomodulating gene therapy for the treatment of malignant diseases is under extensive investigation. In this study, we induced an antitumoral immune response with murine interleukin-12 (mIL-12) and murine granulocyte-macrophage colony-stimulating factor (GM-CSF)-secreting tumor cells in a model of peritoneal carcinomatosis. Intraperitoneal injection of DHD/K12 tumoral cells engineered to produce IL-12 or GM-CSF did not generate any tumors, whereas untransduced DHD/K12 cells gave rise to peritoneal carcinomatosis. IL-12-expressing DHD/K12 cells also protected against tumors derived from coinjected parental cells. To test whether cytokine-producing cells could elicit a memory antitumoral immune response, animals received a challenge with parental DHD/K12 cells 35 days after the injection of proliferating or irradiated DHD/K12 engineered cells. Under our experimental conditions, irradiated tumor cells did not generate any antitumoral immunity. In contrast, tumor development was delayed and survival increased in the animals vaccinated with cytokine-secreting proliferating cells. A specific cytotoxic T-lymphocyte response against DHD/K12 parental cells was observed after vaccination with GM-CSF-expressing cells. Our results demonstrated that intraperitoneal vaccination with IL-12- or GM-CSF-expressing adenocarcinoma cells induced a systemic immune antitumoral response that may be useful as an adjuvant therapy after surgical resection of colorectal cancer.