Fear of falling and falls in people with Parkinson's disease treated with deep brain stimulation in the subthalamic nuclei.

BACKGROUND: No previous study prospectively investigated the effects of subthalamic deep brain stimulation on fear of falling (FOF) and falls. AIM: The aim was to prospectively explore whether FOF and fall rate were affected after STN stimulation in people with Parkinson's disease (PD). METHODS: Twenty participants (mean age: 65, SD 6.4) were included. Falls and near falls were recorded (fall diary) during 3 months before and 1 year after surgery. FOF was evaluated using the Falls-Efficacy Scale, Swedish version, FES(S), and the modified Survey of Activities and Fear of Falling in the Elderly (SAFFE). RESULTS: After surgery, the FES(S) scores of complex activities improved (P=0.026), i.e. median 34 (q1-q3, 26-50) vs 43 (32-55). SAFFE scores also improved (P=0.007): median 25 (22-30) versus 22 (18-27). The rate of near falls decreased (P=0.014). Nine participants reported no near falls. For the remaining ten participants, the median near fall rate decreased from 6 (3-17) to 2 (1-8). The rate of falls showed no significant (P>0.3) difference. CONCLUSIONS: After surgery, fewer activities were avoided owing to the risk of falling, and fall-related self-efficacy had improved during complex activities. The rate of near falls decreased. The results cannot support any change in fall rate.

Slowing of alternating forearm movements is associated with cognitive impairment in community-dwelling older people.

BACKGROUND/AIMS: Motor impairment is an important aspect of cognitive decline in older adults. It has been suggested that complex motor control is affected earlier than gross motor control. The aims were to investigate if complex hand motor function was more affected than gross motor function in cognitively impaired older subjects, and to present reference values. METHODS: Alternating forearm movements and grip strength were studied in 301 cases, 419 intermediates and 1,207 controls, aged 60-93 years, controlling for demographic, health-related and functional factors and comorbidity. Global cognitive function was assessed by the Mini-Mental State Examination, and episodic memory by 3-word delayed recall. Grip strength was assessed by the Grippit(R). The frequency of alternating movements during 10 s was registered electronically. RESULTS: Alternating movements but not grip strength was associated with cognitive impairment (right: p = 0.006; left: p = 0.022). The mean alternating movements for the 70-year-old male cases compared to the controls were 2.3 versus 2.5 Hz for the right, and 2.2 versus 2.4 Hz for the left arm (p < 0.05), and for the 60-year-old women 2.0 versus 2.3 Hz for the right arm (p < 0.05). CONCLUSION: Complex but not gross hand motor function is associated with early cognitive impairment.

Functional balance performance in patients with Parkinson's disease after long-term treatment with subthalamic nucleus high-frequency stimulation.

The aim was to investigate if functional balance performance in patients with Parkinson's disease (PD) was affected by long-term (3 years) treatment with bilateral subthalamic nucleus (STN) high-frequency stimulation. Thirty-five patients were consecutively included, and 28 patients completed the study (mean age 62 years, SD 6.5). The Berg Balance Scale (BBS) was assessed preoperatively and 1 and 3 years postoperatively (with and without anti-PD medication and with the STN stimulation turned OFF or ON). Although the balance performance of patients with PD decreased over time, the functional balance performance was still positively affected by STN stimulation alone 3 years after surgery.

Lower gait speed in older women with dementia compared with controls.

UNLABELLED: Movement time is increased in patients with Alzheimer's disease. OBJECTIVES: To study differences in movement time and ability to increase speed in older women with dementia. METHODS: Four tests were performed at self-selected and maximal speed: walking 2 x 15 m, walking between parallel lines, 'get up and go' (GUG) and rising from lying supine. Twenty-two patients and 22 controls (mean ages 81 and 86 years, respectively) were included in the study. RESULTS: In the groups over 80 years, walking and GUG at both speeds and rising from lying supine from the left at self-selected speed were significantly slower among patients (20-30%). Both patients and controls were able to increase movement speed when changing from self-selected to maximal speed (13-27%). Patients with Alzheimer's disease had lower self-selected walking speed compared with patients with other types of dementia (p = 0.048). CONCLUSION: Testing physical performance in two different speeds was feasible in patients with dementia. Patients had slower gait speed and were slower in the functional tests, such as GUG, but the capacity to increase speed seemed intact.

Coping after trans-femoral amputation due to trauma or tumour--a phenomenological approach.

PURPOSE: To describe, by use of a phenomenological approach, how relatively young trans-femoral amputees experienced their amputation and their coping strategies in the acute phase and over time. METHOD: Eleven trans-femoral amputees, median age 33.5 years, were interviewed. The amputation was caused by tumour, motorcycle accidents or work-related traumas. Amputation was made in median 7.5 years before the interview. The informants were community dwelling and managed well indoors. One had a half disablement pension and all the others were working or studying full time. The interviews were tape-recorded and transcribed verbatim. RESULTS: Two themes emerged. In the first theme 'Experiences of the amputation' denial and avoidance were the coping strategies mainly used. In the second theme 'Coping strategies to relate to a new norm' the informants used downward comparison, positive comparison and repression. Only one informant indicated a full acceptance of his situation. CONCLUSION: Relatively young, trans-femoral amputees within this sample, have not reached the acceptance level, though a long time has passed since the amputation. They might have benefited from professional support and guidance during the rehabilitation process in order to improve coping strategies to relate to a new norm.

Pelvic motion in trans-femoral amputees in the frontal and transverse plane before and after special gait re-education.

Using a special gait re-education programme, combining methods in physiotherapy with a psychological therapeutic approach to integrate the prosthesis with normal movements and to increase body awareness, the authors studied unilateral trans-femoral amputees aged 16-60 years with trauma or tumour as causes. In their service area they found 16 such current prosthetic users with at least 2 years of prosthetic experience and 9 who could complete the programme. Gait was measured before and after treatment and at 6 months follow-up with a three-dimensional motion analysis system and was compared to a reference group of 18 healthy volunteers of similar age. Results showed normalised gait speed and increased symmetry in step length after treatment, but reduced symmetry in pelvic motion. The reference group had a pelvic rotation of + 4 degrees both in the frontal and transverse planes. In the frontal plane, pelvic obliquity increased after treatment to a similar amplitude to the reference group, but with a different timing. Pelvic internal rotation on the amputated side increased to about 8 degrees in the beginning of stance. The amputated and the intact side before treatment were more symmetrical than afterwards and also when compared with the reference group. In spite of this, gait appeared to be more symmetrical, probably due to more efficient pelvic motion and more symmetrical upper-body movements. This was probably an effect of increased work with the intact side to compensate for the lack of power on the amputated side. These results remained at follow-up.

Kinematic and kinetic gait analysis in the sagittal plane of trans-femoral amputees before and after special gait re-education.

A special gait-training programme, combining a psychological therapeutic approach with methods in physiotherapy and body awareness, was used to re-educate nine unilateral trans-femoral amputees. All were rehabilitated trauma or tumour amputees with an age of 16-60 years. They had worn prostheses for more than 18 months. The re-education aimed at integrating the prosthesis in normal movements and increasing body awareness. Gait was measured before and after treatment and at 6 months follow-up with a three-dimensional motion analysis system. Results showed almost normalised gait speed and increased symmetry in the hip joints with increased muscle work on the amputated side both immediately and at follow-up. At follow-up there were significant differences in almost all parameters between the two legs of the subjects and when compared to a reference group of 18 healthy volunteers of similar age. Thus, the intact leg compensates for loss of function in the amputated leg and thereby works differently compared to the reference group. For example, during shock absorption the extension moment in the intact knee increased from 0.6 Nm/kg before to 1.0 Nm/kg after treatment and at follow-up compared to 0.4 Nm/kg in the reference group. The eccentric power of quadriceps increased from 0.6 w/kg before to 1.8 w/kg after treatment and 1.7 w/kg at follow-up compared to 0.4 w/kg in the reference group. The limp of amputees is usually observed in the frontal plane, but the authors' special focus on the sagittal plane here illustrates gait propulsion influences. The positive training results remained after six months.

Observation of vestibular asymmetry in a majority of patients over 50 years with fall-related wrist fractures.

Previously [The abstract has been shortened somewhat, and the headings removed, in order to conform to journal style], we have observed vestibular asymmetry in about one-third of healthy senior citizens and in about two-thirds of subjects with previous hip fractures and no other significant ailments. Wrist fractures are considered a harbinger of hip fractures. If vestibular asymmetry is correlated with falls and fractures among the elderly then it should also be reflected among subjects with wrist fractures. Sixty-six consecutive patients (mean age 67.8 years) who had sustained a fall-related wrist fracture during a 10-month period were included in the study. The frequency of head shake nystagmus among the patients was compared to that found among 49 healthy senior citizens (mean age 74.9 years). Nystagmus after head shaking, indicating asymmetric vestibular function, was found in 50 participants (76%) (p <0.001). Thirty-eight of these were graded with distinct or prominent nystagmus responses. Sixty percent of the subjects with horizontal nystagmus had a wrist fracture coinciding with the slow phase of nystagmus. Twenty-three subjects reported 30 previous fall-related fractures during the previous 10 years. Subjects with nystagmus after head shaking sustained 26 of these fractures. The frequency of signs of vestibular asymmetry was significantly higher (p < 0.001) among the subjects than among healthy senior citizens. These findings suggest that an asymmetric vestibular function could be an epidemiologically important contributory factor to falls and wrist fractures among the elderly population.

Gait improvement in unilateral transfemoral amputees by a combined psychological and physiotherapeutic treatment.

A conscious therapeutic approach was used combining methods in physiotherapy with psychological awareness to re-educate nine transfemoral amputees during 10 months in outdoor environments. All were rehabilitated trauma or tumour cases, mean age 33 years, and had worn their prostheses for more than 18 months. The method aimed at integrating the prosthesis in normal movements and increasing body awareness. Gait was measured with a three-dimensional motion analysis system. Self-selected comfortable and brisk gait speed increased from mean 0.95 m/s and 1.29 m/s before to 1.40 m/s and 1.65 m/s after treatment, respectively. The results remained at a 6-month follow-up. Before treatment three participants used walking-aids and all had problems with low-back pain. After treatment none needed walking-aids and almost all low-back pain had disappeared. Seven participants learnt to jog. Results indicate that this new approach may add skills, mostly on participation level, to lead a relatively normal life.

Asymmetric vestibular function in the elderly might be a significant contributor to hip fractures.

The aim of this study was to assess postural control, vestibular symmetry and health status in otherwise healthy hip fracture subjects and compare these factors with controls. The fracture subjects were recruited from 113 consecutive patients operated 12-33 months earlier. Nineteen of those were otherwise healthy and fulfilled the inclusion criteria. They were assessed and compared with 28 age- and sex-matched controls. Nystagmus after head shake was checked for by video-nystagmoscopy (charged couple device cameras). Vibration sensation was tested with a tuning fork, medical history and posturography of vibration-induced sway were studied. The subjects had a significantly higher frequency of head shake nystagmus (p = 0.03), indicating a vestibular asymmetry and a history of previous fractures (p = 0.002). Nine out of 12 subjects had fallen and sustained the hip fracture towards the slow phase of the nystagmus, which is expected in a vestibular related fall. Losing balance during testing was more frequent among the subjects than among the controls (p = 0.002). The subjects with head shake nystagmus swayed more than those without, especially in the sagittal plane during neck vibration with eyes closed (p < 0.001). Vibration perception was significantly poorer in the operated legs than in the healthy legs (p = 0.021) and in the legs of the controls (p = 0.001). The findings suggest that vestibular asymmetries may contribute to falls and fractures in elderly people. As such asymmetries can be compensated to a certain degree by specific training programs, these might be advisable for elderly people, especially those with a history of falls or fractures or where a vestibular asymmetry is suspected.

Accidental falls and related fractures in 65-74 year olds: a retrospective study of 332 patients.

We investigated, by studying medical records, background factors and consequences of accidental falls of patients 65-74 years who attended the Department of Orthopedics' emergency clinic in Lund. We also assessed possible prevention measures. Fractures occurred in three quarters of the registered falls. Women were more prone to sustain fractures than men. Forearm fractures were commonest among women while hip fractures were commonest among men. One third of the patients were admitted to an orthopedic ward because of the fall. The patients who were less healthy had sustained fractures oftener and also needed more hospital care. Information regarding risk factors for falls and fractures were often missing in the patients' medical records. Impaired walking and balance, and medication increased the risk of falls. Such patients constitute a high risk group for future falls and fractures. A newly developed instrument is suggested as a routine in the emergency department to increase the awareness of risk factors for falls in the elderly. Satisfactory documentation is a prerequisite for further treatment and referrals to prevent falls and fractures.

Comparison of the Gross Motor Function Measure and Paediatric Evaluation of Disability Inventory in assessing motor function in children undergoing selective dorsal rhizotomy.

This study was designed to compare assessment with the functional outcome measures Gross Motor Function Measure (GMFM) and Pediatric Evaluation of Disability Inventory (PEDI) over time, in children with cerebral palsy (CP) undergoing selective dorsal rhizotomy combined with individualised physiotherapeutic interventions. Using the Gross Motor Function Classification System (GMFCS), 18 children with spastic diplegia were divided into two groups according to age-related severity of motor function impairment. Data were collected preoperatively, and at 6 and 12 months postoperatively. Both instruments were sensitive to changes in function over time in the series as a whole and in the group with milder impairment, although the PEDI detected significant changes earlier. In the group with more severe impairment, changes in function were detected only with the PEDI, not with the GMFM. Thus, the instruments are to be considered complementary tests, because they measure different aspects of function.

The American Paediatric Evaluation of Disability Inventory (PEDI). Applicability of PEDI in Sweden for children aged 2.0-6.9 years.

The American Paediatric Evaluation of Disability Inventory (PEDI) is a new instrument for evaluating functional performance in disabled children aged 6 months to 7.5 years. It was developed to determine a child's functional capacity and performance in three domains, self-care, mobility and social function, as reflected in scores on three scales: (i) functional skills (current capability in specific tasks), (ii) caregiver assistance (i.e. provided to facilitate the child's performance), and (iii) modifications (i.e. environmental or technical modifications needed to facilitate the child's function). The present study was designed to compare results obtained using the PEDI in a Swedish sample with the American normative data, and to analyse the content and relevance of PEDI items for use in Sweden. The PEDI was administered as a questionnaire in structured interview form to the parents of 52 non-disabled Swedish children aged 2.0-6.9 years, divided into ten age groups. Correlation analysis (Pearson's r) showed scores for the Swedish sample to manifest strong correlation with the respective American normative data, both for the functional skills (r = 0.90-0.98) and caregiver assistance (r = 0.93-0.99) scales, respectively. Scores for the modification scale were not compared. Thus, the results suggest the American normative data to be appropriate for reference purposes in Sweden.

Reliability of the gross motor function measure in cerebral palsy.

The Gross Motor Function Measure (GMFM), an instrument comprising five dimensions devised by Russell and co-workers (7) to measure gross motor function in children with cerebral palsy (CP) or brain damage, enables changes in performance status to be evaluated after therapy or when monitored over time. We analysed its inter-rater and intra-rater reliability on the three most difficult dimensions. A video-recording of three children with CP performing test tasks was assessed on two occasions at an interval of six months by each of the 15 physiotherapists using the GMFM manual but without previous experience or training in the use of the instrument. Mean percentage scores were similar at the first and second assessments. Both inter- and intra-rater reliabilities were good, inter-rater reliability being 0.77 and 0.88 at the first and second assessments, respectively, and intra-rater reliability 0.68 at the second assessment. The findings suggest the GMFM to be a useful and reliable instrument for assessing motor function and treatment outcome in CP.

Aberrations in postural control, vibration sensation and some vestibular findings in healthy 64-92-year-old subjects.

To assess changes in postural control among healthy elderly and to correlate with suspected age-related events, 33 women and 16 men were studied. Postural control was evaluated by vibration-induced body sway, measured on a force platform, and vibration sensation was tested with a tuning fork. Occurrence of spontaneous gaze and head-shake-induced nystagmus was observed with infrared charged couple device (CCD) cameras and the subjects' medical history was reviewed. Vibration perception was the major determinant for the magnitude of body sway. Although these senior citizens considered themselves healthy, they had a variety of ailments in their medical history, diminished vibration sensation and a high prevalence of vestibular asymmetry. Age per se was not a determinant factor in any of the findings. The study suggests that interest should also be directed to the status of sensation in the legs and vestibular asymmetry when assessing balance function in the elderly. Furthermore, the term "age concomitant" may be more appropriate than "age dependent" when describing decrements of functions such as postural control in elderly subjects.

Background factors to hip fractures.

A questionnaire was distributed to 159 patients with cervical or trochanteric hip fractures about the cause of their accident, their health status, and various social factors. The purpose was to compare background factors in hip fracture patients with factors in subjects without hip fracture. The responses from 102 patients were compared with 102 age- and gender-matched controls. Most patients had fallen during walking or rising, and they often fell sideways. Patients had had more symptoms of diseases, were more often afraid of falling, and were less active than control subjects. Hip fracture patients, even prior to fracture, were more frail and sedentary than average. Fracture prevention training is an important consideration in elderly patients.

Standing balance in hip fracture patients. 20 middle-aged patients compared with 20 healthy subjects.

Twenty hip fracture patients aged 50-64 years were compared with healthy, age- and sex-matched controls concerning balance capacity in standing and in walking. As a whole, the hip fracture patients had many concomitant diseases and low functional capacity. The patients studied did not differ from their controls as regards reported vision, hearing, and other characteristics. However, the patients deemed their balance to be worse and had a lower maximal walking speed than the controls. The patients also showed, in many aspects, more postural sway (i.e., lower balance capacity) on a computerized force platform especially when blindfolded. Patients with cervical fractures had less postural sway and smaller differences compared with their controls than when compared with the total group. About 2 years after the accident, hip fracture patients still perceived their balance to be more impaired, and showed more postural sway than the healthy controls. These factors may force us to emphasize more balance training after and, preferably, before the fracture.

Hip fracture patients. Background factors and function.

The incidence of hip fractures increased from 3.3 per 1,000 inhabitants in 1966 to 5.1 in 1986 for persons more than 50 years old. The incidence almost doubled in persons more than 80 years old, from 13.3 to 25.6 per 1,000. The proportional increase was largest in men with cervical fractures. A higher incidence was found in the city compared to the rural area. The city of Lund had a lower incidence in comparison with larger cities, such as Stockholm, Göteborg and Uppsala. The early rehabilitation at home of hip fracture patients in cooperation with primary health care, rendered good results and a low consumption of resources, compared to continued care at the Orthopedic Department or in a nursing home. About 60 per cent of the patients returned directly to their own home. Most of them regained, within four months, their former capacity of daily life, in spite of their hip fracture and high age. Patients with hip fractures reported more signs of diseases, lower capacity for managing their daily life and were more often afraid of falling than the controls. Most falls, 75 per cent, preceding the fracture, occurred during walking or when rising from or sitting down on a chair. Two thirds of the hip fracture patients had fallen sideways. A test battery for assessing standing balance on a computerized force platform was evaluated. Postural sway in healthy subjects indicated that age and sex were important, when analysing the results. Men and older subjects had larger postural sway than women and younger subjects, respectively. Middle-aged patients with a previous hip fracture showed larger postural sway (= lower balance capacity), lower perceived balance and a lower walking speed than healthy controls. Eighteen 70-year-old women trained their postural control for five weeks. They had significantly better results in the tests after the training period than the controls. These balance tests are simple and applicable in clinical practice. Training of postural control might prevent some hip fractures, which is of the utmost importance both for the elderly person and society.

Hip fractures in primary health care. Evaluation of a rehabilitation programme.

The routine follow-up of hip fracture patients was transferred from the Orthopaedic Department, Lund University Hospital, to the primary health care districts in 1985. The medical state and social functions of all 298 patients during the first 12 months of the follow-up rehabilitation programme were registered. Before fracture, 61% lived in their own homes, 22% in old people's homes, and 14% in geriatric hospitals or nursing homes. Four months after fracture, 13% were dead, 47% were living in their own homes, 14% were in old people's homes, 25% in geriatric hospitals or nursing homes, while the rest were in other types of institutional residence. Of patients coming from their own homes, 75% were back at home four months after fracture and their social and functional status were as good as before fracture. The study has shown that routine check-ups at the orthopaedic department can be omitted. Follow-up in primary health care without radiography and orthopaedic expertise gives equally good functional results as in previous studies, provided that patients with pain and walking problems from the hip are guaranteed rapid specialist treatment.

Hip fracture incidence in Lund, Sweden, 1966-1986.

The hip fracture incidence in the city of Lund and its rural surroundings was studied for the years 1966, 1972, 1981, and 1986. The total incidence increased from 3.3 to 5.1 per 1,000 inhabitants above 50 years of age. For persons more than 80 years old, the incidence almost doubled from 13.2 to 25.5, i.e., this group represented the entire increase in incidence. In the urban population, men with cervical fractures had an increased incidence. A smaller increase in incidence for both men and women was found in the rural area. Compared with larger cities, the incidence increase in the urban population in Lund was lower over time, but in 1986 the figures were comparable to those in Gothenburg in 1981. The total incidence in the mixed urban and rural population was as of 1981 higher than in Denmark and Finland, but lower than in Norway. If the incidence in the elderly continues to increase to 1995, there will be three times as many hip fractures as there were in 1966.