Validity of 2 Fall Prevention Strategy Scales for People With Stroke, Parkinson's Disease, and Multiple Sclerosis.

BACKGROUND AND PURPOSE: Falls are a common and persistent concern among people with neurological disorders (PwND), as they frequently result in mobility deficits and may lead to loss of functional independence. This study investigated the ceiling and floor effects, internal consistency, and convergent validity of 2 patient-reported fall prevention strategy scales in PwND. METHODS: This is a prospective cohort study. Two-hundred and ninety-nine PwND (111 people with multiple sclerosis, 94 people with Parkinson's disease, and 94 people with stroke) were seen for rehabilitation and assessed. The number of retrospective and prospective falls, use of walking assistive devices, scores on the Fall Prevention Strategy Survey (FPSS), Falls Behavioural Scale (FaB), and balance and mobility scales (Berg Balance Scale, Dynamic Gait Index, Timed Up and Go, 10-m walking test, and Activities-specific Balance Confidence) were analyzed. RESULTS: Total score distributions showed negligible ceiling and floor effects for both the FPSS (ceiling: 0.3%, floor: 0.3%) and the FaB (ceiling: 0%, floor: 0%). The Cronbach α (CI) was of 0.87 (0.85-0.89) for the FPSS and 0.86 (0.84-0.88) for the FaB. In terms of convergent validity, the FPSS and FaB were moderately correlated (Spearman correlation coefficient = 0.65). Moreover, the correlations between the FPSS and FaB and balance and mobility scales ranged from 0.25 to 0.49 ( P < .01). Both scales are slightly better able to distinguish between retrospective fallers/nonfallers [area under the curve, AUC (95% CI): FPSS: 0.61 (0.5-0.7); FaB: 0.60 (0.5-0.6)] compared with prospective fallers/nonfallers [AUC (95% CI): FPSS: 0.56 (0.4-0.6); FaB: 0.57 (0.4-0.6)]. Both scales accurately identified individuals who typically required the use of a walking assistive device for daily ambulation [AUC (95% CI): FPSS: 0.74 (0.7-0.8); FaB: 0.69 (0.6-0.7)]. Multiple regression analysis showed that previous falls, use of an assistive device, and balance confidence significantly predicted participants' prevention strategies (FPSS: R2 = 0.31, F(8,159) = 10.5, P < .01; FaB: R2 = 0.31, F(8,164) = 10.89, P < .01). CONCLUSION: The FPSS and the FaB appear to be valid tools to assess fall prevention strategies in people with neurological disorders. Both scales provide unique and added value in providing information on individual behavior for fall prevention.

Identification of modified dynamic gait index cutoff scores for assessing fall risk in people with Parkinson disease, stroke and multiple sclerosis.

BACKGROUND: Balance and gait impairments increase fall rate and injury in people with neurological disorders(PwND). The modified Dynamic Gait Index(mDGI) is a scale assessing dynamic balance during walking, however its ability in identifying Fallers and Recurrent Fallers has not been studied. RESEARCH QUESTION: To evaluate mDGI's ability in identifying retrospective Fallers and Recurrent Fallers establishing cut-off scores for its use in clinical practice. METHOD: In this cross-sectional study, the number of retrospective falls and mDGI scores were collected. PwND were categorised as Non-Fallers or Fallers (falls≥1) and as Recurrent Fallers(falls≥2) or Non-Recurrent/Non-Fallers(falls<2) according to their number of retrospective falls over two months. Two generalised linear logistic models were developed using a machine learning method to detect Fallers (Model 1) and Recurrent Fallers (Model 2) based on mDGI scores. ROC curves were used to identify mDGI cut-off scores to distinguish between different fall categories. RESULTS: 58 PwND (mean ± standard deviation age: 63.4 ± 12 years) including 28 people with Multiple Sclerosis, 15 people with Parkinson's disease and 15 people with Stroke were analysed. The mDGI score(median (IQR)) for Non-Fallers, Fallers, Recurrent Fallers and Non-Recurrent/Non-Fallers was respectively 50(22), 37(22), 26.5(20.25) and 46.5(20.5)points. The cut-off to identify Fallers from Non-Fallers was 49 points(sensitivity:100 %, specificity:50 %, post-test probability with mDGI ≤ cut-off: 53.2 %, post-test probability with mDGI > cut-off: 0%, AUC:0.68), while 29 points(sensitivity:60 %, specificity:79 %, post-test probability with mDGI ≤ cut-off:52.1 %, post-test probability with mDGI > cut-off:16.1 %, AUC:0.70) was the best cut-off to identify Recurrent Fallers. SIGNIFICANCE: People with mDGI score>49 points have low or minimal fall risk, while people with mDGI score≤49 points should be further investigated with other scales before starting a balance-focused rehabilitation intervention. People scoring ≤29 points on the mDGI scale may need a fall prevention intervention, regardless of the results of other balance clinical measures.

Minimal clinically important difference of modified dynamic gait index in people with neurological disorders.

BACKGROUND: The minimal clinically important difference (MCID) of modified Dynamic Gait Index (mDGI) has not yet been determined for People with Neurological Disorders (PwND). RESEARCH QUESTION: To establish the MCID of the mDGI to determine clinically meaningful improvement in balance and gait in PwND. METHODS: In this longitudinal study from a randomised clinical trial, 55 participants both in and outpatients with neurological disorders, received fifteen 40-minute rehabilitation sessions. Inpatients received daily treatments over a period of three weeks while outpatients received three treatments/week over a period of five weeks. An anchor-based method using percentage rating of improvement in balance (Activities Balance Confidence scale, ABC) was used to determine the MCID of mDGI. The MCID was defined as the minimum change in mDGI total score (post - pre intervention) that was needed to perceive at least a 10 % improvement on the ABC scale. A Receiver Operating Characteristic curve was used to define the cut-off for the optimal MCID of the mDGI discriminating between improved and not improved participants. RESULTS: The MCID of the mDGI total score was 6 points and Area under the Curve was 0.64. For the mDGI time sub-scores the MCID was 2 points and Area under the Curve was 0.6. SIGNIFICANCE: The MCID of balance and gait improvement measured by mDGI was prudently establish at ≥7 points, meaning that this is the minimum improvement score PwND need to get to perceive a clinically relevant change in their balance and gait confidence. These reference values can be a tool incorporated into clinicians daily practice to interpret mDGI change scores helping to determine whether the intervention is effective; to develop clinical tailored intervention goals and to establish meaningful perceived change in PwND.

Predictors of mobility domain of health-related quality of life after rehabilitation in Parkinson's disease: a pilot study.

BACKGROUND: Parkinson's disease impacts health-related quality of life (HRQoL), however no studies inquired on predictors of HRQoL changes after rehabilitation. This study assessed the relationship between mobility domain of HRQoL measured by Parkinson's Disease Questionnaires-39 (PDQ-39) and clinical-demographic characteristics and developed a model predicting changes after rehabilitation. METHODS: Subjects with Parkinson's disease underwent rehabilitation treatment and completed the following predictors: 10-m walking test (10MWT), Timed Up and Go (TUG), Berg Balance scale (BBS), Activities-specific Balance Confidence scales (ABC), Freezing of Gait (FOGQ) and PDQ-39. Two general linear models were calculated to predict the relationship between HRQoL at baseline and to predict HRQoL changes after rehabilitation. RESULTS: Forty-two subjects (age 74.9 ± 7.3 years, Hoehn&Yahr 2.8 ± 0.6) completed the baseline evaluation. The first model (multiple R2 = 0.59, F = 5.86, P < 0.001) showed that ABC (B = - 0.51, CI = - 0.86 to 0.15, R2 = 0.41, P = 0.005) and FOGQ (B = 2.38, CI = 1.03 to 3.73, R2 = 0.07, P = 0.001) were statistically significant predictors of mobility aspect of HRQoL at baseline. Thirty seven subjects completed the rehabilitation sessions, data were entered in the second model (multiple R2 = 0.40, F = 4.24, P < 0.004) showing that gender (B = - 5.12, CI = - 9.86 to - 0.39, R2 = 0.23, P = 0.034), Hoehn&Yahr (B = 10.93, CI = + 3.27 to + 18.61, R2 = 0.22, P = 0.006) and PDQ-39 mobility at baseline (B = - 0.38, CI = - 0.63 to - 0.14, R2 = 0.55, P = 0.002) were statistically significant predictors of changes of the mobility aspect of HRQoL. CONCLUSIONS: Balance confidence and Freezing of Gait are associated with the mobility aspect of HRQoL. Changes in mobility domain of HRQoL (as assessed by PDQ-39) are likely to be greater in males, in people at higher stages of the disease and in people with more severe limitation in mobility domain of HRQoL (as assessed by PDQ-39) before rehabilitation. Results might be different when considering different outcomes or different measures for the same outcome (performance mobility test instead of self-report questionnaires). Further investigations are needed to better understand other components of HRQoL in addition to mobility. TRIAL REGISTRATION: NCT02713971 registered March 8, 2016.

Multidisciplinary Rehabilitation is Efficacious and Induces Neural Plasticity in Multiple Sclerosis even when Complicated by Progressive Multifocal Leukoencephalopathy.

A 48-year-old woman with multiple sclerosis (MS), treated with natalizumab for more than one year without clinical and magnetic resonance imaging (MRI) signs of disease activity, was diagnosed with definite progressive multifocal leukoencephalopathy (PML). She presented with subacute motor deficit of the right upper limb (UL), followed by involvement of the homolateral leg and urinary urgency. The patient was treated with steroids and plasma exchange. On follow-up MRI scans, the PML lesion remained stable and no MS rebounds were observed, but the patient complained of a progressive worsening of the right UL motor impairment, becoming dependent in most activities of daily living. A cycle of multidisciplinary rehabilitation (MDR) was then started, including daily sessions of UL robot therapy and occupational therapy. Functional MRI (fMRI) was acquired before and at the end of the MDR cycle using a motor task which consisted of 2 runs: in one run the patient was asked to observe while the second one consisted of hand grasping movements. At the end of the rehabilitation period, both the velocity and the smoothness of arm trajectories during robot-based reaching movements were significantly improved. After MDR, compared with baseline, fMRI showed significantly increased functional activation within the sensory-motor network in the active, motor task, while no significant differences were found in the observational task. MDR in MS, including robot-assisted UL training, seems to be clinically efficacious and to have a significant impact on brain functional reorganization on a short-term, even in the presence of superimposed tissue damage provoked by PML.

Effects of Functional Electrical Stimulation on Reducing Falls and Improving Gait Parameters in Multiple Sclerosis and Stroke.

BACKGROUND: Loss of neuromuscular control of the ankle joint is a common impairment in neurologic conditions, leading to abnormal gait and a greater risk of falling. Limited information, however, is available on the effectiveness of functional electrical stimulation (FES) on reducing falls, and no studies have investigated its usefulness in improving lower limbs kinematics related to foot clearance and energy recovery. SETTING: Clinical setting. STUDY DESIGN: Prospective longitudinal study. PARTICIPANTS: Twenty-four subjects, 14 people with multiple sclerosis (mean age ± standard deviation 50.93 ± 8.72 years) and 10 people with stroke (55.38 ± 14.55 years). METHODS: The number of falls was assessed at baseline and after 8 weeks, and a clinical assessment was performed at the baseline, 4-week, and 8-week time points. A subsample of the 24 subjects comprising 5 people with multiple sclerosis and 5 people with stroke performed a gait analysis assessment at baseline and after 4 weeks. After receiving the equipment and the training schedule, subjects performed daily home walking training using FES for 8 weeks. MAIN OUTCOME MEASUREMENTS: The main outcomes were (1) the number of falls, (2) foot clearance, and (3) energy recovery. RESULTS: A reduction in the number of falls was observed from baseline (n = 10) to the 8-week assessment (n = 2), P = .02. Foot clearance increased (+5.26 mm, P = .04) between the baseline without FES and at 4 weeks with FES (total effect). No statistically significant differences were found in energy recovery between baseline and 4 weeks. CONCLUSIONS: The use of FES had an impact on gait, specifically reducing the number of falls and improving walking. A specific effect at the ankle joint was observed, increasing foot clearance during the swing phase of gait. This effect was not accompanied with a reduction in the energetic expenditure during walking in subjects with multiple sclerosis and stroke.