Inter- and intra-tester reliability of the acute brain injury physiotherapy assessment (ABIPA) in patients with acquired brain injury.

BACKGROUND: The Acute Brain Injury Physiotherapy Assessment (ABIPA) is a new outcome measure with face validity and sensitivity to change in the early stages of neuromotor recovery after acquired brain injury (ABI). Reliability of physiotherapists using the tool has not been established. OBJECTIVE: Determine inter- and intra-tester reliability of physiotherapists using the ABIPA. METHODS: An observational study using video-recorded assessments of patient performance (n = 7) was undertaken with two cohorts of physiotherapists: those receiving training (n = 23) and those provided with guidelines only (n = 7) to administer the ABIPA. RESULTS: Across all physiotherapists (n = 30), inter-tester reliability was excellent (α ≥ 0.9) for total ABIPA score. All individual items, except trunk alignment in supine (α = 0.5), showed excellent or good internal consistency (α ≥ 0.7). For intra-tester reliability, substantial or perfect agreement was achieved for eight items (weighted Kappa Kw ≥ 0.6), moderate agreement for four items (Kw = 0.4-0.6) and three items achieved fair agreement (alignment head supine: Kw = 0.289; alignment trunk supine: Kw = 0.387 and tone left upper limb: Kw = 0.366). CONCLUSION: Physiotherapists are highly consistent using the ABIPA but several items may need revision to improve intra-tester reliability.

Are Changes in Gait and Balance Across the Disease Step Rating Scale in Multiple Sclerosis Statistically Significant and Clinically Meaningful?

OBJECTIVES: To explore differences in gait endurance, speed, and standing balance in people with multiple sclerosis (MS) across the Disease Step Rating Scale, and to determine if differences are statistically significant and clinically meaningful. DESIGN: Observational study. SETTING: Community rehabilitation - primary health care center. PARTICIPANTS: Community-dwelling people with MS (N=222; mean age, 48±12y; 32% men). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were categorized using the Disease Step Rating Scale. Demographics and clinical measures of gait endurance (6-minute walk test [6MWT]), gait speed (10-m walk test [10MWT] and 25-foot walk test [25FWT]), and balance (Berg Balance Scale [BBS]) were recorded in 1 session. Differences in these parameters across categories of the Disease Step Rating Scale were explored, and clinically meaningful differences were identified. RESULTS: The 6MWT showed a greater number of significant differences across adjacent disease steps in those with less disability (P<.001), whereas the 10MWT and 25FWT demonstrated more significant changes in those with greater disability (P<.001). The BBS demonstrated significant differences across the span of the Disease Step Rating Scale categories (P<.001). Differences in gait and balance between adjacent Disease Step Rating Scale categories met most previously established levels of minimally detectable change and all minimally important change scores. CONCLUSIONS: Our findings support the Disease Step Rating Scale is an observational tool that can be used by health professionals to categorize people with MS, with the categories reflective of statistically significant and clinically meaningful differences in gait and balance performance.

Clinimetric evaluation of the physical mobility scale supports clinicians and researchers in residential aged care.

OBJECTIVE: To investigate the interrater agreement and the internal construct validity of the Physical Mobility Scale, a tool routinely used to assess mobility of people living in residential aged care. DESIGN: Prospective, multicenter, external validation study. SETTING: Nine residential aged care facilities in Australia. PARTICIPANTS: Residents (N=186). Phase 1 cohort (99 residents; mean age, 85.22+/-5.1y); phase 2 cohort (87 residents; mean age, 81.59+/-10.69y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Kappa statistics, minimal detectable change (MDC(90)) scores, and Bland-Altman plots were used to assess interrater agreement. Scale unidimensionality, item hierarchy, and person separation were examined with Rasch analysis for both cohorts. RESULTS: Agreement between raters on 6 of the 9 Physical Mobility Scale items was high (kappa>.60). The MDC(90) value was 4.39 points, and no systematic differences in scores between raters were found. The Physical Mobility Scale showed a unidimensional structure demonstrated by fit to the Rasch model in both cohorts (phase 1: chi(2)=23.90, P=.16, person separation index=0.96; phase 2: chi(2)=22.00, P=.23, person separation index=0.96). Standing balance was the most difficult item in both cohorts (phase 1: logit=2.48, SE, 0.16; phase 2: logit=2.53, SE, 0.15). The person-item threshold map indicated no floor or ceiling effects in either cohort. CONCLUSIONS: The Physical Mobility Scale demonstrated good interrater agreement and internal construct validity with good fit to the Rasch model in both cohorts. The comparative results across the 2 cohorts indicate generality of the findings. The Physical Mobility Scale total raw scores can be converted to Rasch transformed scores, providing an interval measure of mobility. The Physical Mobility Scale may be suited to a range of clinical and research applications in residential aged care.

Can a single session of motor imagery promote motor learning of locomotion in older adults? A randomized controlled trial.

PURPOSE: To investigate the influence of a single session of locomotor-based motor imagery training on motor learning and physical performance. PATIENTS AND METHODS: Thirty independent adults aged >65 years took part in the randomized controlled trial. The study was conducted within an exercise science laboratory. Participants were randomly divided into three groups following baseline locomotor testing: motor imagery training, physical training, and control groups. The motor imagery training group completed 20 imagined repetitions of a locomotor task, the physical training group completed 20 physical repetitions of a locomotor task, and the control group spent 25 minutes playing mentally stimulating games on an iPad. Imagined and physical performance times were measured for each training repetition. Gait speed (preferred and fast), timed-up-and-go, gait variability and the time to complete an obstacle course were completed before and after the single training session. RESULTS: Motor learning occurred in both the motor imagery training and physical training groups. Motor imagery training led to refinements in motor planning resulting in imagined movements better matching the physically performed movement at the end of training. Motor imagery and physical training also promoted improvements in some locomotion outcomes as demonstrated by medium to large effect size improvements after training for fast gait speed and timed-up-and-go. There were no training effects on gait variability. CONCLUSION: A single session of motor imagery training promoted motor learning of locomotion in independent older adults. Motor imagery training of a specific locomotor task also had a positive transfer effect on related physical locomotor performance outcomes.

Age-related changes in strength and somatosensation during midlife: rationale for targeted preventive intervention programs.

Age-related changes in strength and somatosensation have a negative impact on balance with advanced age. Knowledge of the decades of life when strength and somatosensation show initial and subsequent reductions could inform balance assessment and targeted preventive intervention. We report a cross-sectional study investigating strength and somatosensation of 316 healthy women aged 20-80 years. Demographics, health profile, and activity level were recorded. Strength of quadriceps, hip abductors and adductors, and lower limb somatosensation (tactile acuity, vibration threshold, and joint position error) were measured. Significant age-related changes in strength and somatosensory function were identified, even when demographic variables of activity level, weight, number of reported conditions, medications used, and history of falls were included as covariates. Tested muscles achieved peak force in women in their 40s and then trending reductions presented for those in their 50s and 60s, with significant reductions by the 70s. Tactile acuity, vibration sensitivity, and joint position sense for a non-weight-bearing toe-matching task were significantly reduced by the 40s or 50s, with further reductions by either the 60s or 70s. For the weight-bearing replication task, joint position error was significantly increased by the 60s. A main effect of activity level and body weight was identified for strength measures, and weight also had a main effect for most of the somatosensory modalities. These findings can inform health professionals to use knowledge of early and any subsequent reductions in muscle strength and somatosensation, along with effects of demographics, to develop targeted, innovative programs across the mid-life, a preclinical change period for balance, to promote healthier aging.

Impacts of small vestibular schwannoma on community ambulation, postural, and ocular control.

OBJECTIVES/HYPOTHESIS: To investigate balance, community mobility, gaze instability, and dizziness handicap and assess falls risk in people who are conservatively managed with small vestibular schwannoma (VS). STUDY DESIGN: Cross-sectional study with controls. METHODS: The study involved 18 people (mean age 58.7 ± 12.2 years) diagnosed with VS (<12 mm) and 22 age-matched controls (mean age 56.9 ± 8.0 years). Measures included standing on firm and foam surfaces with feet apart, then together with eyes open and closed, Timed Up and Go (TUG) test and dual TUG test, Dynamic Gait Index, 6-Minute Walk Test, Halmagyi Impulse Test, Dynamic Visual Acuity Test, and the Dizziness Handicap Inventory. RESULTS: The clinical group failed more trials standing feet together on foam with eyes closed (P < .05); had inferior mobility and walked more slowly with divided attention (P < .05); had more difficulty walking with head movement, negotiating obstacles, and using stairs (P < .01); and walked shorter distances (P < .001) than controls. Reduced gaze stability (P < .01) and higher total (P = .007) and subcategory dizziness handicap scores (P < .05) were revealed compared to age-matched controls. CONCLUSIONS: Although outcomes for the clinical group are inferior to the control group across all measures and the dizziness impact is higher, the results fall in the low-risk category for falls. Preliminary data (level 4 evidence) support using a suite of clinical measures to monitor people with VS during conservative management. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:1147-1152, 2017.

A prospective investigation of changes in the sensorimotor system following sports concussion. An exploratory study.

BACKGROUND: Sports concussion is a risk for players involved in high impact, collision sports. Post-concussion, the majority of symptoms subside within 7-10 days, but can persist in 10-20% of athletes. Understanding the effects of sports concussion on sensorimotor systems could inform physiotherapy treatment. OBJECTIVE: To explore changes in sensorimotor function in the acute phase following sports concussion. DESIGN: Prospective cohort study. METHODS: Fifty-four players from elite rugby union and league teams were assessed at the start of the playing season. Players who sustained a concussion were assessed three to five days later. Measures included assessments of balance (sway velocity), vestibular system function (vestibular ocular reflex gain; right-left asymmetry), cervical proprioception (joint position error) and trunk muscle size and function. RESULTS: During the playing season, 14 post-concussion assessments were performed within 3-5 days of injury. Significantly decreased sway velocity and increased size/contraction of trunk muscles, were identified. Whilst not significant overall, large inter-individual variation of test results for cervical proprioception and the vestibular system was observed. LIMITATIONS: The number of players who sustained a concussion was not large, but numbers were comparable with other studies in this field. There was missing baseline data for vestibular and cervical proprioception testing for some players. CONCLUSIONS: Preliminary findings post-concussion suggest an altered balance strategy and trunk muscle control with splinting/over-holding requiring consideration as part of the development of appropriate physiotherapy management strategies.

Fall risk in people with MS: A Physiological Profile Assessment study.

INTRODUCTION: The Physiological Profile Assessment (PPA) is used in research and clinical practice for assessing fall risk. We compared PPA test performance between people with multiple sclerosis (MS) and healthy controls, determined the fall-risk profile for people with MS and developed a reference database for people with MS. METHODS: For this study, 416 ambulant people with MS (51.5 ± 12.0 years) and 352 controls (52.8 ± 12.2 years) underwent the PPA (tests of contrast sensitivity, proprioception, quadriceps strength, reaction time and sway) with composite fall-risk scores computed from these measures. MS participants were followed prospectively for falls for 3 months. RESULTS: The MS participants performed significantly worse than controls in each PPA test. The average composite fall-risk score was also significantly elevated, indicating a "marked" fall risk when compared with controls. In total, 155 MS participants (37.3%) reported 2 + falls in the follow-up period. Frequent fallers performed significantly worse than non-frequent fallers in the contrast sensitivity, reaction time and sway tests and had higher PPA composite scores. CONCLUSIONS: In line with poor PPA test performances, falls incidence in people with MS was high. This study provides comprehensive reference data for the PPA measures for people with MS that could be used to inform future research and clinical practice.

Balance self-efficacy in older adults following inpatient rehabilitation.

Older adults discharging from inpatient rehabilitation were investigated to determine change in self-efficacy at 1 month after discharge, the relationship with discharge balance performance and physical function, and the influence of diagnosis. A prospective cohort of 101 adults older than 50 years of age, 43% men, average age 75.84 (SD 9.8) years, were recruited at discharge from inpatient rehabilitation. Balance self-efficacy was assessed using Activities-specific Balance Confidence (ABC) scale at discharge and 1 month following discharge. Balance and physical function were measured at discharge using the Functional Independence Measure, Balance Outcome Measure for Elder Rehabilitation, Modified Elderly Mobility Scale and gait speed. At discharge, balance self-efficacy was moderate (ABC score 62, SD 23) and did not change at follow-up. When grouped by discharge self-efficacy (ABC scores: low<50; moderate 51-80; high>80), significant between-group differences were found for balance (P=0.005) and physical function (P=0.035). At the 1-month follow-up, those with low discharge balance self-efficacy showed improvement (mean-change ABC score 12, 95% confidence interval 2-22) and those with high discharge balance self-efficacy had lower scores (mean-change ABC score 18, 95% confidence interval -8 to -28). Differences in ABC change scores were also found between diagnostic groups (F=3.740, P=0.03), with the orthopaedic group improving (ABC mean change=8) and the general frailty group showing a decrease in confidence (ABC mean change=10). The differences in balance self-efficacy change at 1 month following discharge were related to self-efficacy level at discharge and clinical group requiring rehabilitation. Clinicians need to be aware of these changes as patients are prepared for discharge.

Mobility has a non-linear association with falls risk among people in residential aged care: an observational study.

QUESTIONS: What is the association between mobility and falls risk for people living in residential aged care? Can the Physical Mobility Scale discriminate between residents at risk of falling and those not at risk? DESIGN: Prospective longitudinal observational study. SETTING: Six residential aged care facilities in Australia. PARTICIPANTS: Eighty-seven high- and low-level care permanent residents. OUTCOME MEASURES: The primary outcome measure was the number of falls in the six months after the initial mobility assessment. Mobility of all participants was assessed using the Physical Mobility Scale, which includes nine mobility items assessed on a 0-5 scale yielding a total score out of 45. RESULTS: During the six-month study period, 131 falls were reported. Residents with mild mobility impairment (Physical Mobility Scale total score 28-36) had the highest fall risk (hazard ratio = 1.98, 95% CI 1.30 to 3.03). Residents with fully dependent mobility (Physical Mobility Scale total score 0-9) had the lowest risk for falls (HR=0.05, 95% CI 0.01 to 0.32). CONCLUSION: Aged care residents with mild mobility impairment are at increased risk of falls and are an appropriate target for falls prevention strategies. Although improving the mobility of residents with moderate to severe mobility impairment may enhance their independence and reduce their burden on staff, paradoxically this may also increase their risk of falls. When these residents improve enough to progress into a higher category of mobility, physiotherapists should be aware that this may increase the risk of falls and should consider instituting appropriate falls prevention strategies.

Measuring fall risk and predicting who will fall: clinimetric properties of four fall risk assessment tools for residential aged care.

BACKGROUND: The purpose of this prospective cohort study was to describe the clinimetric evaluation of four fall risk assessment tools (FRATs) recommended in best practice guidelines for use in residential aged care (RAC). METHODS: Eighty-seven residents, mean age 81.59 years (SD +/-10.69), participated. The Falls Assessment Risk and Management Tool (FARAM), Peninsula Health Fall Risk Assessment Tool (PHFRAT), Queensland Fall Risk Assessment Tool (QFRAT), and Melbourne Fall Risk Assessment Tool (MFRAT) were completed at baseline, and 2 and 4 months, and falls occurring in the 6 months after the baseline assessment were recorded. Interrater agreement (kappa), predictive accuracy (survival analysis and Youden Index), and fit to the Rasch model were examined. Twelve-month fall history formed the predictive accuracy reference. RESULTS: Interrater risk classification agreement was high for the PHFRAT (small ka, Cyrillic = .84) and FARAM (small ka, Cyrillic = .81), and low for the QFRAT (small ka, Cyrillic = .51) and MFRAT (small ka, Cyrillic = .21). Survival analysis identified that 43%-66% of risk factors on each tool had no (p > .10) association with falls. No tool had higher predictive accuracy (Youden index) than the question, "has the resident fallen in past 12 months?" (p > .05). All tools did not exhibit fit to the Rasch model, invalidating summing of risk factor scores to provide an overall risk score. CONCLUSION: The studied tools have poor clinimetric properties, casting doubt about their usefulness for identifying fall risk factors for those most at risk for falling and measuring fall risk in RAC.