Geriatric Physical Therapy ,

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Balance and Functional Outcomes for Older Community-Dwelling Adults Who Practice Tai Chi and Those Who Do Not: A Comparative Study Background and Purpose: A growing body of literature substantiates that Tai Chi is a form of exercise that may help older adults increase strength, improve balance, lower fall rates, and experience less fear of falling. Few studies, however, offer controlled experimental design and simultaneously investigate multiple factors known to contribute to fall risk. The purpose of this study was to compare performance on measures relating to fall risk (strength, balance, functional mobility, and fear of falling) in older community-dwelling adults who participated in a community-based Tai Chi program with a control group of their peers who had no Tai Chi training over the same time period. Methods: A quasi-experimental comparative pre- and posttest design was used to compare an experimental group of 16 community-dwelling older adults, mean (SD) age = 80.4 (6.8) years, participating in a 16-week Tai Chi training program with a group of 13 adults, mean (SD) age = 71.2 (6.1) years, who had no Tai Chi experience in the areas of knee extension strength (measured by handheld dynamometry), functional strength (by five-time sit to stand), mobility (by Timed Up and Go [TUG] test and Fifty-Foot Walk Test), balance (by Functional Reach and Berg Balance Scale), and fear of falling (by Activity-specific Balance Confidence scale). Within-group and between-groups comparisons were made using 2×2 mixed analysis of variance. Results: Tai Chi participants improved in nearly all measures, whereas controls did not. Tai Chi participants experienced significant improvement in the TUG test during the training period (P = .003), with significant difference when compared with controls (P = .049) and moderate effect size and observed power (ηp2 = 0.165; observed power = 0.512). Significant knee extension strength improvement occurred (P = .042) with moderate effect size and observed power (ηp2 = 0.183; observed power = 0.543). While the total balance confidence scale score did not change significantly, responses on many individual items did reach a level of significant change for persons participating in the Tai Chi training. Conclusion: Older adults' participation in a community-based Tai Chi program may lead to improvement in strength, mobility, and confidence in performing functional tasks. Incorporation of elements of Tai Chi into therapy programs for older adults at risk for fall and referral to community-based Tai Chi programs may be viable options in the continuum of health-related care for older adults.

Four Months of Wearing a Balance Orthotic Improves Measures of Balance and Mobility Among a Cohort of Community-Living Older Adults Background and Purpose: The Centers for Disease Control and Prevention estimated that there were 29 million falls and 7 million injuries in 2014 in the United States. Falls, decreased balance, and mobility disability are common in older adults and often result in loss of independence. Finding interventions to address these issues is important, as this age group is growing exponentially. Prior studies indicate balance and mobility can be improved by the balance-based torso-weighting (BBTW) assessment implemented through wear of a balance orthotic (BO). This study sought to determine the impact of wearing a BO on balance, mobility, and fall risk over time. Methods: This quasiexperimental, 1-group pre-/posttest study investigated the effect of 4 months of daily wear (4 hours per day) of a BO on mobility, balance, and falls efficacy in 30 older adults living in a retirement community with limited mobility defined by a Short Physical Performance Battery (SPPB) score range between 4 and 9 out of a maximum of 12 points. Pre- and posttreatment tests included the Timed Up and Go (TUG), Functional Gait Assessment (FGA), Falls Efficacy Scale (FES), and SPPB. Participants received the BBTW assessment, consisting of individualized assessment of 3-dimensional balance loss, and treatment with a strategically weighted and fitted BO to control balance loss. The BO was worn twice a day for 2 hours (4 hours per day) for 4 months. Participants continued regular activity and no other interventions were provided. All posttests were conducted after 4 months and at least 8 hours after removal of the BO. Subitems from the SPPB (gait speed [GS], 5-time sit-to-stand [FTSST], and tandem stance time [TST]) were analyzed as separate outcome measures. Data were analyzed with paired t tests with a Bonferroni correction (SPPB, GS, FGA, and FES) when statistical assumptions were met. Data that did not meet the statistical assumptions of the paired t test (FTSST, TST, and TUG) were analyzed with Wilcoxon signed rank tests with a Bonferroni correction. Results and Discussion: Twenty-four participants, average age 87 (5.7) years, completed the study. Paired t tests indicated that mean group scores on the SPPB, GS, and FGA significantly improved from pre- to posttests. The SPPB improved by 1.3 points (P = .001). GS improved by 0.09 m/s (P = .004) and both mean values improved beyond fall risk cutoffs. The FGA also improved by 2.6 points (P = .001). There were no significant changes in FES scores (P = .110). Wilcoxon signed rank tests indicated median group scores of the FTSST significantly improved from pre- to posttests by 7.4 seconds (P = .002) and median TUG times improved by 3.5 seconds (P = .004). There were no changes in TST (P = .117). Conclusions: This study suggests that wearing a BO for 4 hours per day for 4 months results in improvements in functional assessments related to fall risk (SPPB, GS, FGA, TUG, and FTSST) in a group of older adult participants with limited mobility.

Examining the Effects of an Otago-Based Home Exercise Program on Falls and Fall Risks in an Assisted Living Facility Background and Purpose: The Otago exercise program is a strengthening, balance, and walking program designed to decrease falls among community-dwelling older adults. Few studies have examined the effects of the Otago program in an assisted living environment. The purpose of the current study was to assess the effects of an Otago-based home exercise program in decreasing falls and the risk of falls among older adults living in an assisted living facility. Methods: A retrospective chart review of 30 individuals residing at either of 2 assisted living facilities in central Florida was undertaken. Participants had a mean age of 87 years, were at risk for falls as determined by the Tinetti Performance-Oriented Mobility Assessment (POMA), and were provided with an Otago-based intervention by home health physical therapy. The outcome measures were the number of falls in the previous year, the number of falls in the year following the intervention, and Tinetti POMA scores pre- and post-intervention. Results and Discussion: The mean (SD) number of falls significantly decreased from 1.4 (0.9) to 0.5 (0.7) fall per person per year after home health physical therapy with the tailored Otago based-exercise intervention. The intervention resulted in a statistically significant improvement in Tinetti POMA scores from 11.8 (2.5) to 17.6 (3.8). Conclusions: An Otago-based strengthening, balance, and walking home exercise program can potentially be used to decrease the number of falls and the risk of falling among older adults residing in an assisted living facility.

Predictors of Improvement in Physical Function in Older Adults in an Evidence-Based Physical Activity Program (EnhanceFitness) Background and Purpose: Declines in strength, flexibility, and balance in older adults can lead to injuries and loss of independence and are particularly common in those of greater age and in worse health. EnhanceFitness (EF) is a nationally disseminated, evidence-based group exercise program for older adults that has been shown to improve function through cardiovascular, strength, flexibility, and balance exercises. This article examines changes in, and predictors of, participant physical function from baseline through 2 program cycles of EF as measured by 3 physical function tests: arm curls, chair stands, and 8-foot up-and-go. Methods: We analyzed data on participants who attended at least 2 consecutive 16-week program cycles between January 2005 and June 2016. We ran 3 random-effects linear regression models, 1 for each physical function test, and accounted for missing data and clustering by class site. Independent variables included attendance, demographics, and health status. Results and Discussion: A total of 7483 participants completed baseline and 2 sets of follow-up physical function tests. For all 3 physical function tests, participants showed some degree of improved physical function at each follow-up, and greater program attendance predicted clinically significant improvements. Some participants had less improvement: females, those less active at baseline, older than 75 years, not married or partnered, or in fair or poor health, those who had experienced at least 1 fall, and those with a disability. Conclusion: EnhanceFitness program providers may need to implement additional measures to support the participants who could benefit most from EF, such as targeting messaging, coordinating with referring providers to emphasize attendance and general activity in specific participants, and offering additional support to groups who show less improvement during classes. The evidence presented here may inform clinical decision making for older adult patients and increase health care provider confidence in EF and similar exercise programs, thereby providing a mechanism to maintain and continue functional gains made in clinical or rehabilitation settings.

Effect of Anodal Transcranial Direct Current Stimulation of the Motor Cortex on Elbow Flexor Muscle Strength in the Very Old Background and Purpose: Muscle weakness predisposes older adults to a fourfold increase in functional limitations and has previously been associated with reduced motor cortex excitability in aging adults. The purpose of this study was to determine whether a single session of anodal transcranial direct current stimulation (tDCS) of the motor cortex would increase elbow flexion muscle strength and electromyographic (EMG) amplitude in very old individuals. Methods: Eleven very old individuals—85.8 (4.3) years—performed 3 maximal isometric elbow flexion contractions before and after 20 minutes of sham or anodal tDCS on different days. Order of stimulation was randomized, and the study participants and investigators were blinded to condition. In addition, voluntary activation capacity of the elbow flexors was determined by comparing voluntary and electrically evoked forces. Results: Anodal tDCS did not alter muscle strength or EMG activity in comparison to sham stimulation. Elbow flexion voluntary activation capacity was very high among the study participants: 99.3% (1.8%). Conclusion: Contrary to our hypothesis, we observed no effect of anodal tDCS and no impairment in elbow flexor voluntary activation capacity in the very old. Whether anodal tDCS would exert a positive effect and support our initial hypothesis in another muscle group that does exhibit impairments in voluntary activation in older adults is a question that is still to be addressed.

The 3-m Backwards Walk and Retrospective Falls: Diagnostic Accuracy of a Novel Clinical Measure Background and Purpose: Several measures of fall risk have been previously developed and include forward walking, turning, and stepping motions. However, recent research has demonstrated that backwards walking is more sensitive at identifying age-related changes in mobility and balance compared with forward walking. No clinical test of backwards walking currently exists. Therefore, this article describes a novel clinical test of backwards walking, the 3-m backwards walk (3MBW), and assessed whether it was associated with 1-year retrospective falls in a population of healthy older adults. Diagnostic accuracy of the 3MBW was calculated at different cutoff points and compared with existing clinical tests. Methods: This study was a retrospective cohort study including residents of a retirement community without a history of neurological deficits. Demographics, medical history, and falls in the past year were collected, and clinical tests included the 3MBW and the Timed Up and Go (TUG), the 5 times sit-to-stand, and the 4-square step test. Frequency distributions and t tests compared baseline characteristics of people who reported falling with people who did not. Diagnostic accuracy (sensitivity and specificity) was calculated for a series of cutoffs for the 3MBW, the TUG (≥8, 10, and 13.5 seconds), 5 times sit-to-stand (≥12 and ≥15 seconds), and 4-step square test (>15 seconds). Receiver operating curve analyses were used to define 3MBW optimal cutoffs, and the difference between the overall area under the curve (AUC) was statistically tested. SPSS 24.0 and MedCalc 17.1 were used for all analyses. Results and Discussion: Fifty-nine adults with a mean (SD) age of 71.5 (7.6) years participated, with 25 people reporting falls in the past year. The mean (SD) time for the 3MBW was 4.0 (2.1) seconds. People who fell had a significantly slower 3MBW time (4.8 vs 3.5 seconds for people who did not fall, P = .015), but not a significantly slower 4-step square test (9.5 vs 8.1 seconds, P = .056), TUG (9.3 vs 8.0 seconds, P = .077), and 5 times sit-to-stand (12.5 vs 10.3 seconds, P = .121). The highest overall AUC for any measure was for the 3MBW at 3.5 seconds (0.707, 95% confidence interval = 0.570-0.821; sensitivity = 74%, specificity = 61%), which was significantly higher than the TUG at 8 seconds (AUC = 0.560, P = .023) and 13.5 seconds (AUC = 0.528, P = .011), the 4-step square test (AUC = 0.522, P = .004), but not significantly higher than the TUG at 10 seconds (P = .098) and the 5 times sit-to-stand at 12 (P = .092) or 15 seconds (P = .276). On the 3MBW, more than 75% of people who were faster than 3.0 seconds did not report any falls, and 94% of people who did not report falling were faster than 4.5 seconds. Of the people who were slower than 4.5 seconds, 81% reported falling. Conclusions: In a study of healthy older adults, the 3MBW demonstrated similar or better diagnostic accuracy for falls in the past year than most commonly used measures. People walking faster than 3.0 seconds on the 3MBW were unlikely to have reported falling, whereas people slower than 4.5 seconds were very likely to have reported falling. Further validation of the 3MBW in prospective studies, larger samples, and clinical populations is recommended.

Investigating the Relationship of the Functional Gait Assessment to Spatiotemporal Parameters of Gait and Quality of Life in Individuals With Stroke Background and Purpose: Walking in the community is an important aspect of independence and quality of life (QOL) that poses challenges for individuals with stroke. This study investigated whether performance on the Functional Gait Assessment (FGA) differentiated spatiotemporal gait parameters, QOL, and fall history of community-ambulating individuals with stroke. We hypothesized that those scoring higher on the FGA would present with better gait speed and cadence, stride width and length, and improved load time on the paretic limb, report a higher QOL, and be less likely to have a fall history than those who scored lower on the FGA. Methods: Participants were screened for cognitive impairment and the ability to walk independently. Participant demographics and stroke characteristics were recorded. The Falls Risk for Older People in the Community (FROP-Com) screening tool determined whether the participant had incurred 1 or more falls within the preceding 12 months. The FGA provided a composite measure of gait with varied walking tasks challenging different aspects of walking. The total score was recorded. The GAITRite instrumented-walkway was used to acquire high-resolution footfall data during performance of the first 9 FGA walking tasks. The Assessment of Quality of Life-6D (AQoL-6D) was used to measure health-related QOL across the domains of independent living, mental health, coping, relationships, pain, and senses. Pearson and Spearman correlations were used to check for correlations between FGA score and the demographic characteristics, AQoL-6D scores, and 12-month fall history. Pearson correlations were used to check for correlations between FGA score and multiple spatiotemporal gait parameters for each FGA item. Results and Discussion: A sample of 29 volunteers who were community-ambulating individuals with stroke was recruited. Participants had a mean age of 62.31 (10.89) years, mean time since stroke of 3.78 (4.10) years, and included both males and females (52% male). Individuals presented with both left- and right-sided strokes. FGA score correlated positively with velocity, cadence, and step length, and negatively with stride width, double-support percent, and single-support variability (P = .001 to P = .031). FGA score correlated positively with the AQoL-6D dimension of independent living. FGA score correlated significantly with the FROP-Com screening tool predicted fall risk, but not with fall history. Conclusions: The FGA is a clinical measure of functional gait performance that reflected spatiotemporal gait parameters and ability of individuals with chronic stroke to live independently. The FGA could be used to target interventions to improve functional gait performance of individuals with chronic stroke.

Validity and Responsiveness to Change of the 30-Second Chair-Stand Test in Older Adults Admitted to an Emergency Department Background and Purpose: Few physical performance measurement tools are validated for acutely admitted older adults, and for this reason we aimed to examine the validity and responsiveness to change of the 30-second Chair-Stand Test (30s-CST) used to assess physical performance in older adults admitted to a short-stay unit in an emergency department. Methods: Construct validity of the 30s-CST, using 8 as a cutoff point for dependency in activities of daily living, was examined using 207 patients. Self-reported information on everyday activities was obtained by asking patients about need for help in bathing, dressing, cooking, cleaning, and shopping. Concurrent validity of the 30s-CST compared with the de Morton Mobility Index (DEMMI) on physical performance of acutely admitted older adults was examined with 156 patients. The analysis of concurrent validity included the entire DEMMI and 2 subsets of DEMMI: “DEMMI walking” and “DEMMI dynamic balance.” The responsiveness to change in the 30s-CST compared with DEMMI was examined with 117 patients. All patients were classified as having either low physical performance (30s-CST ≤8) or high physical performance (30s-CST >8); these groups were used in the analysis of validity and responsiveness to change. Results and Discussion: Regarding construct validity using 8 as a cutoff point, the study showed a significant difference between patients with low physical performance compared with patients with high physical performance. Moreover, a decrease in the 30s-CST was followed by an increase in the need for help with everyday activities. There was a significant association between the 30s-CST and DEMMI (r = 0.72); for every extra repetition in the 30s-CST, the DEMMI score increased by 4.9. There was a significant association between the 30s-CST and the 2 subsets “DEMMI walking” and “DEMMI dynamic balance”; yet, a pronounced floor effect was found in the subsets. The analysis demonstrated a very wide prediction interval, indicating that DEMMI has a better responsiveness to change than the 30s-CST, especially in older adults with low physical performance. However, the 30s-CST is easier and faster to use than DEMMI. Conclusion: This study found a significant difference in the patients' need for help with everyday activities when comparing low and high physical performance groups. The concurrent validity of the 30s-CST was acceptable in assessing physical performance in older adults at the time of admission; the 30s-CST is thus a tool that is easy to use in older adults with acute disease. In contrast, based on very wide prediction intervals, DEMMI demonstrated better responsiveness to change than the 30s-CST, especially in older adults with low physical performance.

Item Distribution in the Berg Balance Scale: A Problem for Use With Community-Living Older Adults Background and Purpose: The Berg Balance Scale (BBS) is a commonly used clinical test measure to determine balance performance and fall risk. However, a ceiling effect of the BBS has been reported in studies of older adults with relatively higher levels of physical performance. The underlying reason for this ceiling effect may be that the task items in the BBS are insufficiently challenging to discriminate individuals with less severe balance limitations. The purpose of this study was to investigate the unidimensional construct, item difficulty hierarchy, and item distribution of the BBS in order to determine its usefulness among community-living older adults (CLOAs). Methods: CLOA volunteers (N = 112; 34 men, 78 women), mean age 82.4 years (SD = 7.9) (range, 65-99 years), were tested with the BBS by physical therapy faculty and students from Drexel University. Rasch principal component analysis (PCA) was used to investigate the dimensionality of the BBS, and the Rasch rating scale model was used to determine the item difficulty hierarchy and distribution. Results: Rasch PCA confirmed the unidimensional construct of the BBS as a balance ability test. Two items failed to fit the Rasch model, “sitting unsupported” and “standing unsupported with eyes closed.” Item difficulty hierarchy indicated that the most difficult test item was “stand on one leg” and the easiest was “sitting unsupported.” Item and person measures ranged from −4.35 to 2.66 and −1.77 to 6.58 logits, respectively. Person and item separation indexes were 2.10 and 6.41 (reliabilities of 0.82 and 0.98, respectively). Conclusions: Comparing the item difficulty and person ability, the balance ability of the CLOAs exceeded the difficulty of the test items, rendering it less useful for detecting balance ability and fall risk in CLOAs. More challenging test items, or selection of a different balance test, are recommended for use with this population.