Elizabeth S. Hile

Association of Body Mass Index With Self-Report and Performance-Based Measures of Balance and Mobility

Background The incidence of obesity is increasing in older adults, with associated worsening in the burden of disability. Little is known about the impact of body mass index (BMI) on self-report and performance-based balance and mobility measures in older adults. Objective The purposes of this study were (1) to examine the association of BMI with measures of balance and mobility and (2) to explore potential explanatory factors. Design This was a cross-sectional, observational study. Methods Older adults (mean age=77.6 years) who participated in an ongoing observational study (N=120) were classified as normal weight (BMI=18.5–24.9 kg/m2), overweight (BMI=25.0–29.9 kg/m2), moderately obese (BMI=30.0–34.9 kg/m2), or severely obese (BMI≥35 kg/m2). Body mass index data were missing for one individual; thus, data for 119 participants were included in the analysis. Mobility and balance were assessed using self-report and performance-based measures and were compared among weight groups using analysis of variance and chi-square analysis for categorical data. Multiple linear regression analysis was used to examine the association among BMI, mobility, and balance after controlling for potential confounding variables. Results Compared with participants who were of normal weight or overweight, those with moderate or severe obesity were less likely to report their mobility as very good or excellent (52%, 55%, 39%, and 6%, respectively); however, there was no difference in self-report of balance among weight groups. Participants with severe obesity (n=17) had the lowest levels of mobility on the performance-based measures, followed by those who were moderately obese (n=31), overweight (n=42), and of normal weight (n=29). There were no differences on performance-based balance measures among weight groups. After controlling for age, sex, minority status, physical activity level, education level, and comorbid conditions, BMI still significantly contributed to mobility (β=−.02, adjusted R2=.41). Conclusions Although older adults with severe obesity were most impaired, those with less severe obesity also demonstrated significant decrements in mobility.

Persistent Mobility Disability After Neurotoxic Chemotherapy

Background and Purpose The impact of cancer and its treatments on balance and functional mobility in older adults remains unknown but is increasingly important, given the evolution of cancer treatments. Subacute and more persistent side effects such as chemotherapy-induced peripheral neuropathy are on the rise, and the effects on mobility and balance, as well as the prognosis for resolution of any functional deficits, must be established before interventions can be trialed. The purpose of this case report is to describe the severity and long-term persistence of mobility decline in an older adult who received neurotoxic chemotherapy. To our knowledge, this is the first case report to describe an older adult with chemotherapy-induced peripheral neuropathy using results of standardized balance and mobility tests and to focus on prognosis by repeating these measures more than 2 years after chemotherapy. Case Description An 81-year-old woman received a neurotoxic agent (paclitaxel) after curative mastectomy for breast cancer. Baseline testing prior to taxane therapy revealed a socially active woman with no reported functional deficits or neuropathic symptoms, 1.2-m/s gait speed, and performance at the ceiling on balance and gait portions of a standardized mobility measure. Outcomes After 3 cycles, paclitaxel therapy was stopped by the oncologist because of neurotoxicity. Declines as large as 50% were seen in performance-based measures at 12 weeks and persisted at 2.5 years, and the patient reported recurrent falls, cane use, and mobility-related disability. Discussion This case highlights the extent to which function can decline in an older individual receiving neurotoxic chemotherapy, the potential for these deficits to persist years after treatment is stopped, and the need for physical therapy intervention and further research in this population.

Challenging Gait Conditions Predict 1-Year Decline in Gait Speed in Older Adults With Apparently Normal Gait

Background Mobility often is tested under a low challenge condition (ie, over a straight, uncluttered path), which often fails to identify early mobility difficulty. Tests of walking during challenging conditions may uncover mobility difficulty that is not identified with usual gait testing. Objective The purpose of this study was to determine whether gait during challenging conditions predicts decline in gait speed over 1 year in older people with apparently normal gait (ie, gait speed of ≥1.0 m/s). Design This was a prospective cohort study. Methods Seventy-one older adults (mean age=75.9 years) with a usual gait speed of ≥1.0 m/s participated. Gait was tested at baseline under 4 challenging conditions: (1) narrow walk (15 cm wide), (2) stepping over obstacles (15.24 cm [6 in] and 30.48 cm [12 in]), (3) simple walking while talking (WWT), and (4) complex WWT. Usual gait speed was recorded over a 4-m course at baseline and 1 year later. A 1-year change in gait speed was calculated, and participants were classified as declined (decreased ≥0.10 m/s, n=18), stable (changed <0.10 m/s, n=43), or improved (increased ≥0.10 m/s, n=10). Analysis of variance was used to compare challenging condition cost (usual − challenging condition gait speed difference) among the 3 groups. Results Participants who declined in the ensuing year had a greater narrow walk and obstacle walk cost than those who were stable or who improved in gait speed (narrow walk cost=0.43 versus 0.33 versus 0.22 m/s and obstacle walk cost=0.35 versus 0.26 versus 0.13 m/s). Simple and complex WWT cost did not differ among the groups. Limitations The participants who declined in gait speed over time walked the fastest, and those who improved walked the slowest at baseline; thus, the potential contribution of regression to the mean to the findings should not be overlooked. Conclusions In older adults with apparently normal gait, the assessment of gait during challenging conditions appears to uncover mobility difficulty that is not identified by usual gait testing.

What Is the Relation Between Fear of Falling and Physical Activity in Older Adults

OBJECTIVE To describe the association between fear of falling (FOF) and total daily activity in older adults. DESIGN Cross-sectional observational study. SETTING Ambulatory clinical research training center. PARTICIPANTS Community-dwelling older adults aged ≥64 years (N=78), who were independent in ambulation with or without an assistive device. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FOF was defined by self-reported fear ratings using the Survey of Activities and Fear of Falling in the Elderly and self-reported fear status determined by response to the following question: Are you afraid of falling? Physical function was assessed using the Late Life Function and Disability Instrument. Physical activity was recorded using an accelerometer worn on the waist for 7 consecutive days, and mean daily counts of activity per minute were averaged over the 7-day period. RESULTS Fear ratings were related to total daily activity (r=-.26, P=.02). The relation was not as strong as the relation of function and physical activity (r=.45, P<.001). When stratified by exercise status or functional status, fear was no longer related to total daily activity. Physical function explained 19% of the variance in physical activity, whereas the addition of fear status did not add to the explained variance in physical activity. CONCLUSIONS FOF is related to total daily physical activity; however, FOF was not independently associated with physical activity when accounting for physical function. Some FOF may be reported as a limitation in function.

The Modified Gait Efficacy Scale: Establishing the Psychometric Properties in Older Adults

Background Perceived ability or confidence plays an important role in determining function and behavior. The modified Gait Efficacy Scale (mGES) is a 10-item self-report measure used to assess walking confidence under challenging everyday circumstances. Objective The purpose of this study was to determine the reliability, internal consistency, and validity of the mGES as a measure of gait in older adults. Design This was a cross-sectional study. Methods Participants were 102 community-dwelling older adults (mean [±SD] age=78.6±6.1 years) who were independent in ambulation with or without an assistive device. Participants were assessed using the mGES and measures of confidence and fear, measures of function and disability, and performance-based measures of mobility. In a subsample (n=26), the mGES was administered twice within a 1-month period to establish test-retest reliability through the intraclass correlation coefficient (ICC [2,1]). The standard error of measure (SEM) was determined from the ICC and standard deviation. The Cronbach α value was calculated to determine internal consistency. To establish the validity of the mGES, the Spearman rank order correlation coefficient was used to examine the association with measures of confidence, fear, gait, and physical function and disability. Results The mGES demonstrated test-retest reliability within the 1-month period (ICC=.93, 95% confidence interval=.85, .97). The SEM of the mGES was 5.23. The mGES was internally consistent across the 10 items (Cronbach α=.94). The mGES was related to measures of confidence and fear (r=.54–.88), function and disability (Late-Life Function and Disability Instrument, r=.32–.88), and performance-based mobility (r=.38–.64). Limitations This study examined only community-dwelling older adults. The results, therefore, should not be generalized to other patient populations. Conclusion The mGES is a reliable and valid measure of confidence in walking among community-dwelling older adults.

Interpreting the Need for Initial Support to Perform Tandem Stance Tests of Balance

Background Geriatric rehabilitation reimbursement increasingly requires documented deficits on standardized measures. Tandem stance performance can characterize balance, but protocols are not standardized. Objective The purpose of this study was to explore the impact of: (1) initial support to stabilize in position and (2) maximum hold time on tandem stance tests of balance in older adults. Design A cross-sectional secondary analysis of observational cohort data was conducted. Methods One hundred seventeen community-dwelling older adults (71% female, 12% black) were assigned to 1 of 3 groups based on the need for initial support to perform tandem stance: (1) unable even with support, (2) able only with support, and (3) able without support. The able without support group was further stratified on hold time in seconds: (1) <10 (low), (2) 10 to 29, (medium), and (3) 30 (high). Groups were compared on primary outcomes (gait speed, Timed “Up & Go” Test performance, and balance confidence) using analysis of variance. Results Twelve participants were unable to perform tandem stance, 14 performed tandem stance only with support, and 91 performed tandem stance without support. Compared with the able without support group, the able with support group had statistically or clinically worse performance and balance confidence. No significant differences were found between the able with support group and the unable even with support group on these same measures. Extending the hold time to 30 seconds in a protocol without initial support eliminated ceiling effects for 16% of the study sample. Limitations Small comparison groups, use of a secondary analysis, and lack of generalizability of results were limitations of the study. Conclusions Requiring initial support to stabilize in tandem stance appears to reflect meaningful deficits in balance-related mobility measures, so failing to consider support may inflate balance estimates and confound hold time comparisons. Additionally, 10-second maximum hold times limit discrimination of balance in adults with a higher level of function. For community-dwelling older adults, we recommend timing for at least 30 seconds and documenting initial support for consideration when interpreting performance.

Imbalance and falls in older cancer survivors: An evidence-informed model for clinical assessment

Evidence suggests that a cancer history increases falls risk in older adults, a group already at higher risk based on advanced age alone. In geriatrics, falls are considered a multifactorial syndrome, generally associated with acquired impairments in postural control systems. Cancer treatments can initiate or worsen such impairments, so the cancer history should be a focus of the rehabilitative approach to older survivors. The purpose of this perspective article is to suggest a model for conducting a balance assessment that integrates evidence from the general geriatric literature with considerations unique to cancer survivorship, individualizing the approach to the survivors diagnosis and treatment response.

Fracture risk in gynecologic cancer survivors: Research round-up

Low bone mineral density is often included in discussions of hormonal therapies for breast cancer and is a concern for most women as they age. While potentially less recognized, bone health awareness is also relevant to rehabilitation therapists treating survivors of gynecologic cancers including cervical and endometrial. In a retrospective analysis of Korean gynecologic cancer survivors aged 45 to 57 years (mean = 51.5 years) who were free of bone metastases, cervical cancer survivors had lower bone mineral density than age-matched controls at the lumbar spine and femur even before any cancer treatment was received.1 Similar findings have been reported in cervical cancer survivors who were premenopausal.2 While another group found low density only at L4 before treatment in cervical cancer survivors, multiple sites were osteopenic or osteoporotic after treatment in both cervical and endometrial survivors.3 In the absence of imaging reports to prove otherwise, it may be safest to assume lower bone density in the spine and hip when evaluating gynecologic cancer survivors. In a recent clinical case (unpublished), a physical therapist suspected a lumbar compression fracture after observing a uterine cancer survivor referred for chemotherapy-induced peripheral neuropathy to be in obvious pain during transfers. The survivor, who had also undergone radiation therapy to the pelvis, had experienced pain for 2 weeks but had not mentioned it to any health care provider, afraid that her cancer had recurred. Because the

Oncology Section Task Force on Breast Cancer Outcomes: Clinical Measures of Chemotherapy-induced Peripheral Neuropathy—A Systematic Review

Background: Chemotherapy‐induced peripheral neuropathy (CIPN) is a common adverse effect of breast cancer treatment that can limit cancer intervention options, and also impact balance, mobility, and quality of life long after chemotherapy ends. The purpose of this systematic review was to provide physical therapists (PT) with evidence‐based recommendations on tools for clinical assessment of CIPN in adult breast cancer survivors. Methods: A team of reviewers identified all published measures of CIPN meeting the criteria of: clinically feasible, addressing the CIPN experience (signs/symptoms/or both), and with published psychometric properties established in survivors of breast cancer, or a cancer for which the same chemotherapy agents are used. Identified measures were then systematically reviewed and scored according to the Breast Cancer EDGE Task Force Rating Scale from 1 (Do Not Recommend) to 4 (Highly Recommend). Results: Of 11 measures meeting the review criteria, only one, the Functional Assessment of Cancer Therapy/ Gynecologic Oncology Group‐Neurotoxicity Scale (FACT/GOG‐Ntx) received the highest rating of 4 (highly recommend). The FACT‐GOG‐Ntx has high clinical utility for PT, well‐established psychometric properties, and published validation with chemotherapies used in breast cancer survivors. The 10 remaining measures received ratings of 2 (unable to recommend at this time). Conclusions: The Oncology Section Breast Cancer EDGE Task Force on Clinical Measures of CIPN recommends the FACT/GOG‐Ntx during physical therapy screening or assessment of CIPN in breast cancer survivors who have received neurotoxic chemotherapy; however, it is not recommended for use in isolation. Therapists are encouraged to supplement with further tests and measures to capture sensory, motor, and autonomic deficits specific to each survivor, along with related activity and participation restrictions.