Gun-Britt Jarnlo

Predictors of falls in the elderly by location

Background and aims: In the elderly, balance and walking impairments are assumed to play an important role in causing falls. We have assessed prospectively the predictive ability of health, function and balance variables regarding falls and their location. Methods: Falls which occurred during one year in a random sample of 307 women aged 75 years and over (mean 80.8 years, response rate 74.5%) living in the community were recorded and related to baseline registrations of health, medication and tests of walking and balance. Results: In all, 155 women (50.5%) reported 308 falls. Outdoor falls were significantly more frequent than indoor falls (57.5 vs 42.5%). The variables having had a fall before the start of the study, osteoporosis, hypertension, feeling depressed, unable to climb 40 cm high steps and walking slowly, all independently predicted a higher number of falls overall. Regarding fall location, having experienced a fall before study start was associated with more falls indoors as well as outdoors. Vision impairment, symptoms of depression, a faster comfortable walking speed, and being able to cope with higher steps were all independent predictors of more outdoor falls also after adjustment for outdoor exposure. A slower comfortable walking speed, a higher amplitude of the center of pressure movements in the frontal plane, a poorer score on the Timed Up & Go test, multi-morbidity, poor cognition and hypertension were independent risk factors for indoor falls. Neither number of drugs used nor any specific medication appeared as independent risk factors for falls in this study. Conclusions: The findings of this study suggest that risk factors for indoor and outdoor falls are different. Location of fall may be an important confounder in studies of predictors of falls in the elderly which should encompass this type of information.

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.

Balance training in 70-year-old women

The aim of this study was to discover whether or not the balance of a group of older women could be improved using nine simple, clinical balance tests before and after a training period. A total of 34 healthy 70-year-old women volunteered for the study and they were randomised into two groups: the first received 1 hours training twice a week for 5 weeks; the second the control group did not receive any training. The tests included: standing on one leg (a) with or without visual feedback and (b) with or without rotation of the neck; walking along a beam; walking in a figure-of-eight; and walking as fast as possible. The balance of the training group improved significantly in six out of the nine tests, whereas no such improvement was seen among the controls. We conclude that healthy women aged 70 years are able to improve their balance both when standing and walking.

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.

Longitudinal Construct Validity of the GMFM-88 Total Score and Goal Total Score and the GMFM-66 Score in a 5-Year Follow-up Study

Background: The Gross Motor Function Measure (GMFM) is the instrument most commonly used to measure gross motor function in children with cerebral palsy (CP). Different scoring options have been developed, and their measurement properties have been assessed. Limited information is available regarding longitudinal construct validity. Objective: The objective of this research was to study the longitudinal construct validity of 3 scoring options: the 88-item GMFM (GMFM-88) total, the GMFM-88 goal total, and the 66-item GMFM (GMFM-66). Design: A clinical measurement design was used in this study. Methods: Forty-one children with CP diplegia who were undergoing selective dorsal rhizotomy (SDR) were monitored with the GMFM for 5 years. The mean age at SDR was 4.4 years (range=2.5–6.6). Two subgroups for gross motor function before surgery were created according to the Gross Motor Function Classification System (GMFCS): GMFCS levels I to III and GMFCS levels IV and V. This study included results obtained before SDR and at 6, 12, and 18 months and 3 and 5 years after SDR. The effect size (ES) and the standardized response mean (SRM) were calculated. Results: At 6 months postoperatively, ES and SRM values were small (≤0.5) for all GMFM scoring options. The GMFM-88 total and goal total scores showed large changes in ES values (range=0.8–0.9) and SRM values (range=0.9–1.3) at 12 months postoperatively, whereas the GMFM-66 scores showed lower ES values (range=0.3–0.4) and SRM values (range=0.7–0.8) for both subgroups. Later postoperatively, larger values for longitudinal construct validity were found. The ES and SRM values generally were lower for the GMFM-66 scores than for the GMFM-88 total and goal total scores. Limitations: All children underwent an extensive intervention, and changes in gross motor function were expected. Conclusion: All 3 scoring options showed large longitudinal construct validity in the long-term follow-up. The GMFM-88 total and goal total scores revealed large changes in gross motor function earlier postoperatively than the GMFM-66 scores.

Early rehabilitation at home of elderly patients with hip fractures and consumption of resources in primary care.

From 1976 onwards an active rehabilitation programme has been applied to elderly patients with fresh hip fractures at the Department of Orthopaedics in Lund in Southern Sweden. This involves early mobilisation in the hospital (internal fixation and immediate weight-bearing) and at home, rehabilitation in cooperation with primary health care personnel from the time of the patients admission. The purposes of this investigation were to evaluate the effect of this programme in primary care and to assess the consumption of resources for rehabilitation at home of patients with cervical or trochanteric hip fractures. One hundred of 161 consecutive patients returned home directly on discharge from the hospital and were followed up until four months after the fracture by the home care unit (a primary health care centre). Most patients regained their previous functions within four months of their fractures. Patients with cervical fractures consumed less resources for rehabilitation than patients with trochanteric fractures. The total cost per patient was ten times higher for care at a convalescent-home than for rehabilitation at home through primary care. Early at home rehabilitation of elderly patients with hip fractures gives good results at a minimal cost and is thus of advantage both to the patient and to the community.

Observation of Vestibular Asymmetry in a Majority of Patients over 50 Years With Fall-Related Wrist Fractures

Previously, 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.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.

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.

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.

Motor function after selective dorsal rhizotomy: a 10-year practice-based follow-up study.

Aim  The aim of this study was to explore changes in motor function up to 10 years after selective dorsal rhizotomy (SDR).