Jonathan Marsden

Identification of Risk Factors for Falls in Multiple Sclerosis: A Systematic Review and Meta-Analysis

Background Falls are a significant issue in people with multiple sclerosis (MS), with research demonstrating fall rates of more than 50%. Purpose The purpose of this study was to evaluate the risk factors associated with falling in people with MS. Data Sources Mixed search methods were used, including computer-based and manual searches. Additionally, hand searches of reference lists and conference abstracts were performed. All literature published from the sources earliest date to January 2012 was included; only full-text English-language sources (or those where a translation was available) were included. Study Selection Eligibility criteria specified articles evaluating any aspect of fall risk in adults with a confirmed MS diagnosis, where the incidence of falling as determined by prospective or retrospective participant report was included. Data Extraction Data were extracted independently by 2 reviewers using a written protocol and standardized extraction documentation. Detailed assessment of each article was independently undertaken by both reviewers, including assessment of study quality using an adaptation of the Newcastle Ottawa Scale plus extraction of key data (participant characteristics, fall incidence, and outcomes). Data Synthesis The final review comprised 8 articles with a total of 1,929 participants; 1,037 (53.75%) were classified as fallers. Eighteen different risk factors were assessed within the included studies. Meta-analysis demonstrated an increase in fall risk associated with impairments of balance and cognition, progressive MS, and use of a mobility aid. Narrative review of the qualitative articles and those factors where meta-analysis was not possible also was undertaken. Limitations Variation in assessment, analysis, and reporting methods allowed meta-analysis for only 4 factors. Conclusion There is limited evidence of the factors associated with fall risk in people with MS. Further methodologically robust studies are needed.

Risk factors for falls in multiple sclerosis: an observational study.

Background: People with multiple sclerosis (MS) experience frequent falls, which are associated with impairments and limitations to activities and participations. Objective: The objective of this paper is to evaluate falls risk factors using robust clinical measures. Methods: A total of 150 individuals (confirmed MS diagnosis, Expanded Disability Status Scale (EDSS) 3.5–6.5) were recruited, with 148 participants included in the final analysis. Demographic data were collected and performance assessed in eight predictor measures (Physiological Profile Assessment (PPA), Brief Ataxia Rating scale, Ashworth scale (Ashworth), Modified Falls Efficacy scale, Symbol Digit Modalities Test, dual-task interference, lying/standing blood pressure, static/dynamic visual acuity). Participants prospectively recorded falls over three months using a daily diary. People were classified as “fallers” based on reports of ≥ two falls. Results: A total of 104 participants recorded 672 falls; 78 (52.7%) reported ≥ two falls. Continence issues, previous falls history and use of prescribed medications were each associated with increased risk of being a “faller”. Ashworth and PPA risk score contributed significantly to a logistic regression model predicting faller/non-faller classification. The reduced model (Ashworth, PPA, EDSS) showed fair-to-good predictive ability (ROC c-statistic 0.73, sensitivity 70%, specificity 69%). Conclusion: This study confirms the high prevalence of falls in ambulant people with MS. Important potentially modifiable risk factors are identified, suggesting aspects to target in falls interventions.

Patients’ Experience of therapeutic footwear whilst living at risk of neuropathic diabetic foot ulceration: an interpretative phenomenological analysis (IPA)

BackgroundPrevious work has found that people with diabetes do not wear their therapeutic footwear as directed, but the thinking behind this behaviour is unclear. Adherence to therapeutic footwear advice must improve in order to reduce foot ulceration and amputation risk in people with diabetes and neuropathy. Therefore this study aimed to explore the psychological influences and personal experiences behind the daily footwear selection of individuals with diabetes and neuropathy.MethodsAn interpretative phenomenological analysis (IPA) approach was used to explore the understanding and experience of therapeutic footwear use in people living at risk of diabetic neuropathic foot ulceration. This study benefited from the purposive selection of a small sample of four people and used in-depth semi structured interviews because it facilitated the deep and detailed examination of personal thoughts and feelings behind footwear selection.FindingsFour overlapping themes that interact to regulate footwear choice emerged from the analyses: a) Self-perception dilemma; resolving the balance of risk experienced by people with diabetes and neuropathy day to day, between choosing to wear footwear to look and feel normal and choosing footwear to protect their feet from foot ulceration; b) Reflective adaption; The modification and individualisation of a set of values about footwear usage created in the minds of people with diabetes and neuropathy; c) Adherence response; The realignment of footwear choice with personal values, to reinforce the decision not to change behaviour or bring about increased footwear adherence, with or without appearance management; d) Reality appraisal; A here and now appraisal of the personal benefit of footwear choice on emotional and physical wellbeing, with additional consideration to the preservation of therapeutic footwear.ConclusionFor some people living at risk of diabetic neuropathic foot ulceration, the decision whether or not to wear therapeutic footwear is driven by the individual ‘here and now’, risks and benefits, of footwear choice on emotional and physical well-being for a given social context.

Rater reliability and scoring duration of the Quality Function Measure in ambulant children with hyperkinetic movement disorders

To examine intra‐ and interrater reliability/agreement, and time taken to score, when the Quality Function Measure (QFM) is applied to children with hyperkinetic movement disorders (HMD; e.g. dystonia, chorea, athetosis, tremor, and myoclonus).

Effect of a Forefoot Off-loading Postoperative Shoe on Muscle Activity, Posture, and Static Balance

BACKGROUND We investigated whether a forefoot off-loading postoperative shoe (FOPS) alters standing posture, ankle muscle activity, and static postural sway and whether any effects are altered by wearing a shoe raise on the contralateral side. METHODS Posture, ankle muscle activity, and postural sway were compared in 14 healthy participants wearing either a FOPS or a control shoe with or without a contralateral shoe raise. Participants were tested under different sensory and support surface conditions. Additionally, reductions in peak pressure under the forefoot while walking were assessed with and without a contralateral shoe raise to determine whether the FOPS continued to achieve its primary off-loading function. RESULTS Compared with the control condition, wearing a FOPS moved the center of pressure posteriorly, increased tibialis anterior muscle activity, and reduced ankle plantarflexor activity. These changes decreased when a contralateral shoe raise was added. No difference in postural sway was found between footwear conditions. Forefoot peak pressure was always reduced when wearing the FOPS. CONCLUSIONS The posterior shift in center of pressure toward and behind the ankle joint axis is believed to result in the increase in tibialis anterior muscle activity that now acts as the primary stabilizer around the ankle. Instability may, therefore, increase in patients with weak tibialis anterior muscles (eg, diabetic neuropathy) who need to wear offloading devices for ulcer management. We suggest that the addition of a contralateral shoe raise fitted with a FOPS may potentially be beneficial in maintaining stability while off-loading the forefoot in this patient group.

Exploring the effect of pelvic belt configurations upon athletic lumbopelvic pain

Background: Lumbopelvic injuries are often refractory to treatment and can limit return to sport. Research shows that 50 Newtons (N) of force applied transversely to the pelvis improves lumbopelvic stability and pain. This study applies transverse and diagonal forces to the pelvis in athletes with lumbopelvic pain, and investigates effects on pain and function. Objective: To investigate the effects of transverse and diagonal compressive forces applied to the pelvis of athletes with lumbopelvic pain Study Design: A randomized, repeated measures design using 20 athletes with lumbopelvic pain. Methods: No belt and four pelvic belt configurations (50 N force) were tested. Outcome measures were: resting pain, pain on active straight leg raise (ASLR), resisted hip adduction force and pain on 1-metre broad jump. Force on the adduction test was determined via load cell. Results: Data were analyzed using repeated measures ANOVA. Squeeze test showed significant effect of condition F (4, 76) = 2.7, P < 0.05. On ASLR ipsilateral to the side of pain, pain decreased across conditions (F (4, 76) = 2.5 P = 0.05). Conclusion: Results suggest application of diagonal forces towards the site of pain may have additional benefits in improving pain and function. Such information may inform the development of an orthosis. Clinical relevance The results may be used clinically to determine the effectiveness of different belt placements (with belts or straps) in managing athletic lumbopelvic pain. The results offer an alternative to the application of transverse belts, and may inform new approaches in the development of orthotics.

The use of dynamic elastomeric fabric orthosis suits as an orthotic intervention in the management of children with neuropathic onset scoliosis: A retrospective audit of routine clinical case notes.

BackgroundTo date the main treatment approach for neuropathic onset scoliosis has utilised thoracic lumbar sacral orthoses (TLSO) to stabilize the spine and enable stable sitting. Dynamic elastomeric fabric orthoses (DEFOs) may achieve both of these aims if used as an early intervention. Due to a lack of evidence in this area, a retrospective audit of case notes was undertaken to understand current orthotic practice investigating the usage, outcomes and clinical characteristics of treated children with neuropathic onset scoliosis. Clinical notes of 180 children at risk for, or identified with, scoliosis were audited using a search matrix to identify diagnostic group, spinal muscle tone, Gross Motor Functional Classification Scale (GMFCS) level, orthotic treatment modalities, scoliosis specific data, surgical interventions, adaptive technologies used, and outcome measurements reported.ResultsOf the 180 notes examined, 85 were male; mean age nine years one month [SD four years seven months]. Spinal muscle tone was reported in 137 cases: 122/137 presented as low tone, 4/137 high tone, 6/137 fluctuating tone and 5/137 typical tone. Scoliosis was confirmed in (77/180) of whom (39/77) used a DEFO. Another (43/180) had a spinal curve developing, of whom (22/43) used a DEFO. The remaining (60/180) had no report of spinal curvature, but used a DEFO as a preventative measure. GMFCS scores were reported for 49 children of whom 14/49 were graded as level 4 and 17/49 level 5. Of the children with scoliosis who had spinal curve shapes reported, 48/60 had a C-shape presentation and 12/60 had an S-shape.ConclusionsThe findings confirm previously reported papers in children with neuropathic onset scoliosis in relation to curve shape and GMFCS levels. It provides some evidence of the role DEFOs may have in the management of these children, and highlights the need for further research in this area due to the lack of peer-reviewed publications.

The Use of a Dynamic Elastomeric Fabric Orthosis in Supporting the Management of Athletic Pelvic and Groin Injury.

CONTEXT Athletic pelvic and groin injuries are a common yet challenging problem. Pelvic belts have been successfully used to reduce pain and improve function but are not a practical solution for athletes. Therefore, there is scope to explore the use of a more dynamic intervention developed to aid in the management of this type of injury. OBJECTIVES To undertake a preliminary investigation into the effectiveness of a dynamic elastomeric fabric orthosis (DEFO) in supporting the management of athletic pelvic and groin injury. DESIGN A case series with an AB design. Daily assessments were undertaken over 15 days; the onset of intervention was randomized with a minimum baseline period of 6 d. Follow-up assessment was undertaken after 1 mo. SETTINGS Community and university. PARTICIPANTS 8 athletes presenting with pelvic or groin injury confirmed through clinical screening. INTERVENTION A bespoke DEFO. MAIN OUTCOME MEASURES Force produced on bilateral resisted hip adduction and self-scored pain (using a numerical rating scale of 0-10) at rest and during an active straight-leg raise and a broad jump. RESULTS In 7 cases a significant improvement was observed on at least 1 measure (2-SD method, celeration line, and/or the point of nonoverlapping data). The remaining case showed minimal symptoms during testing.

Superficial warming and cooling of the leg affects walking speed and neuromuscular impairments in people with spastic paraparesis.

BACKGROUND People with hereditary and spontaneous spastic paraparesis (HSSP) report that their legs are stiffer and walking is slower when their legs are cold. OBJECTIVES This study explored the effects of prolonged superficial cooling and warming of the lower leg on walking speed and local measures of neuromuscular impairments. METHODS This was a randomised pre- and post-intervention study of 22 HSSP participants and 19 matched healthy controls. On 2 separate occasions, one lower leg was cooled or warmed. Measurements included walking speed and measures of lower limb impairment: ankle movement, passive muscle stiffness, spasticity (stretch reflex size), amplitude and rate of force generation in dorsi- and plantarflexors and central and peripheral nerve conduction time/velocity. RESULTS For both participants and controls, cooling decreased walking speed, especially for HSSP participants. For both groups, cooling decreased the dorsiflexor rate and amplitude of force generation and peripheral nerve conduction velocity and increased spasticity. Warming increased dorsiflexor rate of force generation and nerve conduction velocity and decreased spasticity. CONCLUSIONS Superficial cooling significantly reduced walking speed for people with HSSP. Temperature changes were associated with changes in neuromuscular impairments for both people with spastic paraparesis and controls. This study does not support the use of localised cooling in rehabilitation for people with spastic paraparesis as reported in other neurological conditions. Rehabilitation interventions that help prevent heat loss (insulation) or improve limb temperature via passive or active means, particularly when the legs and/or environment are cool, may benefit people with spastic paraparesis.

Effects of the site and extent of plantar cutaneous stimulation on dynamic balance and muscle activity while walking.

BACKGROUND Previous studies have demonstrated that stimulating the cutaneous plantar sensory receptors of the foot through textured insoles improves human balance and walking. This study investigated the effect of medial and lateral zoned textured insoles using tibialis anterior/peroneus longus surface electromyographic activity and Centre-of-Pressure as indicators of postural stability while walking. METHODS 15 asymptomatic subjects were tested using a within-subject randomised repeated measures design. The effect of lateral and medial zoned insoles of varying heights (control, 2, 4 and 6mm) on stability while walking under normal and impaired visual conditions was assessed. RESULTS Impaired vision resulted in an increase in foot CoP variability while walking (p<0.05). The laterally zoned insole was associated with a significant (repeated measures ANOVA p<0.05) increase in the rate of medial-lateral CoP change. CONCLUSION These findings suggest that the site of stimulation of the plantar foot cutaneous receptors may increase postural instability during walking. This should be considered in the design of insoles that aim to improve balance and reduce falls risk. The importance of vision in balance control has been highlighted and using impaired vision may serve as a way of trialling clinical products in the healthy population.