Patricia Noritake Matsuda

Falls in Multiple Sclerosis

To examine incidence, associated factors, and health care provider (HCP) response to falls in persons with multiple sclerosis (MS).

Understanding Falls in Multiple Sclerosis: Association of Mobility Status, Concerns About Falling, and Accumulated Impairments

Background Falls in people with multiple sclerosis (MS) are a serious health concern, and the percentage of people who restrict their activity because of concerns about falling (CAF) is not known. Mobility function and accumulated impairments are associated with fall risk in older adults but not in people with stroke and have not been studied in people with MS. Objective The purposes of this study were: (1) to estimate the percentage of people who have MS and report falling, CAF, and activity restrictions related to CAF; (2) to examine associations of these factors with fall status; and (3) to explore associations of fall status with mobility function and number of accumulated impairments. Design A cross-sectional survey was conducted. Methods A total of 575 community-dwelling people with MS provided information about sociodemographics, falls, CAF, activity restrictions related to CAF, mobility function, and accumulated impairments. Chi-square statistics were used to explore associations among these factors. Results In all participants, about 62% reported CAF and about 67% reported activity restrictions related to CAF. In participants who did not experience falls, 25.9% reported CAF and 27.7% reported activity restrictions related to CAF. Mobility function was associated with fall status; participants reporting moderate mobility restrictions reported the highest percentage of falls, and participants who were nonwalkers (ie, had severely limited self-mobility) reported the lowest percentage. Falls were associated with accumulated impairments; the participants who reported the highest percentage of 2 or more falls were those with 10 impairments. Limitations This cross-sectional study relied on self-reported falls, mobility, and impairment status, which were not objectively verified. Conclusions Both CAF and activity restrictions related to CAF were common in people with MS and were reported by people who experienced falls and those who did not. The association of fall status with mobility function did not appear to be linear. Fall risk increased with declining mobility function; however, at a certain threshold, further declines in mobility function were associated with fewer falls, possibly because of reduced fall risk exposure.

Understanding physical factors associated with participation in community ambulation following stroke.

Purpose. This study examined the association between impaired physical function and participation in community ambulation following stroke. We hypothesised that participation would be significantly less following stroke, and that physical impairments would be associated with participation. Method. Using a case–control design 30 survivors of stroke aged 45 and older and 30 controls provided health status information and a self-report of participation in community ambulation (number of trips and walking-related activities (WRA) reported prospectively over a 12-day period). The association of physical impairments (strength, range of motion, sensation, muscle tone, vision, and activity limitations (gait speed and performance on complex walking tasks)) with level of participation was analysed using negative binomial regression and goodness of fit. Results. Participants included 30 individuals with and 30 without stroke, average age 68 years, majority were Caucasian women. Average time since stroke was 40 months. Participation in survivors of stroke was characterised by fewer trips and WRA and lower satisfaction (p  <  0.001). Usual gait speed, balance, muscle strength and muscle length were impaired (p  <  0.001) in stroke vs. controls, and associated with number of trips and WRA (p  <  0.05). However, these factors explained less than very little of the variance in participation. Conclusions. While individual factors were associated with level of participation, results failed to accurately predict participation in community ambulation following stroke. Other factors, such as depression, cognition and self-efficacy may be stronger determinants of participation.

Participation in Community Walking Following Stroke: The Influence of Self-Perceived Environmental Barriers

Background Community walking is limited among survivors of stroke; however, the contributing factors are not clearly understood. Objective This study examined the association of features in the environment with frequency of community walking following stroke. Design An observational study design was used, with frequency of community walking data collected prospectively. Method Thirty survivors of stroke (mean age=67 years; mean months since stroke=40), and 30 older adults without stroke (mean age=68 years) participated. Frequency of community walking (number of trips, walking-related activities [WRA], and the ratio of WRA to trips) and satisfaction were measured using self-report. The Environmental Analysis of Mobility Questionnaire (EAMQ) was used to determine frequency of encounter with versus avoidance of environmental features during community walking. Negative binomial and linear regression models were used to analyze the association of environmental features with measures of community walking. Results Survivors of stroke reported reduced community walking and fewer encounters with and greater avoidance of features within 8 dimensions of the environment compared with a control group of adults without stroke. Following stroke, avoidance of features in some environmental dimensions was associated with frequency of community walking as measured by number of trips, number of WRA, and the ratio of WRA to trips. Environmental features explained little of the variability in community walking. Limitations Limitations included a small sample size and limited diversity among participants. This study examined only physical features in the environment and did not include other environmental factors, such as social support, which may influence participation. Conclusions Avoidance of features within some, but not all, environmental dimensions was associated with self-reported frequency of community walking following stroke, suggesting that some environmental features may limit community walking more than others.

The Effects of a Home-Based Exercise Program on Physical Function in Frail Older Adults

Background and PurposeExercise has been shown to improve physical function in frail older adults; however, the effects of exercise may vary with degree of frailty, the format and intensity of the exercise intervention, and level of supervision. This cohort study describes the effects of participation in a 6-week home-based exercise program on measures of physical function as well as exercise-related beliefs, including exercise self-efficacy and outcomes expectation, in frail older adults. MethodsParticipants were 72 frail older adults who participated in a 6-week home-based exercise program supervised by graduate physical therapy students. Individualized home-based exercises targeted strength, flexibility, balance, gait, and cardiovascular fitness. Physical function was measured at baseline and after completion of the 6-week exercise program using the Functional Fitness Test (Biceps Curl, Chair Stand, 8-Foot Up and Go) and velocity on a 4-m walk. Measures of exercise-related beliefs included the Self-Rated Abilities for Health Practices Scale and Exercise Outcome Expectations. OutcomesParticipation in the 6-week home-based exercise program was associated with improvements in measures of physical function, including an average increase of 3 repetitions (35%) on the biceps curl, 2.4 repetitions (59%) on the chair stand, and an average increase of 0.17 m/s (33%) in gait velocity. Average decrease in Timed Up and Go test scores was 5.7 seconds (26%). Scores for exercise-related beliefs also improved (self-efficacy average increase was 7 points [40%], and average increase in outcome expectations was 3 [47%]). DiscussionA supervised 6-week, multidimensional home-based exercise program was safe and associated with improvements in physical and exercise-related belief outcome measures in this cohort study of frail older adults.

Falls Among Adults Aging With Disability

OBJECTIVE To investigate the prevalence of and risk factors for falling among individuals aging with multiple sclerosis (MS), muscular dystrophy (MD), postpolio syndrome (PPS), and spinal cord injury (SCI). DESIGN Cross-sectional survey data from 2009 to 2010 were analyzed. We used forward logistic regression models to examine whether risk factors such as age, sex, mobility level, years since diagnosis, vision, balance, weakness, number of comorbid conditions, and physical activity could distinguish participants who reported falling from those who did not. SETTING Surveys were mailed to community-dwelling individuals who had 1 of 4 diagnoses (MS, MD, PPS, or SCI). The survey response rate was 91%. PARTICIPANTS A convenience sample of community-dwelling individuals (N=1862; age, 18-94y) with MS, MD, PPS, or SCI in the United States. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Self-reported fall within the last 6 months. RESULTS Fall prevalence for people with MS (54%), MD (70%), PPS (55%), and SCI (40%). Across all 4 groups, fall rates peaked in middle age (45-64y) and among people with moderate mobility limitations. Seven risk factors differentiated participants who fell from those who did not: mobility level, imbalance, age, curvilinear age (age(2)), number of comorbid conditions, duration of diagnosis, and sex. The models differed across diagnostic groups. CONCLUSIONS People aging with long-term physical disabilities experience unique challenges that affect their risk of falls. A better understanding of the frequency, severity, and risk factors of falls across diagnostic groups is needed to design and implement customized, effective fall prevention and management programs for these individuals.

Expanding the Scoring System for the Dynamic Gait Index

Background The Dynamic Gait Index (DGI) measures the capacity to adapt gait to complex tasks. The current scoring system combining gait pattern (GP) and level of assistance (LOA) lacks clarity, and the test has a limited range of measurement. Objective This study developed a new scoring system based on 3 facets of performance (LOA, GP, and time) and examined the psychometric properties of the modified DGI (mDGI). Design A cross-sectional, descriptive study was conducted. Methods Nine hundred ninety-five participants (855 patients with neurologic pathology and mobility impairments [MI group] and 140 patients without neurological impairment [control group]) were tested. Interrater reliability was calculated using kappa coefficients. Internal consistency was computed using the Cronbach alpha coefficient. Factor analysis and Rasch analysis investigated unidimensionality and range of difficulty. Internal validity was determined by comparing groups using multiple t tests. Minimal detectable change (MDC) was calculated for total score and 3 facet scores using the reliability estimate for the alpha coefficients. Results Interrater agreement was strong, with kappa coefficients ranging from 90% to 98% for time scores, 59% to 88% for GP scores, and 84% to 100% for LOA scores. Test-retest correlations (r) for time, GP, and LOA were .91, .91, and .87, respectively. Three factors (time, LOA, GP) had eigenvalues greater than 1.3 and explained 79% of the variance in scores. All group differences were significant, with moderate to large effect sizes. The 95% minimal detectable change (MDC95) was 4 for the mDGI total score, 2 for the time and GP total scores, and 1 for the LOA total score. Limitations The limitations included uneven sample sizes in the 2 groups. The MI group were patients receiving physical therapy; therefore, they may not be representative of this population. Conclusions The mDGI, with its expanded scoring system, improves the range, discrimination, and facets of measurement related to walking function. The strength of the psychometric properties of the mDGI warrants its adoption for both clinical and research purposes.

Investigating the Validity of the Environmental Framework Underlying the Original and Modified Dynamic Gait Index

Background The modified Dynamic Gait Index (mDGI), developed from a person-environment model of mobility disability, measures mobility function relative to specific environmental demands. The framework for interpreting mDGI scores relative to specific environmental dimensions has not been investigated. Objective The aim of this study was to examine the person-environmental model underlying the development and interpretation of mDGI scores. Design This was a cross-sectional, descriptive study. Methods There were 794 participants in the study, including 140 controls. Out of the total study population, 239 had sustained a stroke, 140 had vestibular dysfunction, 100 had sustained a traumatic brain injury, 91 had gait abnormality, and 84 had Parkinson disease. Exploratory factor analysis was used to investigate whether mDGI scores supported the 4 environmental dimensions. Results Factor analysis showed that, with some exceptions, tasks loaded on 4 underlying factors, partially supporting the underlying environmental model. Limitations Limitations of this study included the uneven sample sizes in the 6 groups. Conclusions Support for the environmental framework underlying the mDGI extends its usefulness as a clinical measure of functional mobility by providing a rationale for interpretation of scores that can be used to direct treatment and infer change in mobility function.

Evidence for the validity of the modified dynamic gait index across diagnostic groups

Background The modified Dynamic Gait Index (mDGI) measures the capacity to adapt gait to complex tasks utilizing 8 tasks and 3 facets of performance. The measurement stability of the mDGI in specific diagnostic groups is unknown. Objective This study examined the psychometric properties of the mDGI in 5 diagnostic groups. Design This was a cross-sectional, descriptive study. Methods A total of 794 participants were included in the study: 140 controls, 239 with stroke, 140 with vestibular dysfunction, 100 with traumatic brain injury, 91 with gait abnormality, and 84 with Parkinson disease. Differential item functioning analysis was used to examine the comparability of scores across diagnoses. Internal consistency was computed using Cronbach alpha. Factor analysis was used to examine the factor loadings for the 3 performance facet scores. Minimal detectable change at the 95% confidence level (MDC95%) was calculated for each of the groups. Results Less than 5% of comparisons demonstrated moderate to large differential item functioning, suggesting that item scores had the same order of difficulty for individuals in all 5 diagnostic groups. For all 5 patient groups, 3 factors had eigenvalues >1.0 and explained 80% of the variability in scores, supporting the importance of characterizing mobility performance with respect to time, level of assistance, and gait pattern. Limitations There were uneven sample sizes in the 6 groups. Conclusions The strength of the psychometric properties of the mDGI across the 5 diagnostic groups further supports the validity and usefulness of scores for clinical and research purposes. In addition, the meaning of a score from the mDGI, regardless of whether at the task, performance facet, or total score level, was comparable across the 5 diagnostic groups, suggesting that the mDGI measured mobility function independent of medical diagnosis.

Participation as an Outcome in Multiple Sclerosis Falls-Prevention Research Consensus Recommendation from the International MS Falls Prevention Research Network

Selecting the outcomes for an intervention trial is a key decision that influences many other aspects of the study design. One of the major tasks during the 3-day inaugural meeting of the International MS Falls Prevention Research Network was to identify the key outcomes for the falls-prevention intervention that was being designed by the Network members for testing across their multiple sites. Through a nominal group process, meeting participants described how engagement in important, meaningful everyday activities, beyond traditional basic and instrumental activities of daily living, should be a long-term outcome of a successful falls-prevention intervention for people with MS. Post-meeting work, which involved literature reviews and comparisons of definitions of major constructs identified during the meeting discussions, led to the consensus recommendation of including participation as a long-term outcome in MS falls-prevention interventions. Participation reflects involvement in a life situation. This article explains the rationale for this recommendation and presents four measures that have the potential for use in tracking long-term participation outcomes in MS falls-prevention research.