Victoria Hood

The biomechanical functional demand placed on knee and hip muscles of older adults during stair ascent and descent

Age-related decline in physical capabilities may lead to older adults experiencing difficulty in performing everyday activities due to high demands placed on the muscles of their lower extremity. This study aimed to determine the biomechanical functional demand in terms of joint moments and maximal muscle capabilities at the knee and hip joints while older adults performed stair ascent (SA) and stair descent (SD). Eighty-four healthy older adults aged 60-88 years were tested. A torque dynamometer attached to a purpose-built plinth was utilized to measure muscle moments at the knee and hip joints. Participants also underwent full body 3-D biomechanical assessment of stair ascent and descent using an 8-camera VICON system (120Hz) with 3 Kistler force plates. Stair negotiation required knee extensor moments in excess of the maximum isometric muscle strength available (SA 103%, SD 120%). For the hip, the levels of demand were high, but were slightly lower than those of the knee joint. Stair negotiation placed a high level of demand on the knee extensors with demand in SA reaching maximal isometric capacity and demand in SD exceeding maximal isometric capacity. The levels of demand leave little reserve capacity for the older adult to draw on in unexpected situations or circumstances.

Towards a design tool for visualizing the functional demand placed on older adults by everyday living tasks

This paper discusses the development of a design tool using data calculated from the biomechanical functional demand on joints in older adults during activities of daily living, portrayed using a visual ‘traffic-light’ system. Whole body movements of 84 older adults were analysed using a 3D motion capture system and reaction forces were measured by force platforms, and translated into a 3D software model. Although originally intended as a tool for designers, the early evaluation of this method of visualizing the data suggests that it may be of value across those involved in the professional care of older adults.

The Association of Specific Executive Functions and Falls Risk in People with Mild Cognitive Impairment and Early-Stage Dementia

Background/Aims: Impairment in executive function is associated with a heightened risk for falls in people with mild cognitive impairment (MCI) and dementia. The purpose of this study was to determine which aspects of executive function are associated with falls risk. Methods: Forty-two participants with a mean age of 81.6 years and a diagnosis of MCI or mild dementia completed five different executive function tests from the computerised CANTAB test battery and a comprehensive falls risk assessment. Results: A hierarchical regression analysis showed that falls risk was significantly associated with spatial memory abilities and inhibition of a pre-potent response. Conclusion: The concept of executive function may be too general to provide meaningful results in a research or clinical context, which should focus on spatial memory and inhibition of a pre-potent response.

Interventions incorporating physical and cognitive elements to reduce falls risk in cognitively impaired older adults

BackgroundCognitive impairment is a risk factor for falls. Older adults with cognitive impairment (such as dementia) have an increased risk of falling compared with age-matched individuals without a cognitive impairment. To reduce falls in this population, interventions could theoretically target and train both physical and cognitive abilities. Combining and addressing cognitive components in falls rehabilitation is a novel and emerging area of healthcare. ObjectivesThe objective of this review was to identify the effectiveness of combined cognitive and physical interventions on the risk of falls in cognitively impaired older adults. Inclusion criteria Types of participantsOlder persons who were 65 years or older and identified as having a cognitive impairment either through diagnosis or assessment of global cognition. Types of intervention(s)Multifactorial or multiple interventions where physical and cognitive elements were combined was compared against standard care or a single element intervention. Types of studiesRandomized controlled trials (RCTs), controlled clinical trials and experimental studies in which randomization was used. OutcomesOutcomes related to falls, including falls rate, specific falls risk measures (i.e. Physiological Profile Assessment) or related clinical outcome measures (i.e. Timed Up and Go test, Tinetti and gait speed). Search strategyA three-step search strategy was utilized in this review, including search of electronic databases: CENTRAL, JBISRIR, MEDLINE, EMBASE, AMED, CINAHL and PsychINFO. Initial keywords used were dementia, cognitive impairment, memory loss, exercise, rehabilitation and accidental falls. Grey literature (Google Scholar) and trials registers (Current Controlled Trials) searches were also completed. Methodological qualityThe methodological quality of included studies was assessed using Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) software. Data extractionData was extracted from articles included in the review using the standardized data extraction tool from JBI-MAStARI. Data synthesisA quantitative meta-analysis was performed where possible. Otherwise, data synthesis was in the form of narrative review. Sub-group analysis according to level of cognitive impairment was completed where possible. ResultsEight RCTs were included in this review; they evaluated the effectiveness of multicomponent exercise programs, including physical and cognitive activities, music-based group exercise and mind-body tai chi on falls related outcomes. Most of the studies were of good quality with an average quality score of 7.5. Four studies reported effectiveness based on the number of falls, half of which reported a significant difference between the groups, but pooling of results into meta-analysis was not possible because of differences in reporting of the outcome. Falls related outcomes that were combined in meta-analysis included balance (Berg balance scale), functional mobility (Timed Up and Go) and gait speed (m/s). There was a statistically significant improvement in balance and gait speed following the intervention; however, the studies were too heterogeneous to be included in the analysis from the functional mobility results. ConclusionOverall, multicomponent interventions incorporating both physical and cognitive components demonstrated positive effects on balance, functional mobility and gait speed when compared with a control and had significantly better effect on balance and gait speed within mild cognitive impairment populations.

InclusiveCAD: a software resource for designers

Rapid and unprecedented population ageing poses a serious social and economic challenge across the developed world. Shifts in dependency ratios point to escalating welfare and pensions costs which require radical and imaginative responses from Government and industry. The key to this is maintaining a healthy population that is able and willing to work longer before retirement and can remain independent for as long as possible afterwards as well as bringing disabled people into mainstream life and employment. ontributions focus on the following topics. This chapter focuses on design issues for a more inclusive world, explaining InclusiveCA as a software resource for designers involved in the development and evaluation of truly usable and accessible systems for users with special needs.

Understanding the theoretical underpinning of the exercise component in a fall prevention programme for older adults with mild dementia: a realist review protocol

BackgroundOlder adults with mild dementia are at an increased risk of falls. Preventing those at risk from falling requires complex interventions involving patient-tailored strength- and balance-challenging exercises, home hazard assessment, visual impairment correction, medical assessment and multifactorial combinations. Evidence for these interventions in older adults with mild cognitive problems is sparse and not as conclusive as the evidence for the general community-dwelling older population. The objectives of this realist review are (i) to identify the underlying programme theory of strength and balance exercise interventions targeted at those individuals that have been identified as falling and who have a mild dementia and (ii) to explore how and why that intervention reduces falls in that population, particularly in the context of a community setting. This protocol will explain the rationale for using a realist review approach and outline the method.MethodsA realist review is a methodology that extends the scope of a traditional narrative or systematic evidence review. Increasingly used in the evaluation of complex interventions, a realist enquiry can look at the wider context of the intervention, seeking more to explain than judge if the intervention is effective by investigating why, what the underlying mechanism is and the necessary conditions for success. In this review, key rough programme theories were articulated and defined through discussion with a stakeholder group. The six rough programme theories outlined within this protocol will be tested against the literature found using the described comprehensive search strategy. The process of data extraction, appraisal and synthesis is outlined and will lead to the production of an explanatory programme theory.DiscussionAs far as the authors are aware, this is the first realist literature review within fall prevention research and adds to the growing use of this methodology within healthcare. This synthesis of evidence will provide a valuable addition to the evidence base surrounding the exercise component of a fall intervention programme for older adults with mild dementia and will ultimately provide clinically relevant recommendations for improving the care of people with dementia.Systematic review registrationPROSPERO CRD42015030169

Upper limb joint position sense during shoulder flexion in healthy individuals: a pilot study to develop a new assessment method:

Background Altered shoulder joint position sense (JPS) following shoulder injury has been demonstrated in the literature and may increase the risk of injury. A JPS assessment targeting the shoulder will provide the clinician with an objective marker. The present study aimed to develop an assessment method of JPS using an active relocation test (ART). Methods In total, 40 healthy participants were recruited. A laser-pointer attached to the index finger during an ART allowed measurement (mm) of JPS by measuring the distance between the target and relocated position. Participants were blindfolded and stood an arm’s length (approximately 1 m) away from the wall. Whilst keeping the wrist in neutral and elbow extended, the participant actively moved to the target position (90° glenohumeral flexion), held for 5 seconds, returned their arm to their side and actively returned to the target position. A mean was calculated from three trials to provide an ART score. Results The mean (SD) dominant and nondominant ART score was 89.2 (SD 35.5) mm (95% confidence interval = 77.87 mm to 100.5 mm) and 94.1 (34.5) mm (95% confidence interval = 83.1 mm to 105.2 mm), respectively. Arm dominance did not significantly affect ART scores. Conclusions No significant difference was demonstrated between the dominant and nondominant arm using an ART assessing JPS acuity. Further studies are needed to establish inter-rater and intra-rater reliability.

The effectiveness of surgery for adults with hallux valgus deformity: a systematic review protocol

Objective To establish the effectiveness of surgery compared to conservatory management for adults with hallux valgus. Background Hallux valgus (HV) is a complex progressive triplanar forefoot deformity, characterized by a valgus deviation of the big toe, a metatarsus primus varus and a medial prominence on its head. It develops gradually due to interaction of biomechanical factors, structural anomalies, systemic diseases, hereditary predispositions and wearing of inappropriate footwear.1 Hallux valgus is common foot deformity. One published systematic review with meta‐analysis on this topic reported the wide variation in prevalence of HV in analyzed primary studies and confirmed higher prevalence of HV in woman and older adults. They found that HV deformity affects on average 23% of adults aged 18‐65 years and 35.7% of older adults aged over 65 years.2 The patients usually complain about pain, difficulties during walking and problems with footwear. Nix et al.3 found in a systematic review that there are biomechanical changes in the gait of patients with HV. These included reduced peak of dorsiflexion and rear foot supination during terminal stance. In older patients with HV they described a less stable gait pattern with reduced velocity and stride length during walking on irregular surface. Over the past 80 years, HV problems have been dealt primarily by surgeons specialized in orthopaedics. In the available literature more than 130 surgical procedures have been described, correcting the axis of the first ray.4 Although the most effective therapy is generally prevention, in clinical practice many patients with foot disorders visit a healthcare professional at a more advanced stage of their problem. In mild stages of HV, conservative treatment is recommended and this usually involve the use of different type of orthoses, e.g. night splints, or taping. Other options are physical therapy, including manual therapy, mobilization, foot exercise, sensomotoric training, thermotherapy, hydrotherapy and ultrasound therapy. Brantingham et al.5 found that a progressive mobilization of the first metatarsophalangeal joint had positive effects on pain and Foot Function Index (FFI). Du Plessis et.al.6 tested the effect of a modified structured protocol of manual and manipulative therapy (the Brantingham protocol) on HV related pain (visual analog scale), FFI and range of hallux dorsiflexion (goniometry) and compared to orthotic therapy using a night splint. They did not find any significant differences between these two interventions after three weeks in patients with mild to moderate HV. Bayar et.al.7 reported that eight‐weeks taping of the first ray and forefoot combined with foot exercise decreased hallux valgus angle (goniometry), foot pain (visual analog scale), and improved walking ability (the walking ability scale) by at least one grade in the patients with HV. Radovic and Shah8 demonstrated that use of botulinum toxin A injection reduced the hallux abducto valgus deformity clinically and radiographically and also its associated pain in a 43‐year‐old woman presented with a chief complaint of bilateral bunion pain. In severe stages of this condition surgery is often used. The aim of HV surgery is either to correct the bony or soft tissues or both tissues.9 Surgical procedures for HV include simple bunionectomy, various soft tissue procedures, metatarsal and phalangeal osteotomies, resection arthroplasty and metatarsophalangeal arthrodesis.10 Bunionectomy is a simple procedure based on shaving off the medial prominence on the medial side of the first metatarsophalangeal joint. Arthroplasty is combination of bunionectomy and removal of part of the proximal phalanx; this procedure is indicated in severe stages of HV and leaves a flexible joint, but shorter first ray. Arthrodesis is more radical procedure than arthroplasty and is based on excision of head of first MTPJ and fusion of the operated segment. Osteotomy of the first metatarsus includes proximal and distal procedures. Distal osteotomy, e.g. Chevron osteotomy, is indicated in patients with mild HV and proximal osteotomy, such as scarf osteotomy, in severe stages of HV deformity. Soft technique procedures often complement the bony procedures.9,11,12 The effectiveness of HV treatment is verified in clinical practice, in most cases by radiological examination (Hallux valgus angle and 1,2‐intermetatarsal angle), visual analog scale (pain), assessment scoring system developed by American Orthopaedic Foot and Ankle Society (pain, satisfaction, range of movement), FFI, etc.9 In 1979, Stokes et al.13 did the first evaluation of the effect of HV surgery using biomechanical analysis of gait. During the last 30 years, many other researchers have used different type of motion analysis software to evaluate the impact of HV surgery on dynamic and kinematic parameters of gait.13‐17 Many primary studies have evaluated effect of treatment of HV surgery, however to date there is no systematic review which has studied the effect of HV surgery or conservative management on gait, pain or function.

P-087: The Balance and the Mind study: baseline data

OBJECTIVES: The purpose of the study was to establish falls risk factors for people with mild cognitive impairment and mild dementia. METHODS: Survey of 76 people recruited from Memory Clinics (n=56), Falls Services (n=12), Community Geriatricians (n=4), Cognitive Stimulation Therapy groups (n=2), and a Rehabilitation Unit (n=2). The assessments included falls risk, the Falls Efficacy Scale International (FESi), the Montreal Cognitive Assessment (MoCA) as well as neuropsychological tests. RESULTS: Mean age was 80.9 years (SD 6.5, age range: 67-94 years). The sample included 45% men, 98% had a white ethnic background and 48% lived alone. Mean MoCA score was 20.95 (SD 3.6), and 26 people (34%) had between 1 and 24 falls (mean 3.04; SD 4.65). Regarding any fall participants had in the past, 41% sustained an injury, 36% needed medical attention and 32% had been admitted to hospital as a consequence of a fall. The mean FESi score was 27 (SD 10.6) with 59% scoring >23, which is associated with a high fear of falling. The mean Timed Up and Go score was 16.0 seconds with 44% scoring ≥13.5 seconds, which is associated with high risk of falling. The mean Berg Balance score was 46 with 28% scoring ≤40, which is associated with a 100% chance of future falls. All assessments were acceptable to the particpants. CONCLUSIONS: The proportion of falls and falls risk factors was quite high in this population, which reflects findings from similar studies. Specialized falls prevention intervention should take these factors into account.

An investigation into hip muscle strength and biomechanical moments produced during chair sit down in older adults

Background Muscle strength is an important component of performance and is a vital measure for characterisation of functional capability in everyday activities. Currently, there is little evidence with regard to the impact of loss of strength at the hip joint on the ability to perform a chair sit down activity in older adults. Method A custom-built torque dynamometer was used to measure muscle strength of hip extensors in 82 older adults who were aged 60 years and over. Isometric strength was measured at three positions namely 45°, 30° and 0° of hip flexion within the joint range of motion. Biomechanical analysis with Vicon motion analysis system and Kistler force platforms was performed to determine functional moments produced during chair sit down. Results Muscle strength decreased with increasing age for hip extensors in all the three joint positions. The 80 year olds had lower strengths (22% ± 3%) compared to those in the younger age cohorts and the differences were statistically significant. (P value <0.05) Hip extensor strength was significantly correlated with functional moments with a correlation coefficient r = 0.47. (P value = Conclusion This investigation showed that poor hip extensor strength was associated with reduced functional moments produced at hip during chair sit down in older adults. Hence, loss of muscle strength with advancing age is likely to increase the demands of performing this activity in older adults.