Army aviation maintenance engineering manual [microform] : weight and balance.

"29 August 1986."

Guidelines for filming digital camera video clips for the assessment of gait and movement disorders by teleneurology

Digital still cameras capable of filming short video clips are readily available, but the quality of these recordings for telemedicine has not been reported. We performed a blinded study using four commonly available digital cameras. A simulated patient with a hemiplegic gait pattern was filmed by the same videographer in an identical, brightly lit indoor setting. Six neurologists viewed the blinded video clips on their PC and comparisons were made between cameras, between video clips recorded with and without a tripod, and between video clips filmed on high- or low-quality settings. Use of a tripod had a smaller effect than expected, while images taken on a high-quality setting were strongly preferred to those taken on a low-quality setting. Although there was some variability in video quality between selected cameras, all were of sufficient quality to identify physical signs such as gait and tremor. Adequate-quality video clips of movement disorders can be produced with low-cost cameras and transmitted by email for teleneurology purposes.

Visual signs and symptoms of progressive supranuclear palsy

Progressive supranuclear palsy is a rare, degenerative brain disorder and the second most common syndrome in which the patient exhibits 'parkinsonism', that is, a variety of symptoms involving problems with movement. General symptoms include difficulties with gait and balance; the patient walking clumsily and often falling backwards. The syndrome can be difficult to diagnose and visual signs and symptoms can help to separate it from closely related movement disorders such as Parkinson's disease, multiple system atrophy, dementia with Lewy bodies and corticobasal degeneration. A combination of the presence of vertical supranuclear gaze palsy, fixation instability, lid retraction, blepharospasm and apraxia of eyelid opening and closing may be useful visual signs in the identification of progressive supranuclear palsy. As primary eye-care practitioners, optometrists should be able to identify the visual problems of patients with this disorder and be expected to work with patients and their carers to manage their visual welfare.

Mobility changes in older age: neuropsychological, neurophysiological and cognitive predictors of successful adaptation in a real world scenario

The aims of this thesis were to investigate the neuropsychological, neurophysiological, and cognitive contributors to mobility changes with increasing age. In a series of studies with adults aged 45-88 years, unsafe pedestrian behaviour and falls were investigated in relation to i) cognitive functions (including response time variability, executive function, and visual attention tests), ii) mobility assessments (including gait and balance and using motion capture cameras), iii) motor initiation and pedestrian road crossing behavior (using a simulated pedestrian road scene), iv) neuronal and functional brain changes (using a computer based crossing task with magnetoencephalography), and v) quality of life questionnaires (including fear of falling and restricted range of travel). Older adults are more likely to be fatally injured at the far-side of the road compared to the near-side of the road, however, the underlying mobility and cognitive processes related to lane-specific (i.e. near-side or far-side) pedestrian crossing errors in older adults is currently unknown. The first study explored cognitive, motor initiation, and mobility predictors of unsafe pedestrian crossing behaviours. The purpose of the first study (Chapter 2) was to determine whether collisions at the near-side and far-side would be differentially predicted by mobility indices (such as walking speed and postural sway), motor initiation, and cognitive function (including spatial planning, visual attention, and within participant variability) with increasing age. The results suggest that near-side unsafe pedestrian crossing errors are related to processing speed, whereas far-side errors are related to spatial planning difficulties. Both near-side and far-side crossing errors were related to walking speed and motor initiation measures (specifically motor initiation variability). The salient mobility predictors of unsafe pedestrian crossings determined in the above study were examined in Chapter 3 in conjunction with the presence of a history of falls. The purpose of this study was to determine the extent to which walking speed (indicated as a salient predictor of unsafe crossings and start-up delay in Chapter 2), and previous falls can be predicted and explained by age-related changes in mobility and cognitive function changes (specifically within participant variability and spatial ability). 53.2% of walking speed variance was found to be predicted by self-rated mobility score, sit-to-stand time, motor initiation, and within participant variability. Although a significant model was not found to predict fall history variance, postural sway and attentional set shifting ability was found to be strongly related to the occurrence of falls within the last year. Next in Chapter 4, unsafe pedestrian crossing behaviour and pedestrian predictors (both mobility and cognitive measures) from Chapter 2 were explored in terms of increasing hemispheric laterality of attentional functions and inter-hemispheric oscillatory beta power changes associated with increasing age. Elevated beta (15-35 Hz) power in the motor cortex prior to movement, and reduced beta power post-movement has been linked to age-related changes in mobility. In addition, increasing recruitment of both hemispheres has been shown to occur and be beneficial to perform similarly to younger adults in cognitive tasks (Cabeza, Anderson, Locantore, & McIntosh, 2002). It has been hypothesised that changes in hemispheric neural beta power may explain the presence of more pedestrian errors at the farside of the road in older adults. The purpose of the study was to determine whether changes in age-related cortical oscillatory beta power and hemispheric laterality are linked to unsafe pedestrian behaviour in older adults. Results indicated that pedestrian errors at the near-side are linked to hemispheric bilateralisation, and neural overcompensation post-movement, 4 whereas far-side unsafe errors are linked to not employing neural compensation methods (hemispheric bilateralisation). Finally, in Chapter 5, fear of falling, life space mobility, and quality of life in old age were examined to determine their relationships with cognition, mobility (including fall history and pedestrian behaviour), and motor initiation. In addition to death and injury, mobility decline (such as pedestrian errors in Chapter 2, and falls in Chapter 3) and cognition can negatively affect quality of life and result in activity avoidance. Further, number of falls in Chapter 3 was not significantly linked to mobility and cognition alone, and may be further explained by a fear of falling. The objective of the above study (Study 2, Chapter 3) was to determine the role of mobility and cognition on fear of falling and life space mobility, and the impact on quality of life measures. Results indicated that missing safe pedestrian crossing gaps (potentially indicating crossing anxiety) and mobility decline were consistent predictors of fear of falling, reduced life space mobility, and quality of life variance. Social community (total number of close family and friends) was also linked to life space mobility and quality of life. Lower cognitive functions (particularly processing speed and reaction time) were found to predict variance in fear of falling and quality of life in old age. Overall, the findings indicated that mobility decline (particularly walking speed or walking difficulty), processing speed, and intra-individual variability in attention (including motor initiation variability) are salient predictors of participant safety (mainly pedestrian crossing errors) and wellbeing with increasing age. More research is required to produce a significant model to explain the number of falls.

Fear of Falling and Balance Confidence in Older Adults with Diabetes Mellitus

Several determinants of fear of falling (FoF) and low balance confidence overlap with the consequences/complications of diabetes mellitus (DM). FoF is strongly associated with low balance confidence, and balance confidence mediates the relationship between FoF and balance and physical function. The purpose of this thesis was two-fold: (1) to examine the prevalence, severity and determinants of FoF in older adults (aged≥65) with DM, and (2) to evaluate the validity of the short version of the Activities-specific Balance Confidence scale (ABC-6) and its association with balance and postural control in older adults with DM. Three separate studies were conducted of older adults with DM (DM-group) and without DM (noDM-group). Study I revealed that although FoF prevalence adjusted for age and sex was not different between-groups, the DM-group had 8.8% fewer participants in the low and 8.4% more in the high Falls-Efficacy Scale International categories when compared to the noDM-group. Higher FoF severity in the DM-group was associated with poor physical performance, being female, fall history and clinical depressive symptoms. Study II provided evidence of convergent, discriminant and concurrent validity of the ABC-6 for use in older adults with DM with and without diabetic peripheral neuropathy (DPN). Notably, the ABC-6 was more sensitive in detecting subtle differences in balance confidence between the DM-group and noDM-group when compared to the original ABC scale (ABC-16), and can be administered in less time. Study III explored balance confidence (ABC-6) and its association with balance and postural control in older adults with DM. Subtle differences in axial segmental control (i.e., lower trunk roll velocity and higher head-trunk correlations) while walking and lower balance confidence were apparent in the DM-group, even in the absence of DPN, when compared to the noDM-group. Balance confidence partially explained the variance in head-trunk stiffening between-groups, and consequently low balance confidence in older adults with DM may contribute to the dependence on postural control strategies that are normally only utilized in high-risk situations. Findings from this thesis will help to guide the development of protocols for screening and intervention recommendations of patient education and targeted rehabilitation programs for older adults with DM.

Does an In-Season Detraining Period Affect the Shoulder Rotator Cuff Strength and Balance of Young Swimmers?

Aims: To compare the physical activity, sedentary activity and health-related quality of life (HRQoL) in institutionalized vs. non-institutionalized elderly, and to establish a pattern of relationship and prediction of physical and sedentary activity with physical and mental components of HRQoL. Methods: The sample consisted of 383 elderly with ≥ 75 years old (n=187 institutionalized and n=196 non-institutionalized). Were administered the International Physical Activity Questionnaire (IPAQ) and Short Form 36 Health Survey (SF-36) for evaluated the physical and sedentary activity and HRQoL. Also was used the Mini Mental State Examination (MMSE) as exclusion criteria for cognitive problems in the elderly. Results: Differences between institutionalized and non-institutionalized elderly were found in moderate-intensity activities and walking, a favour of non-institutionalized. The institutionalized elderly remain more minutes in sedentary activity. Also, were observed differences between both groups in physical component of HRQoL, a favour of non-institutionalized elderly. The mental component remained unchanged. The multivariate regression analyses showed that physical activity predicted the physical (8 to 12%) and mental (5 to 8%) components of HRQoL for institutionalized and non-institutionalized elderly. Conclusions: Non-institutionalized elderly were more physically active, spent less time in sedentary activity and showed better perception physical component of HRQoL that institutionalized elderly. An important and encouraging result of this study was that physical activity is a predictor of improved physical and mental component of HRQoL for institutionalized and non-institutionalized elderly.

Relatório de estágio em reabilitação neurológica

Mestrado em Fisioterapia.

THE HIGH DIAGNOSTIC YIELD OF A GERIATRIC OUTPATIENT CLINIC

Objectives: To determine characteristics of older patients referred to a geriatric outpatient clinic; 2) to determine the prevalence of geriatric syndromes in this population; 3) to identify main recommendations made to referring primary care physicians. Design: Cross-sectional analysis Setting: Outpatient clinic of the service of geriatric medicine at the University of Lausanne Medical Center, Lausanne, Switzerland. Participants: Community-dwelling patients aged 65 and over referred to the clinic. Measurements: Demographics, social, functional and health status data, main diagnoses identified and recommendations made for primary care physicians were collected prospectively. Results: Subjects (N=206, mean age 79.7±7.6 years, 57.3% women, 48.5% living alone, 36.9% receiving formal home care) were referred by primary care physicians (76%), hospitalists (18%), or family members (7%). Main reasons for referral were request for comprehensive assessment, cognitive evaluation, and mobility assessment (45.2%, 26.2%, and 15.5%, respectively). 21.4% of patients are independent in Lawton's Instrumental ADL and 47.1% are independent in Katz's Basic ADL, and 57.3% of patients reported having fallen once or more over the last year. Overall, 76.2% of patients had gait and balance impairment, 72.8% cognitive impairment, 57.3% polypharmacy (≥6 drugs; median 6.5±3.9, IQR 4-8), 54.4% affective disorder, 48.3% osteoporosis, 45.1% urinary incontinence and 33.8% orthostatic hypotension. Polymorbidity (≥6 geriatric syndromes) was present in 58.3% of referred patients. On average, patients received 10.6±4.0 recommendations, including fall prevention interventions (85.2 % of patients: walking aid adaptation in 48.1%, vitamin D prescription in 59.7%, home hazards assessment in 59.2%, and exercise prescription in 53.4%), referral to a memory clinic (45.6%), and treatment modifications (69.9 % of all patients and 81.6% of patients with polypharmacy, mostly psychotropic drugs discontinuation). Conclusions: Polymorbidity was frequent in these older outpatients, with polypharmacy, mobility and cognitive impairments being most prevalent. Outpatient geriatric consultation is a good opportunity to identify geriatric syndromes and propose interventions to prevent or delay functional decline.

Evaluation préopératoire des patients ages [Preoperative assessment in elderly patients].

Age-related physiological changes and comorbidities affect older patients' tolerance to surgery. Pre-operative assessment in these patients requires, beside the usual physical evaluation, the systematic screening of common geriatric syndromes. Cognitive, gait and balance, nutritional, and functional impairments, all flag patients at higher risk for per- and postoperative complications. Preoperative assessment is an opportunity to detect these syndromes and propose preventative interventions (physical therapy, nutritional and cognitive support measures) likely to reduce the incidence of postoperative morbidity.

Urinary incontinence in the prediction of falls in hospitalized elderly

Objective Analyzing the effect of urinary incontinence as a predictor of the incidence of falls among hospitalized elderly. Method Concurrent cohort study where 221 elderly inpatients were followed from the date of admission until discharge, death or fall. The Kaplan-Meier methods, the incidence density and the Cox regression model were used for the survival analysis and the assessment of the association between the exposure variable and the other variables. Results Urinary incontinence was a strong predictor of falls in the surveyed elderly, and was associated with shorter time until the occurrence of event. Urinary incontinence, concomitant with gait and balance dysfunction and use of antipsychotics was associated with falls. Conclusion Measures to prevent the risk of falls specific to hospitalized elderly patients who have urinary incontinence are necessary.



Facteurs de risque de chutes chez les aînés vivant dans la communauté et ayant recours aux services de soutien à domicile : covariables dépendantes du temps et événements récurrents

Les chutes chez les personnes âgées représentent un problème majeur. Il n’est donc pas étonnant que l’identification des facteurs qui en accroissent le risque ait mobilisé autant d’attention. Les aînés plus fragiles ayant besoin de soutien pour vivre dans la communauté sont néanmoins demeurés le parent pauvre de la recherche, bien que, plus récemment, les autorités québécoises en aient fait une cible d’intervention prioritaire. Les études d’observation prospectives sont particulièrement indiquées pour étudier les facteurs de risque de chutes chez les personnes âgées. Leur identification optimale est cependant compliquée par le fait que l’exposition aux facteurs de risque peut varier au cours du suivi et qu’un même individu peut subir plus d’un événement. Il y a 20 ans, des chercheurs ont tenté de sensibiliser leurs homologues à cet égard, mais leurs efforts sont demeurés vains. On continue aujourd’hui à faire peu de cas de ces considérations, se concentrant sur la proportion des personnes ayant fait une chute ou sur le temps écoulé jusqu’à la première chute. On écarte du coup une quantité importante d’information pertinente. Dans cette thèse, nous examinons les méthodes en usage et nous proposons une extension du modèle de risques de Cox. Nous illustrons cette méthode par une étude des facteurs de risque susceptibles d’être associés à des chutes parmi un groupe de 959 personnes âgées ayant eu recours aux services publics de soutien à domicile. Nous comparons les résultats obtenus avec la méthode de Wei, Lin et Weissfeld à ceux obtenus avec d’autres méthodes, dont la régression logistique conventionnelle, la régression logistique groupée, la régression binomiale négative et la régression d’Andersen et Gill. L’investigation est caractérisée par des prises de mesures répétées des facteurs de risque au domicile des participants et par des relances téléphoniques mensuelles visant à documenter la survenue des chutes. Les facteurs d’exposition étudiés, qu’ils soient fixes ou variables dans le temps, comprennent les caractéristiques sociodémographiques, l’indice de masse corporelle, le risque nutritionnel, la consommation d’alcool, les dangers de l’environnement domiciliaire, la démarche et l’équilibre, et la consommation de médicaments. La quasi-totalité (99,6 %) des usagers présentaient au moins un facteur à haut risque. L’exposition à des risques multiples était répandue, avec une moyenne de 2,7 facteurs à haut risque distincts par participant. Les facteurs statistiquement associés au risque de chutes incluent le sexe masculin, les tranches d’âge inférieures, l’histoire de chutes antérieures, un bas score à l’échelle d’équilibre de Berg, un faible indice de masse corporelle, la consommation de médicaments de type benzodiazépine, le nombre de dangers présents au domicile et le fait de vivre dans une résidence privée pour personnes âgées. Nos résultats révèlent cependant que les méthodes courantes d’analyse des facteurs de risque de chutes – et, dans certains cas, de chutes nécessitant un recours médical – créent des biais appréciables. Les biais pour les mesures d’association considérées proviennent de la manière dont l’exposition et le résultat sont mesurés et définis de même que de la manière dont les méthodes statistiques d’analyse en tiennent compte. Une dernière partie, tout aussi innovante que distincte de par la nature des outils statistiques utilisés, complète l’ouvrage. Nous y identifions des profils d’aînés à risque de devenir des chuteurs récurrents, soit ceux chez qui au moins deux chutes sont survenues dans les six mois suivant leur évaluation initiale. Une analyse par arbre de régression et de classification couplée à une analyse de survie a révélé l’existence de cinq profils distinctifs, dont le risque relatif varie de 0,7 à 5,1. Vivre dans une résidence pour aînés, avoir des antécédents de chutes multiples ou des troubles de l’équilibre et consommer de l’alcool sont les principaux facteurs associés à une probabilité accrue de chuter précocement et de devenir un chuteur récurrent. Qu’il s’agisse d’activité de dépistage des facteurs de risque de chutes ou de la population ciblée, cette thèse s’inscrit dans une perspective de gain de connaissances sur un thème hautement d’actualité en santé publique. Nous encourageons les chercheurs intéressés par l’identification des facteurs de risque de chutes chez les personnes âgées à recourir à la méthode statistique de Wei, Lin et Weissfeld car elle tient compte des expositions variables dans le temps et des événements récurrents. Davantage de recherches seront par ailleurs nécessaires pour déterminer le choix du meilleur test de dépistage pour un facteur de risque donné chez cette clientèle.

Limiting glutamate transmission in a Vglut2-expressing subpopulation of the subthalamic nucleus is sufficient to cause hyperlocomotion

The subthalamic nucleus (STN) is a key area of the basal ganglia circuitry regulating movement. We identified a subpopulation of neurons within this structure that coexpresses Vglut2 and Pitx2, and by conditional targeting of this subpopulation we reduced Vglut2 expression levels in the STN by 40%, leaving Pitx2 expression intact. This reduction diminished, yet did not eliminate, glutamatergic transmission in the substantia nigra pars reticulata and entopeduncular nucleus, two major targets of the STN. The knock-out mice displayed hyperlocomotion and decreased latency in the initiation of movement while preserving normal gait and balance. Spatial cognition, social function, and level of impulsive choice also remained undisturbed. Furthermore, these mice showed reduced dopamine transporter binding and slower dopamine clearance in vivo, suggesting that Vglut2-expressing cells in the STN regulate dopaminergic transmission. Our results demonstrate that altering the contribution of a limited population within the STN is sufficient to achieve results similar to STN lesions and high-frequency stimulation, but with fewer side effects.

Capacidade funcional de hemiparéticos crônicos submetidos a um programa de fisioterapia em grupo

Este estudo tem como objetivos analisar a eficácia da fisioterapia em grupo sobre a marcha, o equilíbrio corporal e o risco de queda, e verificar se há correlação entre a capacidade funcional da marcha e o equilíbrio em indivíduos com hemiparesia crônica. Participaram do estudo 21 adultos hemiparéticos, com idade média de 58,9±10,6 anos, com seqüela de no mínimo 1 ano após acidente vascular encefálico isquêmico ou hemorrágico. Os sujeitos foram submetidos a um programa de 1 hora de fisioterapia em grupo duas vezes por semana durante seis meses. Foram avaliados por meio da escala de equilíbrio de Berg (EEB) e do teste de levantar e caminhar cronometrado TLCC (TUG, na sigla em inglês de timed up & go) antes do programa, após 13 e ao fim de 26 semanas. Os resultados mostram uma redução progressiva, embora não-significativa, no tempo de execução do TLCC e aumento progressivo, também não-significativo, do escore na EEB. Foi observada forte correlação entre as duas escalas (r=0,7, p<0,05). Assim, a terapia não foi efetiva para produzir melhora nos escores dos testes, mas contribuiu para manter a mobilidade.

Qualidade de vida no envelhecimento: situação dos idosos assistidos em unidades de saúde da família do município do interior paulista

Pós-graduação em Enfermagem (mestrado profissional) - FMB

Limiting glutamate transmission in a Vglut2-expressing subpopulation of the subthalamic nucleus is sufficient to cause hyperlocomotion

The subthalamic nucleus (STN) is a key area of the basal ganglia circuitry regulating movement. We identified a subpopulation of neurons within this structure that coexpresses Vglut2 and Pitx2, and by conditional targeting of this subpopulation we reduced Vglut2 expression levels in the STN by 40%, leaving Pitx2 expression intact. This reduction diminished, yet did not eliminate, glutamatergic transmission in the substantia nigra pars reticulata and entopeduncular nucleus, two major targets of the STN. The knock-out mice displayed hyperlocomotion and decreased latency in the initiation of movement while preserving normal gait and balance. Spatial cognition, social function, and level of impulsive choice also remained undisturbed. Furthermore, these mice showed reduced dopamine transporter binding and slower dopamine clearance in vivo, suggesting that Vglut2-expressing cells in the STN regulate dopaminergic transmission. Our results demonstrate that altering the contribution of a limited population within the STN is sufficient to achieve results similar to STN lesions and high-frequency stimulation, but with fewer side effects.