Significantly Earlier Ambulation and Reduced Risk of Near-Falls with Continuous Infusion Nerve Blocks: A Retrospective Pilot Study of Adductor Canal Block Compared to Femoral Nerve Block in Total Knee Arthroplasty

Background: One option in total knee arthroplasty (TKA) perioperative pain management is femoral nerve block (FNB). Its association with quadriceps weakness has led to a focus on adductor canal block (ACB), with the aim of avoiding weakness in adjacent muscles. This study reviewed cases at our institution. Methods: In this pilot non-blinded study, nerve block (FNB or ACB) was performed under ultrasonic guidance after induction of general anesthesia, with an initial bolus followed by continuous levobupivacaine infusion into the perineurium as needed until postoperative day (POD) 2 or 3. Pain levels and falls/near-falls with knee-buckling were monitored from POD 1 to POD 3. The score on the manual muscle test, MMT (0 to 5, 5 being normal), of the patients who had been able to ambulate on POD 1, was investigated. Results: A total of 73 TKA cases, 37 FNB and 36 ACB, met the inclusion criteria. Episodes of near-falls in the form of knee-buckling were witnessed in 14 (38%) cases in the FNB group and in 4 (11%) in the ACB group (p = 0.0068). In the ACB group, 81.1% of patients were able to ambulate with parallel bars on POD 1, while only 44.4% of FNB patients could do so (p = 0.0019). The quadriceps MMT values of patients able to ambulate with parallel bars on POD 1 in the ACB group was 2.82, significantly higher than 1.97 in the FNB group (p = 0.0035). There were no significant differences in pain as measured with a numerical rating scale (NRS) through POD 3. Conclusion: Compared to FNB, ACB was associated with significantly less knee-buckling and earlier initiation of ambulation post-TKA, with better quadriceps muscle strength. These findings support the use of ACB as the anesthesia method of choice for TKA.

Clinical Usefulness of Retropulsion Tests in Persons with Mild to Moderate Parkinson’s Disease

People with Parkinson’s disease (PwPD) have an increased risk for falls and near falls. They have particular difficulties with maintaining balance against an external perturbation, and several retropulsion tests exist. The Unified PD Rating Scale item 30 (UPDRS30) is the most common, involving an expected shoulder pull. Others recommend using an unexpected shoulder pull, e.g., the Nutt Retropulsion Test (NRT). We aimed to evaluate the clinical usefulness of these tests for detecting future fallers. By using two different golden standards related to self-reported prospective falls and near falls over 6 months following two different time points with 3.5 years between, we estimated sensitivity/specificity, Youden index, predictive values, and likelihood ratios for each test. The different time points yielded a different prevalence of falls and near falls, as well as different predictive values. When comparing the performance of the NRT and UPDRS30 for detecting future fallers, we found that the NRT consistently performed better than UPDRS30. However, neither test exhibited optimal performance in terms of predictive values and associated likelihood ratios. Our findings speak against using either of these tests as a single assessment for this purpose and support previous recommendations of using a multifactorial approach when targeting balance problems in PwPD.

Development of a Parkinson’s disease specific falls questionnaire

Background Falls are a major health burden for older adults with Parkinson’s disease (PD), but there is currently no reliable questionnaire to capture the circumstances and consequences of falls in older adults with PD. This study aimed to develop a PD-specific falls questionnaire and to evaluate its test-retest reliability in older adults with PD. Methods A novel PD-specific falls questionnaire (PDF-Q) was developed in two modes (online and paper-based version) and used to assess falls and near-falls events over the past 12-months. Questions were agreed upon by an expert group, with the domains based on previous falls-related questionnaires. The questions included the number and circumstances (activities, location and direction) of falls and near-falls, and consequences (injuries and medical treatment) of falls. The PDF-Q was distributed to 46 older adults with PD (online n = 30, paper n = 16), who completed the questionnaire twice, 4 weeks apart. Kappa (κ) statistics were used to establish test-retest reliability of the questionnaire items. Results Pooled results from both questionnaires for all participants were used to assess the overall test-retest reliability of the questionnaire. Questions assessing the number of falls (κ = 0.41) and the number of near-falls (κ = 0.51) in the previous 12-months demonstrated weak agreement, while questions on the location of falls (κ = 0.89) and near-falls (κ = 1.0) demonstrated strong to almost perfect agreement. Questions on the number of indoor (κ = 0.86) and outdoor (κ = 0.75) falls demonstrated moderate to strong agreement, though questions related to the number of indoor (κ = 0.47) and outdoor (κ = 0.56) near-falls demonstrated weak agreement. Moderate to strong agreement scores were observed for the most recent fall and near-fall in terms of the direction (indoor fall κ = 0.80; outdoor fall κ = 0.81; near-fall κ = 0.54), activity (indoor fall κ = 0.70; outdoor fall κ = 0.82; near-fall κ = 0.65) and cause (indoor fall κ = 0.75; outdoor fall κ = 0.62; near-fall κ = 0.56). Conclusions The new PDF-Q developed in this study was found to be reliable for capturing the circumstances and consequences of recent falls and near-falls in older adults with PD.

Longitudinal Assessment of Balance Using Virtual Reality in Patients Receiving Potentially Neurotoxic Adjuvant Chemotherapy

PurposeChemotherapy-induced peripheral neuropathy (CIPN) commonly affects people treated for cancer, with functional consequences of impaired balance and falls. Virtual reality technology (VR) may be able to assess balance, identifying patients at increased risk of falls. We aimed to assess the impact of neurotoxic chemotherapy on balance and falls risk using VR, and explore whether changes in balance threshold were associated with falls or validated CIPN measures. MethodsWe conducted a prospective, longitudinal cohort study at two Australian oncology centres. Eligible participants were commencing adjuvant chemotherapy containing a taxane for breast cancer, or oxaliplatin for colon cancer. Excluded: insufficient English to complete assessments, VR intolerance, or pre-existing balance disorder. VR balance threshold was recorded at baseline, intervals during chemotherapy, and 3- and 6-months after chemotherapy completion. Additional measures: 1) clinician-graded peripheral sensory neuropathy (Common Terminology Criteria for Adverse Events), 2) Total Neuropathy Score-clinical, 3) patient-reported neuropathy, 4) ‘Timed Up-and-Go’ test, 5) participant-reported falls/near-falls. ResultsOf 34 participants consented, 24 (71%) had breast cancer and 10 (29%) had colon cancer. Compared to baseline, balance threshold worsened in 10/28 (36%) evaluable participants assessed at the end-of-chemotherapy; this persisted in 7/22 (32%) at 6 months. CIPN affected 86% at end of chemotherapy, and 73% at 6-months post-chemotherapy . Falls/near-falls were reported by 12/34 (35%), and associated with impaired balance (p = 0.002). ConclusionVR balance assessment warrants further investigation as a surrogate method to objectively identify patients at risk of falls from CIPN, however was no better at diagnosing CIPN than existing tools. Trial Registration: N/A

Near-falls in Singapore community-dwelling older adults: a feasibility study

Background A near-fall is defined as a loss of balance that would result in a fall if sufficient balance recovery manoeuvres are not executed. Compared to falls, near-falls and its associated balance recovery manoeuvres have been understudied. Older adults may not recognise a near-fall or identify the use of their balance recovery manoeuvres to prevent a fall. The consensus on the methods to collect near-fall data is lacking. The primary objective of this study was to determine the feasibility of recruitment and retention. Secondary objectives were to establish evidence that Singapore community-dwelling older adults can identify near-falls and associated balance recovery manoeuvres. Texting and calling methods were explored as reporting methods. Methods This study took place in Singapore (September to October 2019). Participants were healthy, community-dwelling adults aged 65 or older. Recruitment was done through poster advertisement, and all participants gave informed consent. Participants attended a briefing session and reported their near-fall or fall incidence over 21 days using either daily texting or calling. The primary outcome measures were the recruitment rate, retention rate, preferred modes for data reporting and ability to report near-falls or falls. Secondary outcomes included the self-reported incidence of falls and near-falls. Results Thirty older adults were recruited in 5 weeks. All participants completed the study. They understood near-fall concepts and were able to report the occurrence and relevant balance recovery manoeuvres used to prevent a fall. 87% (26/30) chose to text while 13% (4/30) selected calling as their reporting method. One actual fall (0.16%) out of 630 responses was reported. Thirty-six incidents (5.7%) of near-falls were recorded. Sixteen participants (53.3%) experienced near-falls and half of this group experienced two or more near-falls. The use of reach-to-grasp strategy (36%), compensatory stepping (52.8%), and other body regions (11.2%) were used to prevent the fall. Conclusions The study provided evidence that studying near-falls in Singapore community-dwelling older adults is feasible and can be applied to a large-scale study. Recruitment and retention rates were good. Older adults were able to identify near-falls and balance recovery manoeuvres. Both texting and calling were feasible reporting methods, but texting was preferred. Trial registration ClinicalTrials identifier: NCT04087551. Registered on September 12, 2019

Improving gait adaptability in patients with hereditary spastic paraplegia (Move-HSP): study protocol for a randomized controlled trial

Background People with hereditary spastic paraplegia (HSP) experience difficulties adapting their gait to meet environmental demands, a skill required for safe and independent ambulation. Gait adaptability training is possible on the C-Mill, a treadmill equipped with augmented reality, enabling visual projections to serve as stepping targets or obstacles. It is unknown whether gait adaptability can be trained in people with HSP. Aim The aim of Move-HSP is to study the effects of ten 1-h sessions of C-Mill training, compared with usual care, on gait adaptability in people with pure HSP. In addition, this study aims to identify key determinants of C-Mill training efficacy in people with pure HSP. Method Move-HSP is a 5-week, two-armed, open-label randomized controlled trial with a cross-over design for the control group. Thirty-six participants with pure HSP will be included. After signing informed consent, participants are randomized (1:1) to intervention or control group. All participants register (near) falls for 15 weeks, followed by the first assessment (week 16), and, thereafter, wear an Activ8 activity monitor for 7 days (week 16). The intervention group receives 10 sessions of C-Mill training (twice per week, 1-h sessions; weeks 17–21), whereas control group continues with usual care (weeks 17–21). Afterwards, both groups are re-assessed (week 22). Subsequently, the intervention group enter follow-up, whereas control group receives 10 sessions of C-Mill training (weeks 23–27), is re-assessed (week 28), and enters follow-up. During follow-up, both groups wear Activ8 activity monitors for 7 days (intervention group: week 23, control group: week 29) and register (near) falls for 15 weeks (intervention group: weeks 23–37, control group: weeks 29–43), before the final assessment (intervention group: week 38, control group: week 44). The primary outcome is the obstacle subtask of the Emory Functional Ambulation Profile. Secondary outcomes consist of clinical tests assessing balance and walking capacity, physical activity, and fall monitoring. Discussion Move-HSP will be the first RCT to assess the effects of C-Mill gait adaptability training in people with pure HSP. It will provide proof of concept for the efficacy of gait adaptability training in people with pure HSP. Trial registration Clinicaltrials.gov NCT04180098. Registered on November 27, 2019.

Near-Falls in Singapore Community-Dwelling Older Adults: A Feasibility Study

BackgroundA near-fall is defined as a loss of balance that would result in a fall if sufficient balance recovery manoeuvres are not executed. Compared to falls, near-falls and its associated balance recovery manoeuvres have been understudied. Older adults may not recognise a near-fall or identify the use of their balance recovery manoeuvres to prevent a fall. The consensus on the methods to collect near-fall data is lacking. The primary objective of this study was to determine the feasibility of recruitment and retention. Secondary objectives were to establish evidence that Singapore community-dwelling older adults can identify near-falls and associated balance recovery manoeuvres. Texting and calling methods were explored as reporting methods.MethodsThis study took place in Singapore (September to October 2019). Participants were healthy, community-dwelling adults aged 65 or older. Recruitment was done through poster advertisement, and all participants gave informed consent. Participants attended a briefing session and reported their near-fall or fall incidence over 21 days using either daily texting or calling. The primary outcome measures were the recruitment rate, retention rate, preferred modes for data reporting and ability to report near-falls or falls. Secondary outcomes included the self-reported incidence of falls and near-falls.ResultsThirty older adults were recruited in five weeks. All participants completed the study. They understood near-fall concepts and were able to report the occurrence and relevant balance recovery manoeuvres used to prevent a fall. 87% (26/30) chose to text while 13% (4/30) selected calling as their reporting method. One actual fall (0.16%) out of 630 responses was reported. Thirty-six incidents (5.7%) of near-falls were recorded. Sixteen participants (53.3%) experienced near-falls and half of this group experienced two or more near-falls. Use of reach-to-grasp strategy (36%), compensatory stepping (52.8%), and other body regions (11.2%) were used to prevent the fall. ConclusionsThe study provided evidence that studying near-falls in Singapore community-dwelling older adults is feasible and can be applied to a large-scale study. Recruitment and retention rates were good. Older adults were able to identify near-falls and balance recovery manoeuvres. Both texting and calling were feasible reporting methods, but texting was preferred. Trial registrationClinicalTrials identifier: NCT04087551. Registered 12th September 2019

Longitudinal prediction of falls and near falls frequencies in Parkinson’s disease: a prospective cohort study

Introduction and objective Several prediction models for falls/near falls in Parkinson’s disease (PD) have been proposed. However, longitudinal predictors of frequency of falls/near falls are poorly investigated. Therefore, we aimed to identify short- and long-term predictors of the number of falls/near falls in PD. Methods A prospective cohort of 58 persons with PD was assessed at baseline (mean age and PD duration, 65 and 3.2 years, respectively) and 3.5 years later. Potential predictors were history of falls and near falls, comfortable gait speed, freezing of gate, dyskinesia, retropulsion, tandem gait (TG), pain, and cognition (Mini-Mental State Exam, MMSE). After each assessment, the participants registered a number of falls/near falls during the following 6 months. Multivariate Poisson regression was used to identify short- and long-term predictors of a number of falls/near falls. Results Baseline median (q1–q3) motor (UPDRS) and MMSE scores were 10 (6.75–14) and 28.5 (27–29), respectively. History of falls was the only significant short-time predictor [incidence rate ratio (IRR), 15.17] for the number of falls/near falls during 6 months following baseline. Abnormal TG (IRR, 3.77) and lower MMSE scores (IRR, 1.17) were short-term predictors 3.5 years later. Abnormal TG (IRR, 7.79) and lower MMSE scores (IRR, 1.49) at baseline were long-term predictors of the number of falls/near falls 3.5 years later. Conclusion Abnormal TG and MMSE scores predict the number of falls/near falls in short and long term, and may be indicative of disease progression. Our observations provide important additions to the evidence base for clinical fall prediction in PD.