Falls are a significant public health problem with serious consequences. Fall related consequences have the potential to drastically and negatively impact the quality of life of patients who fall, and the care for fall patients is already putting a significant strain on the health care system. Advanced age has long been associated with falls. The fraction of the population represented by those of such an advanced age is increasing rapidly, subsequently the number of persons at risk for falling is also rapidly increasing. While advanced age is non-modifiable, there are many risk factors for falls which can be modified to potentially and ideally decrease the prevalence of falls. Physical inactivity is one such risk factor. Efforts to increase the amount of physical activity performed by a population at risk of falling could reduce number of falls in that population, and in turn could reduce the negative impact of fall related consequences in that population and have significant public health benefits. A particular set of exercises called the Otago exercise has already demonstrated efficacy at reducing fall rates in the elderly. Prior studies of the Otago exercise program were limited by poor compliance. There is evidence that behavioral interventions, particularly social cognitive theory, can be an effective means of increasing compliance with recommended physical activity regimens. Smartphones have the potential to be used as more cost effective means of delivery for social cognitive theory. The effectiveness of such a strategy has not been evaluated in the elderly population at risk for falling however. The following proposal is for a randomized controlled trial to investigate the effectiveness of a smartphone application designed to utilize the principles of social cognitive theory to increase compliance with the Otago exercises in an elderly population at risk of falling compared to the standard delivery of the Otago exercise. Patients from the Boston Medical Center geriatric practice will be enrolled to the protocol. Outcomes will include compliance with the prescribed exercises, falls, and engagement with the application.

Background and Purpose: The adverse effects of drugs may influence results on tests of mobility and balance, but the drug-specific impact is not identified when using these tests. We propose that a quantitative drug index (QDI) will assist in assessing fall risk based on these tests, when combined with other fall risk variables. Methods: Fifty-seven community-dwelling older adults who could walk independently on a treadmill and had Mini-Mental State Examination (MMSE) scores equal to or greater than 24 participated. Mobility and balance outcome measures included the Balance Evaluation Systems Test (BESTest), Berg Balance Scale (BBS), Timed Up and Go (TUG) and cognitive dual task TUG (TUGc). Fall history, current drug list, and Activity-Specific Balance Confidence (ABC) scale scores were also collected. Body mass index (BMI) was calculated. The QDI was derived from the drug list for each individual, and based on fall-related drug adverse effects. Multiple linear regression analyses were conducted using age, BMI, and QDI as predictor variables for determining mobility and balance test scores, and ABC scale scores. Subsequently, participants were divided into (QDI = 0) low-impact drug group (LIDG) and (QDI > 0) high-impact drug group (HIDG) for Mann-Whitney 2-group comparisons. Results: Age, BMI, and QDI were all significant (P <.001) independent variables in multiple regression analyses for mobility and balance test scores, but not for the ABC scale. Separately, the 2 group comparisons for the BESTest, BBS, TUG, and TUGc demonstrated that HIDG scored significantly (P <.05) worse on these tests compared with the LIDG. Drug counts were also significantly higher for the HIDG than for the LIDG. In contrast, age, BMI, MMSE, and reported falls in the last 12 months were not significantly different between groups. Conclusion: Age, BMI, and QDI - all contributed independently to the mobility and balance test scores examined, and may provide health care professionals a screening tool to determine whether additional mobility and balance testing is required. In addition, the QDI is a more precise marker of adverse effects of drugs compared with drug counts, as the latter does not quantitate the influence of drugs on physiologic function.

Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) is considered a rare autoimmune disorder which makes it difficult to accurately diagnose and creates a lot of opportunity for active research. With its wide array of presentations and even similarities to other neurological disorders, improvement must be made in the field of diagnostic methods in order to offer concise and effective treatments. As with many other neurological disorders, CIDP patients are at a higher risk for falls. The dual effect of gait impairment due to neuropathy and general effects of older age create a dangerous combination and increase the risk for falls. By increasing the accuracy with which physicians and health professionals predict falls in patients, they can effectively prevent serious injury and improve quality of life. Consequently, in order to predict the risk of falls, and therefore prevent severe injury, the ability to accurately access the specific qualities of the patient’s gait is critical. Without the ability to precisely identify patients’ particular gait impairment presentation it is very difficult to establish their risk for falls. The current methods of diagnoses focuses mainly on PROs (patient reported outcomes) which are often gathered through patient questionnaires. Previous research has shown that such methods are simply not detailed and patient specific enough to offer a complete picture of a patient’s condition. We believe ProtoKinetics Movement Analysis Software (PKMAS) is an objective, examiner independent measure of patients’ gait, and offers a method of quantifying patients’ functional gait outcomes in a way that is superior to the current standard of care procedures. Therefore, in this study we aim to reveal the shortcomings of current standard of care procedures in the diagnosis and treatment of CIDP, while also demonstrating the superior value of PKMAS in providing a detailed patient disease profile for CIDP afflicted individuals. Specifically, we demonstrate PKMAS’ increased ability to predict fall risk in CIDP patients, as compared with currently used methods. In this study PKMAS data was collected under two conditions: Dual Task and PWS (preferred walking speed). During each condition the patient was asked to walk across the Gait Map/Zeno Walkway as the ProtoKinetics Software collected detailed information about the patients’ gait. For PWS, patients were asked to walk across the map at a speed they were most comfortable at as PKMAS data was collected. For Dual Task, patients are asked to walk at their preferred walking speed while simultaneously doing a simple cognitive task, for instance, counting backwards from a hundred. This second condition is particularly important. The point of such a task is to mimic real-life walking. When we walk on a daily basis we are usually thinking or doing something else simultaneously, even if we may not be consciously aware of this. As such, comparing the results for PWS and Dual Task for patients can shine light onto their real-life gait experience. In order to do so, we measured the percent change in abilities between PWS and Dual Task walking. A greater change signifies greater gait impairment, and a change of greater than 15% places the patient at risk for falls. Among the PROs, INCAT is the one most often referred to in neurological standard of care and as such we focused on this particular questionnaire separately as well. To do so, t-tests were completed to demonstrate the lack of validity in scoring, by looking at the PKMAS data as compared between two INCAT scores. In this study we seek to demonstrate the superiority of ProtoKinetics Movement Analysis Software (PKMAS) over the current standard of care for CIDP patients. Specifically, in accurately evaluating patients’ gait and future fall risk. The ability to do so is vitally important for elderly patients who already suffer from decreased gait stability and the additional impact of CIDP can accentuate that risk.

Gait initiation (GI) is an important locomotor transition task that includes anticipatory postural adjustments and the joint propulsion necessary for the first step of walking. Metrics associated with this task are known to change across the lifespan and may provide valuable information for fall risk indication, as falls often occur during transitional tasks. Assessments of discrete variables between fallers and non-fallers at GI have provided insight into differences between groups. However, more complex approaches such as time-series principal component analysis (PCA) may allow the examination of changes in magnitude, pattern, and timing not detectable using discrete comparisons alone. Therefore, this thesis aims to characterize differences between fallers and non-fallers by examining the kinematics and kinetics of gait initiation using time-series PCA. A sample of 56 community-dwelling older adults was recruited for this study and completed five walking trials where GI was measured by two force platforms. PCA of centre of pressure kinematics and kinetics time-series data were used to identify the critical features of the signal, and multivariate analysis of covariance was used to compare the individual loading scores of each principal component for each phase between groups. It was revealed that fallers demonstrated differences in the range of mediolateral movement during weight transfer and forward progression, a greater range of anteroposterior movement in forward progression, and a more gradual rise in vertical forces in the first step, associated with a shorter first step length. These findings point to a tendency for fallers to prioritize stability over forward progression performance, and differences in postural control strategies, compared to non-fallers. Further, the use of time-series PCA helped to highlight differences not detectable using discrete analysis alone. / Graduate

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<p>Some individuals remain at risk for adverse outcomes such as chronic wrist/hand pain, falls, and fall-related osteoporotic fractures after distal radius fracture (DRF) remain. This thesis includes five studies that were conducted to establish prediction rules for assessing the risk of these adverse outcomes following DRF.</p> <p>The first manuscript outlines a theoretical framework (RACE - <strong>R</strong>educing pain, <strong>A</strong>ctivating, <strong>C</strong>ognitive reshaping, <strong>E</strong>mpowering) for managing the risk of adverse outcomes, mainly chronic pain, in individuals with DRF. The RACE is one of the first frameworks to suggest a risk-based management approach for individuals with DRF.</p> <p>The Patient-Rated Wrist Evaluation (PRWE) is a condition-specific measure for DRF used in research as well as clinical practice to measure pain and functions in individuals with different wrist/hand injuries. The second manuscript contributes to the literature by providing the first systematic literature review that synthesizes the evidence regarding the psychometric properties of the PRWE. The review determined that the PRWE has excellent reliability, construct validity, and responsiveness in individuals with DRF.</p> <p>The third manuscript indicates that the baseline pain intensity is an independent predictor of chronic pain in individuals with DRF. The results also suggest that the individuals who score ≥35/50 on the pain scale of the PRWE at baseline have 8 times greater risk for developing chronic wrist/hand pain compared to those who score < 35/50.</p> <p>The fourth and fifth manuscripts describe results of a two step study. The fourth manuscript is a structured literature synthesis that identified suitable measures for predicting the risk of falls and fall-related osteoporotic fractures following DRF. The fifth manuscript summarizes the results of preliminary analysis of psychometric properties of selected fall risk measures identified in the fourth manuscript. The fifth manuscript also provides feasibility and sample size requirements for conducting a fall prevention trial in individuals with DRF.</p> / Doctor of Philosophy (PhD)

Yes / Older people have an increased risk of falling during locomotion, with falls on stairs being particularly common and dangerous. Step going (i.e., the horizontal distance between two consecutive step edges) defines the base of support available for foot placement on stairs, as with smaller going, the user's ability to balance on the steps may become problematic. Here we quantified how stair negotiation in older participants changes between four goings (175, 225, 275, and 325 mm) and compared stair negotiation with and without a walking approach. Twenty-one younger (29 ± 6 years) and 20 older (74 ± 4 years) participants negotiated a 7-step experimental stair. Motion capture and step-embedded force platform data were collected. Handrail use was also monitored. From the motion capture data, body velocity, trunk orientation, foot clearance and foot overhang were quantified. For all participants, as stair going decreased, gait velocity (ascent pA = 0.033, descent pD = 0.003) and horizontal step clearance decreased (pA = 0.001), while trunk rotation (pD = 0.002) and foot overhang increased (pA,D < 0.001). Compared to the younger group, older participants used the handrail more, were slower across all conditions (pA < 0.001, pD = 0.001) and their foot clearance tended to be smaller. With a walking approach, the older group (Group x Start interaction) showed a larger trunk rotation (pA = 0.011, pD = 0.015), and smaller lead foot horizontal (pA = 0.046) and vertical clearances (pD = 0.039) compared to the younger group. A regression analysis to determine the predictors of foot clearance and amount of overhang showed that physical activity was a common predictor for both age groups. In addition, for the older group, medications and fear of falling were found to predict stair performance for most goings, while sway during single-legged standing was the most common predictor for the younger group. Older participants adapted to smaller goings by using the handrails and reducing gait velocity. The predictors of performance suggest that motor and fall risk assessment is complex and multifactorial. The results shown here are consistent with the recommendation that larger going and pausing before negotiating stairs may improve stair safety, especially for older users. / This study was supported by the New Dynamics of Aging (RES-356-25-0037).

Falls are a serious issue for the elderly living in long-term care facilities, as falls contribute to signi�cant health problems such as increased dependence, loss of autonomy, confusion, immobilization, depression, restriction in daily activities, and, in some cases, death. An estimated 424,000 fatal falls in elderly patients residing in long-term facilities occur annually in the United States costing $34 billion in direct medical costs. One way to reduce falls among elderly patients in long-term care is to assess for fall risk frequently and implement evidence-based strategies to prevent falls. Patients in this project site facility had been assessed for fall risk via the Briggs Fall Risk Assessment Tool with implementation of fall risk iinterventions only upon admission or when there was a fall. The purpose of this project was to assess whether changing to weekly use of the Briggs Fall Risk Assessment Tool with implementation of fall risk interventions by nursing staff could decrease fall rates in the elderly in long-term care in Harris County, Texas. The model of prevention served as the conceptual framework for this project. Thirty participants (20 females and 10 males) between the ages of 65-115 participated in the program. Pre-implementation data were collected for 1 month and post-implementation data were collected for 1 month. The total number of falls reported weekly was counted before and after the weekly implementation of the Briggs Fall Risk Assessment Tool. The number of falls decreased from 12(70.6%) before the implementation of the assessment tool to 5(29.4%) falls afterwards. A fall prevention program in long-term care may affect social change positively by reducing fall risk in long term care by reinforcing the importance of increased awareness of risk of falls to implement fall prevention strategies

Class of 2017 Abstract / Objectives: The aim of this project was to assess community-dwelling older adults’ knowledge of prescription and Over-the-Counter (OTC) medications associated with fall risk, then provide an online educational intervention tailored to older adults on the topics they answer incorrectly. The knowledge assessment of the missed questions will be repeated after the online education to detect the effectiveness of the online intervention in increasing the knowledge of community-dwelling older adults. Methods: This study used an interventional design with pre-test, post-test survey method to quantitatively analyze community-dwelling older adults’ knowledge on medication-related fall risk. The persons taking the survey were community dwelling older adults, 65 years of age and older, living in the greater Tucson and Phoenix areas. Data was obtained through an online Qualtrics questionnaire between February 1, 2016 and February 1, 2017. The survey respondents answered questions regarding prescription and OTC medications associated with fall risk. For the questions they answered incorrectly, an online educational intervention tailored to older adults was provided immediately. The knowledge assessment of the missed questions was repeated after the online education to detect the effectiveness of the intervention. Results: Questionnaires were completed by 302 community-dwelling older adults. The mean age of the participants was 79 (range 65 to > 96), and majority were women (61.2%). A majority of respondents (53.87%) reported falling once in the last 5 years. Of the total participants, 50% were taking between 5 and 9 prescribed medications and 56% taking 0 to 4 OTC medications. The primary outcome of this study is that online education was effective in educating community dwelling older adults on medication-related fall risk. Patients whose pharmacist had previously educated them did not directly correlate with better performance on the pretest than those who did not receive counseling. Participants that received online education during the survey improved their score from 69% before education to 84% post education. Conclusions: The online educational intervention on medication-related fall among older adults was effective and informative. Such educational strategy may be used by pharmacists to educate older patients using medications that may increase fall risks.

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