Diabetes (DM) and hypertension (HTN) are prevalent chronic diseases among older adults. For example, in the U.S., 1 in 4 older adults have DM, 3 in 4 have HTN and 1 in 6 have DM and HTN. Moreover, each year, health care costs attributable to DM and HTN are estimated at $327 billion and $131 billion USD respectively. Both diseases also impose tremendous burden on the health and well-being of older adults. For example, gait speed (GS) is reduced in older adults with DM or HTN compared to older adults without DM or HTN. Gait speed is a powerful indicator of health status among older adults. Reduced GS predicts various adverse health outcomes including falls, frailty, cognitive impairment, reduced quality of life, hospitalization and even death. Moreover, adequate GS is required to safely execute daily activities. For example, GS of 1.14 m/s or faster is required to safely cross the street. Reduced GS in older adults with DM or HTN can partly be explained by multimorbidity (e.g., older adults with DM are at increased risk of developing HTN) as well as complications that are frequently associated with DM and HTN. For example, older adults with DM or HTN are at increased risk of developing peripheral artery disease, which causes reduced lower extremity muscle strength and pain, as well as retinopathy, which causes vision impairment. Additionally, older adults with DM are at increased risk of developing peripheral neuropathy, which causes pain and impaired balance. Although the physiological mechanisms of these complications are largely understood, research is needed to determine the extent to which these complications contribute to GS decline among older adults with DM, HTN or DM and HTN. The overarching objective of this thesis was to examine how multimorbidity patterns (i.e., types/combinations of chronic diseases), and sensory and motor impairments impact GS in older adults with DM, HTN or DM and HTN. This thesis also examined how GS changes over time (i.e., trajectories) in this population. This thesis is comprised of 3 manuscripts and was conducted using data from the National Health and Aging Trends Study (NHATS); a large, nationally representative sample of American older adults. Annual data collection began in 2011 and is ongoing. In 2015, the NHATS was replenished with approximately 50% new participants, to account for death and loss-to-follow-up. Therefore, data was analyzed in two cohorts: cohort A (individuals recruited in 2011) and cohort B (individuals recruited in 2015 and individuals recruited in 2011 who remained in the sample at the time of replenishment). In manuscript 1, latent class analysis was performed to identify multimorbidity patterns in older adults with DM, HTN or DM and HTN. Additionally, analysis of covariance (ANCOVA) was conducted to examine differences in GS among these multimorbidity patterns. This study identified a total of nine multimorbidity patterns in cohort A: two patterns in older adults with DM (low multimorbidity and cardiovascular-joint multimorbidity), three patterns in older adults with HTN (low multimorbidity, psychological multimorbidity and cardiovascular multimorbidity) and four patterns in older adults with DM and HTN (metabolic-cardiovascular-psychological-joint multimorbidity, metabolic-bone-joint multimorbidity, metabolic-cardiovascular-joint multimorbidity and metabolic multimorbidity). Additionally, this study identified a total of ten multimorbidity patterns in cohort B: two patterns in older adults with DM (low multimorbidity and joint multimorbidity), four patterns in older adults with HTN (cardiovascular-joint-respiratory multimorbidity, cardiovascular multimorbidity, psychological-joint multimorbidity and joint multimorbidity) and four patterns in older adults with DM and HTN (metabolic-cardiovascular-joint-respiratory multimorbidity, metabolic-psychological-joint multimorbidity, metabolic-bone-joint multimorbidity and metabolic-joint multimorbidity). Overall, multimorbidity patterns with larger numbers of chronic diseases patterns or patterns that included depression or anxiety were associated with the slowest GS. In manuscript 2, multinomial logistic regression was used to conduct state-based analyses which examined the relationship between impairments (i.e., hearing, and vision impairment, pain, balance, and lower extremity strength impairment) and GS transitions (i.e., fast to, intermediate walker, intermediate to slow walker etc.) in older adults with DM, HTN or DM and HTN. Balance and lower extremity strength impairment were associated with an increased risk of GS decline (i.e., transitioning from an intermediate to slow walker). Moreover, older adults with vision, hearing, balance, or lower extremity strength impairment and those who used pain medication at least 5 days/week were more likely to be slow walkers at baseline and remain slow walkers at follow-up. In manuscript 3, group-based trajectory modeling was used to identify longitudinal trajectories of GS in older adults with DM, HTN or DM and HTN. Multinomial logistic regression was then conducted to examine the correlates of these trajectories. This study identified four GS trajectories in both cohorts: i) fast-stable GS, ii) intermediate GS with slow decline, iii) intermediate GS with moderate decline and iv) slow GS with fast decline. Additionally, one trajectory was unique to cohort A: intermediate-stable GS and two trajectories were unique to cohort B: fast GS with slow decline, and intermediate GS with fast decline. In both cohorts, individuals who were older, Black (non-Hispanic), had a higher number of chronic diseases or higher body mass index (BMI) were more likely to belong to a trajectory group with faster GS decline. Conversely, individuals with higher education, or higher baseline GS were less likely to belong to a trajectory group with faster GS decline. From a population health perspective, findings from this thesis can inform large-scale monitoring and management strategies to mitigate GS decline in older adults with DM, HTN or DM and HTN. For example, individuals who are older, identify as Black non-Hispanic or those with a higher number of chronic diseases or higher BMI may benefit from more frequent monitoring of their GS. Moreover, findings from this thesis can be used to determine how older adults with different multimorbidity patterns, or different types of sensory and motor impairments respond to interventions. Lastly, older adults with DM and/or HTN should be educated about the importance of maintaining their GS as they age to prevent adverse outcomes including falls, hospitalization, and premature death. / Thesis / Doctor of Philosophy (PhD) / Diabetes and hypertension are common chronic diseases among older adults globally. Moreover, these two chronic diseases are frequently found in the same individual due to shared risk factors including physical inactivity, and family history. Additionally, older adults with diabetes and/or hypertension are at risk of developing complications including vision loss, heart disease and stroke. These complications often cause impairments (i.e., changes in body structure or function) which also occur with aging including vision and hearing impairment, pain, and balance impairment which may reduce physical function (e.g., walking speed). There is a need for research to examine which other chronic diseases are linked to diabetes and hypertension and the impact of these diseases and disease-related impairments on walking speed among older adults with diabetes and/or hypertension. Moreover, it is important to examine how walking speed changes over time (i.e., trajectories) in older adults with diabetes and/or hypertension. Results from this thesis show that older adults with diabetes and/or hypertension who used pain medication at least 5 days/week, had vision, balance, or lower extremity strength impairment as well as older adults who are female, Black non-Hispanic, had a higher number of chronic diseases and a higher body mass index were at greatest risk of reduced walking speed. On the other hand, higher education and higher baseline walking speed were linked to lower risk of walking speed decline. Older adults who were identified as “high-risk” may benefit from closer monitoring and management of their walking speed to prevent further decline.

Thesis (M.S.M.) PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / BACKGROUND/PURPOSE: Gait speed and walking endurance are measures of performance and overall health in older adults; however it is unclear whether measuring both provides additional clinically useful information over measuring just one. The purpose of this study is to systematically explore the co-variation of trajectories of speed and endurance over 8 years in healthy older adults, and to examine the association of knee extensor strength and cardiorespiratory impairment with distinct trajectories. Understanding such trajectories and their determinants will help clarify the utility of testing each outcome separately. METHODS: Data were obtained prospectively in a subset of the Health, Aging and Body Composition study (Health ABC), which included 2364 initially well-functioning men and women 70 to 79 years of age. Gait speed was determined from a 20-meter walk. Walking endurance was measured from a two-minute walk. The dual trajectories of gait speed and walking endurance were estimated using a group-based mixture model using SAS macro “PROC TRAJ”. The procedure calculates the probabilities of trajectory group membership for gait speed membership conditioning on walking endurance groups and vice versa. We also examined the association of knee extensor strength and cardiorespiratory impairment with distinctive trajectories adjusting for age, sex, and body mass index (BMI). RESULTS: We identified four gait speed trajectories and three walking endurance trajectories. Older adults with the greatest decline in gait speed and walking endurance slowed 0.032 m/s and 0.025 m/s per year, respectively. There was high correlation between gait speed and walking endurance trajectories, r= 0.84, p<0.0001. Less knee extensor strength and the presence of cardiorespiratory impairment were associated with membership in worse gait speed and walking endurance trajectories. After adjustment for walking endurance trajectories, only knee extensor strength was associated with worse gait speed trajectories. After adjustment for gait speed trajectories, both strength and cardiorespiratory impairments continued to be associated with walking endurance trajectories. CONCLUSIONS: There was high convergence of trajectories of gait speed and walking endurance. Therefore, changes in walking endurance can be inferred from measuring gait speed alone. However, cardiorespiratory impairment had a unique association with trajectories of walking endurance, but not gait speed. Therefore, measuring gait speed alone may not provide as much information as measuring walking endurance for those with cardiorespiratory impairment. / 2031-01-01

Bakgrund:Stroke är den vanligaste orsaken till neurologisk funktionsnedsättning i Sverige. Tiden efter insjuknandet i stroke delas in i tre återhämtningsfaser och patienter kan uppleva förbättringar under alla tre faser. Bålfunktion är grundläggande för gångförmåga och balans varför bålträning är en av flera fysioterapeutiska behandlingsmetoder vid rehabilitering av stroke. Viss tillförlitlighet finns avseende effekt av bålträning vid akut och subakut fas av stroke men den är oklar vid kronisk fas av stroke. Kunskapsläget behöver därför granskas och sammanställas.  Syfte: Att undersöka effekten av bålträning på gånghastighet och balans vid kronisk stroke.  Metod:Studiens design var en systematisk översikt där randomiserade kontrollerade studier inkluderades. Systematiska sökningar utfördes i databaserna PubMed, CINAHL och Web of Science samt kompletterande sökning i referenslista i Cochrane protokoll. Bedömning av artiklarnas kvalitet genomfördes enligt PEDro skalan och den sammanvägda tillförlitligheten granskades med modifierad förenklad GRADE. Resultat:Urvalsprocessen genererade tio artiklar, varav en artikel med låg kvalitet exkluderades från vidare granskning. En artikel bedömdes ha måttlig kvalitet och åtta artiklar bedömdes ha hög kvalitet enligt PEDro. Resultatet av granskningen visade på motstridiga resultat gällande effekter av bålträning på balans och gånghastighet samt en låg tillförlitlighet i den sammanvägda bedömningen. Konklusion:Utifrån denna systematiska översikt är det inte möjligt att fastställa bålträningens effekt på gånghastighet eller balans vid kronisk stroke. Översikten visar på motstridiga resultat samt låg tillförlitlighet i den sammanvägda bedömningen. Ytterligare forskning behövs för att fastställa bålträningens effekt på gånghastighet och balans vid kronisk stroke. / Background: Stroke is the most common cause of neurological disability in Sweden. Stroke is divided into different phases and improvements can occur several years after debut. Trunk function is fundamental for gait ability and balance, which is why trunk training is one of several physical therapy methods. Regarding the chronic phase of stroke, there is a need to compile state of evidence for trunk training. Purpose: To investigate the effect of trunk training on gait speed and balance in chronic stroke. Method: Literature review with randomized controlled trials included. Systematic searches were made in the databases PubMed, CINAHL and Web of Science and in the reference list of a Cochrane protocol. Quality assessment of the articles was done with PEDro and the combined reliability was examined with Modifierad förenklad GRADE. Results: The selection process generated ten articles, of which one low-quality article was excluded. one article were of moderate quality and eight of high quality. The results of the review showed conflicting results regarding the effects of trunk training on balance and walking speed, as well as a low reliability in the combined assessment.  Conclusion: Based on this systematic review, it is not possible to determine the effect of trunk training on walking speed or balance in chronic stroke. The overview shows conflicting results and low reliability in the combined assessment. Further research should determine the effect of trunk training on gait speed and balance in chronic stroke.

The United States is a rapidly aging nation. Older adults have higher rates of falls than any other age group. One in four older adults fall each year. Many of these falls are associated with sedentary lifestyles and decreased muscular strength effecting balance and gait performance. Physical activity (exercise) can reduce the risk of falls among older adults, yet adherence remains low. Exergames can increase adherence to interventions that promote health and physical activity. Social engagement can increase self-efficacy and motivation to exercise. By design, the Bingocize® health promotion mobile application (app) increases social engagement, while providing a multi-factorial fall prevention intervention. The purpose of this investigation was to evaluate the efficacy of the app to improve gait in community-dwelling older adults (N=38; mean age 72.42 years +12.58). Participants were clustered and randomly assigned to (a) experimental (n=20; using app with bingo game, health education and exercise) or (b) control (n=18; using app with bingo game, health education without exercise) condition. Each group completed a tenweek intervention that consisted of two- 45-60 minute sessions per week. Pre and post gait analysis, at self-selected (SS) and fast-walking speeds, measured using the GAITRite® Electronic Walkway (GWS). Gait analysis included parameters of velocity, cadence, step time, step length and width, and single and double support time. A mixedmodel ANOVA (p < .05) was used for statistical analysis. There were no main effects observed. Significant interactions (group x time) were observed at fast speed and SS speed compared to the control group. Significant interactions were observed at fast speed included velocity (λ = .886, F (1, 36) = 4.61, p = .039, 𝜼𝒑 𝟐 = .114); and step length (λ = .864, F (1, 36) = 5.64, p = .023, 𝜼𝒑 𝟐 = .136); and were observed at SS speed for single support time (λ = .887, F (1, 36) = 4.59, p = .039, 𝜼𝒑 𝟐 = .113). Post hoc analyses using paired and independent samples t-tests were conducted on gait variables with observed significant interactions. The independent samples t-test for Single Support Time (SS) post was significant (t (36) = 2.454, p = .019, two-tailed). None of the remaining post hoc analyses were significant. There was a meaningful detectable change (MDC) in mean velocity (>5 cm/s) over time, for both SS and fast walking speeds, within the experimental condition. MDC in gait speed ranges from 5 cm/s (small) to 10 cm/s (large). As for clinical significance, this should be considered a small, yet meaningful detectable change. It is the conclusion of the investigators, that the app, with the exercise intervention, can effectively produce a meaningful change in gait speed (5 cm/s), which has the potential for reducing the risk of falls in older adults. This investigation was funded by The Retirement Research Foundation.

Background: High blood pressure (BP) is the leading risk factor for disease and mortality worldwide. However, risks associated with high BP in very old age (≥ 80 or ≥ 85 years) are not entirely understood, as the majority of scientific studies have been performed with younger populations and existing scientific knowledge about very old individuals is sometimes contradictory. Results of previous studies of very old individuals suggest that the associations of BP with mortality and stroke differ with levels of physical and cognitive function. More studies that are representative of very old individuals, including individuals with multimorbidity, that are of adequate size, involve proper adjustment, and investigate non-linear associations, are needed to investigate these issues. Systolic blood pressure (SBP) decline is common among very old individuals and has been shown to precede adverse events. Previous studies have shown that SBP change is associated with baseline SBP, age, and health-related factors, but determinants of SBP change have not been investigated using comprehensive, multivariate models. The three main aims of this thesis were to investigate, in a sample of individuals aged ≥ 85 years, 1) determinants of SBP change, 2) the association of BP with mortality risk and whether this association differs with respect to gait speed and/or Mini-Mental State Examination (MMSE) score, and 3) the association of BP with stroke risk and whether this association differs with respect to the Barthel Activities of Daily Living (ADL) index and/or MMSE score. Methods: The studies conducted for this thesis were based on data from the population-based Umeå 85+/Gerontological regional database study, which provided cross-sectional and longitudinal data on socioeconomic factors, medical conditions, drug prescriptions, and health-related assessments from 2000 to 2015. Participants were aged 85, 90, and ≥ 95 years, and lived in Västerbotten, Sweden, and Österbotten/Pohjanmaa, Finland. Follow-up assessments were conducted after 5 years. Mortality data were collected after 2 and 5 years, and stroke data were collected after 5 years, from death certificates, medical records, population registers, and the inpatient diagnosis register. Comprehensive multivariate models were developed to investigate determinants of SBP change using multiple linear regression, and to investigate associations of mortality and stroke risks with BP using Cox proportional-hazard regression models. Results: Average (± standard deviation) baseline SBP was 146 ± 23 mm Hg, and average diastolic blood pressure (DBP) was 74 ± 11 mm Hg. Within 5 years, 61% of participants had died and 10% had had incident strokes. Among participants followed for 5 years, the average annual SBP decline was 2.6 ± 5.4 mm Hg. In a multivariate model, SBP decline was associated with later investigation year (p = .009), higher baseline SBP (p &lt; .001), baseline antidepressant drug use (p = .011), incident acute myocardial infarction during follow-up (p = .003), use of a new diuretic drug during follow-up (p = .044), and declining Barthel ADL index scores during follow-up (p &lt; .001). In an age- and sex-adjusted analysis of the total sample, mortality risk was decreased in higher (vs. lower) BP categories (SBP ≥ 165 vs. ≤ 125 mm Hg: hazard ratio [HR] .50, p &lt; .001; DBP 70–74 vs. 75–80 mm Hg: HR 1.32, p = .031). In a comprehensively adjusted analysis of the total sample, SBP was not associated significantly with mortality risk. The associations of SBP with mortality in the gait speed &lt; .5 m/s subcohort corresponded with those found in the total sample. In comprehensively adjusted analyses in the gait speed ≥ .5 m/s subcohort, mortality risk increased independently with higher (vs. lower) BP (SBP ≥ 165 vs. 126–139 mm Hg: HR 2.13, p = .048; DBP &gt; 80 vs. 75–80 mm Hg: HR 1.76, p = .026). In comprehensively adjusted analyses in the MMSE score subcohorts, SBP was associated significantly with mortality risk only in the 0–10 MMSE score subcohort; high and low SBP categories were associated independently with increased mortality risk, compared with an intermediary SBP category (SBP ≥ 165 vs. 126–139 mm Hg; HR 4.54, p = .007; SBP ≤ 125 vs. 126–139 mm Hg: HR 2.23, p = .023). Higher BP was associated significantly with increased stroke risk in multivariate models (SBP per 10 mm Hg increment: HR 1.19, p &lt; .001; DBP per 10 mm Hg increment: HR 1.26, p = .013). SBP was not associated with stroke risk in participants with SBP &lt; 140 mm Hg. Interaction effects on the association with mortality were significant between SBP and gait speed (age- and sex-adjusted model: p = .031) but not between SBP and MMSE score. No interaction in the association with stroke was found between any BP measure and Barthel ADL index or MMSE score. Conclusion: The decline in BP in very old age may be explained by health-related factors. Low BP may be a risk marker for short life expectancy, due to morbidity, in the general very old population and among very old individuals with low gait speeds. High BP seems to be an independent risk factor for mortality only in certain groups, which may be distinguished by high gait speed or very severe cognitive impairment. High SBP and DBP seem to increase stroke risk in very old age. These findings may contribute to a better understanding of the risks of adverse outcomes in very old individuals with different BP levels, the importance of comorbidity for these risks, and the etiology of SBP change. / Bakgrund: Högt blodtryck är den största bidragande orsaken till sjukdom och död i världen. Man har ännu inte fastslagit om högt blodtryck ökar risken för sjukdom och död även i mycket hög ålder, vilket kan definieras som 80 år och äldre. Detta beror bland annat på att endast en liten andel av forskningen hittills har fokuserat på den här åldersgruppen. Mycket gamla människor skiljer sig från yngre på olika sätt som skulle kunna påverka riskerna med högt blodtryck. Till exempel är det vanligare med sjukdomar och att ha många samtidiga sjukdomstillstånd bland mycket gamla människor än i yngre åldersgrupper. Då andelen mycket gamla människor i befolkningen ökar kraftigt får dessa frågor allt större betydelse. Det är vanligt med sjunkande blodtryck i mycket hög ålder, något som verkar föregå sjukdom och död. Tidigare studier har funnit att sjunkande blodtryck skulle kunna bero på ökande sjuklighet, högre ålder och högre begynnelseblodtryck. Man vet ännu inte vilka enskilda faktorer som bäst förklarar blodtrycksförändringen i mycket hög ålder, oberoende av andra faktorer. Tidigare studier har visat att lägre blodtryck kan vara förenat med en ökad risk för tidig död bland mycket gamla människor. Det är oklart om risken för tidig död bättre kan förklaras av andra faktorer, s.k. störfaktorer. Störfaktorer kan till exempel vara sjukdomar som både påverkar blodtrycket och risken. Fynd från tidigare studier av personer som är minst 65 år tyder på att sambandet mellan blodtryck och död kan skilja sig mellan grupper med hög eller låg gånghastighet, vilket används som ett ungefärligt mått på hälso-tillståndet. Detta skulle även kunna ha betydelse för mycket gamla människor eftersom deras hälsotillstånd kan skilja sig mycket mellan individer. Man har också utrett huruvida sambandet mellan blodtryck och död skiljer sig mellan grupper med och utan kognitiv svikt, som till exempel kan bero på demenssjukdom, men inte kommit fram till entydiga resultat. Ett fåtal studier har utrett strokerisken med högt blodtryck i mycket hög ålder. På grund av motsägelsefulla resultat är det ännu oklart om högt blodtryck ökar risken för stroke bland mycket gamla människor. Man har sett tecken på att sambandet mellan blodtryck och strokerisk skulle kunna skilja sig mellan grupper av mycket gamla människor med och utan kognitiv svikt, samt mellan grupper med och utan hjälpbehov i dagliga aktiviteter. Dagliga aktiviteter innefattar bland annat att tvätta sig, klä sig, gå på toaletten, äta och resa sig från en stol. Frågeställningar: I den här avhandlingen undersöktes huvudsakligen tre frågeställningar. Den första var vilka faktorer som påverkar hur blodtrycks-nivåerna förändras över tid i mycket hög ålder. Den andra frågeställningen var om olika blodtrycksnivåer är förenade med ökad risk för tidig död i mycket hög ålder och huruvida risken skiljer sig mellan grupper av mycket gamla människor med olika gånghastighet eller olika grader av kognitiv svikt. Den tredje frågeställningen var om olika blodtrycksnivåer är förenade med ökad risk för stroke i mycket hög ålder och om risken skiljer sig mellan grupper av mycket gamla människor med och utan kognitiv svikt eller hjälpbehov i dagliga aktiviteter. Även skillnader mellan gånghastighets-grupper testades. Metod: Avhandlingen bygger på befolkningsmaterialet Umeå85+/Gerontologisk regional databas (GERDA). Umeå85+/GERDA innehåller information från individer i åldrarna 85, 90 och 95 år och äldre, boende i Västerbotten, Sverige och Österbotten/Pohjanmaa, Finland. Informationen är insamlad vart femte år under perioden 2000-2015. Umeå85+/GERDA innehåller information om socioekonomiska faktorer, sjukdomar och läkemedel. Informationen inhämtades med hjälp av ett standardiserat frågeformulär som deltagarna besvarade under ett hembesök, samt med hjälp av journaler, boendepersonal och anhöriga. Det gjordes även hälsorelaterade mätningar och tester under hembesöken, bl.a. av blodtryck och gånghastighet i vanlig takt. Skattningsskalorna Mini-Mental State Examination (MMSE) och Barthel Activities in daily living (ADL) index användes för att skatta kognitiv funktion respektive hjälpbehov i dagliga aktiviteter. Deltagarna delades in i två gånghastighetsgrupper. Personer med högre gånghastighet (minst 0,5 m/s) utgjorde en grupp. I den andra gruppen var personer med lägre gånghastighet (under 0,5 m/s) och de som inte klarade av att genomföra testet på grund av bestående begränsningar av gångfunktionen. Deltagarna grupperades också med avseende på olika grader av kognitiv svikt. Gruppindelningen baserades på MMSE-poäng; mycket svår kognitiv svikt (0-10 poäng), svår kognitiv svikt (11-17 poäng) och mild kognitiv svikt (18-23 poäng). Deltagare utan kognitiv svikt utgjorde en egen grupp (24-30 poäng). Deltagarna delades även in i grupper med och utan hjälpbehov i dagliga aktiviteter, baserat på Barthel ADL index (under 20 respektive 20). Blodtrycksförändring observerades över tiden mellan två Umeå85+/GERDA-insamlingar, vilket var 5 år. Dödsdatum och datum för stroke inhämtades från dödsbevis, befolkningsregister, journaler och sjukvårdens diagnoskodsregister i upp till 5 år. Frågeställningarna utreddes med hjälp av statistiska metoder, baserat på materialet från Umeå85+/GERDA. Sambanden prövades med avseende på störfaktorer och skillnader mellan grupper. Resultat: Förändringar av det systoliska blodtrycket undersöktes bland 297 deltagare. I genomsnitt sjönk blodtrycket med 2,6 mm Hg per år. För nästan två tredjedelar (62%) av deltagarna sjönk blodtrycket med minst 5 mm Hg på 5 år. Ungefär en fjärdedel (26%) hade minst 5 mm Hg stigande blodtryck på 5 år. Ett antal faktorer var förenade med förändring av det systoliska blodtrycket över 5 år, oberoende av varandra. Sjunkande systoliskt blodtryck var förenat med ett högre begynnelseblodtryck, senare undersökningsår, att ha antidepressiv behandling, att få en hjärtinfarkt, att påbörja läkemedels-behandling med diuretika eller få ökat hjälpbehov i dagliga aktiviteter. Man vet ännu inte vad som är orsak och verkan i dessa samband. Frågeställningen om olika blodtrycksnivåer är förenade med ökad risk för tidig död undersöktes i ett urval av 806 deltagare. Inom 5 år avled nästan två tredjedelar (61%) av deltagarna. Risken för tidig död var mindre bland deltagare med högre blodtryck, jämfört med dem som hade lägre blodtryck. Största skillnaden uppmättes mellan deltagare med minst 165 mm Hg i systoliskt blodtryck, där risken var halverad, jämfört med dem som hade 125 mm Hg eller lägre. Detta samband verkar bero på störfaktorer, främst sjukdomar, som både orsakar lågt blodtryck och den ökade risken för tidig död. Gånghastighetsgrupperna utgjordes av 312 deltagare med högre gånghastighet och 433 med lägre gånghastighet, varav 136 inte kunde genomföra mätningen på grund av bestående begränsning av gångfunktionen. Sambandet mellan blodtryck och risken att dö inom 5 år verkade skilja sig mellan gånghastighetsgrupperna. Gruppen med lägre gånghastighet uppvisade samma samband som hela urvalet och hade ökad risk för tidig död med lägre blodtryck. Även här verkade sambandet förklaras av störfaktorer. Personer med högre gånghastighet uppvisade ett annat samband, där högre systoliskt blodtryck på minst 165 mm Hg var förenat med en fördubblad risk för tidig död, jämfört med 126-139 mm Hg. Högre diastoliskt blodtryck på över 80 mm Hg var också förenat med ökad risk för tidig död, jämfört med 75-80 mm Hg. Sambandet berodde inte på störfaktorer. Grupperna med svår, måttlig och mild kognitiv svikt innehöll 118, 166 och 289 deltagare vardera. Gruppen utan kognitiv svikt innehöll 542 deltagare. Dessa grupper verkade också skilja sig något med avseende på sambandet mellan blodtryck och risken för tidig död, men skillnaderna var inte statistiskt säkerställda. Särskilt gruppen med mycket svår kognitiv svikt uppvisade ett annorlunda samband mellan systoliskt blodtryck och risken för tidig död, jämfört med övriga deltagare. Bland dessa deltagare var risken för tidig död mer än fyrdubblad med höga blodtryck på minst 165 mm Hg, jämfört med 126-139 mm Hg. De med blodtryck 125 mm Hg eller lägre hade dubbelt så hög risk för tidig död, jämfört med 126-139 mm Hg. Dessa samband var oberoende av störfaktorer. Frågeställningen om strokerisk med högt blodtryck utreddes i ett urval av 955 deltagare. Inom 5 år fick 94 deltagare en stroke, vilket motsvarar en av tio. Högre blodtryck var förenat med ökad risk för stroke, jämfört med lägre blodtryck. Risken att få en stroke inom 5 år var fördubblad bland deltagare med högt systolisk blodtryck på minst 160 mm Hg, jämfört med under 140 mm Hg, eller med höga diastoliska blodtryck på minst 90 mm Hg, jämfört med under 90 mm Hg. Sambanden var oberoende av en mängd andra riskfaktorer. Strokerisken med högt blodtryck verkade inte påverkas av gånghastigheten, den kognitiva nivån, eller hjälpbehovet i dagliga aktiviteter. Slutsatser: Blodtrycket verkar sjunka hos de flesta i mycket hög ålder. Sjunkande systoliskt blodtryck kan till stor del förklaras av högre begynnelseblodtryck, senare undersökningsår, att ha antidepressiv läkemedelsbehandling, att få en hjärtinfarkt, att påbörja läkemedels-behandling med diuretika eller få ökat hjälpbehov i dagliga aktiviteter. Lågt blodtryck verkar i mycket hög ålder vara ett tecken på olika underliggande sjukdomsprocesser, som ökar risken att dö inom 5 år. Detta samband verkar särskilt gälla personer med lägre gånghastighet, vilket kan vara ett tecken på sämre hälsa. Högt blodtryck verkar endast vara förenat med ökad risk för tidig död i särskilda grupper, som kan utmärkas av högre gånghastighet eller mycket svår kognitiv svikt. Även lågt systoliskt blodtryck kan vara förenat med ökad risk för tidig död bland personer med mycket svår kognitiv svikt. I dessa grupper kan sambandet vara oberoende av störfaktorer. Högre blodtryck verkar vara förenat med ökad risk för stroke i mycket hög ålder, oberoende av en mängd andra sjukdomstillstånd. Det finns sannolikt en gräns för hur lågt blodtryck som är gynnsamt med avseende på strokerisken, men det är ännu inte klarlagt var den gränsen går. Sambandet mellan högt blodtryck och strokerisk verkar inte skilja sig mellan grupper med olika hög gånghastighet, kognitiv nivå, eller hjälpbehov i dagliga aktiviteter. Dessa fynd kan bidra till en bättre förståelse för blodtrycksförändring, risker med högt och lågt blodtryck i mycket hög ålder samt hälsotillståndets betydelse för dessa risker.

No description available.

Parkinsons sjukdom drabbar 15 av 10 000 personer. Sjukdomen kan påverka gången genom freezing, då individen stannar upp och är oförmögen att fortsätta att gå. Detta är ett mycket besvärande symtom som kan behandlas med olika cueingstrategier. Även gånghastighet kan förbättras med hjälp av cueingstrategier. I den senaste litteraturstudien var evidensen för cueing oenig. Syftet med litteraturöversikten var att undersöka om evidensen för auditiv och visuell cueings effekt på freezing och gånghastighet har stärkts sedan den senaste litteraturstudiens kartläggning. En deskriptiv design valdes för litteraturöversikten. Sju artiklar från databaserna PubMed, Amed, PEDro och Cinahl uppfyllde inklusionskrierierna och granskades enligt PEDro scale. Auditiva och visuella cueingstrategier minskade freezing och hade varierande effekt på gånghastighet. Flera studier kombinerade båda cueingstrategierna tillsammans eller med annan träning. Vidare studier där enbart en cueingstrategi används behöver göras för att fastställa vilken cueingstrategi som ger vilken effekt. / Parkinson’s disease affects 15 of 10 000 people. The disease can affect gait through freezing, which is when the individual stagnates, unable to continue walking. This disabling symptom can be managed with cueing strategies. Gait speed can also improve with cueing. The latest literature review that examined cueing showed disagreeing results. The aim of this literature review was to investigate if the evidence for the effect of auditory and visual cueing on freezing and gait speed has improved since the latest review. A descriptive design was chosen. Seven articles from the databases PubMed, Amed, PEDro and Cinahl met the inclusion criteria and were analyzed with PEDro scale. Auditory and visual cueing decreased freezing and showed varying results on gait speed. Several studies combined both cueing strategies with each other and other training. Future research that only uses one cueing strategy is needed to determine the effects of each strategy.

Background: Stroke is the leading cause of disability in the United States. Physical therapists treating patients post acute stroke use measurement tools specifically designed to measure gait and balance ability. People with sub-acute stroke typically have rapid and large changes in gait and balance ability while undergoing inpatient physical therapy. There is a lack of information about how much change in gait speed is needed in hospitalized people with sub-acute stroke to be considered an important amount. There is no information regarding the validity, and reliability of the Tinetti Performance Oriented Mobility Assessment (POMA) to measure balance ability in people with stroke or how much change is needed to be important to people in the sub acute phases of stroke. Objective: The purpose of this study was to 1) estimate minimal clinically important difference (MCID) for comfortable gait speed in persons who have experienced stroke and are undergoing inpatient physical therapy using 3 different anchors of change; 2) estimate minimal clinically important difference (MCID) for Tinetti POMA in persons who have experienced stroke and are undergoing inpatient physical therapy using 3 different anchors of change; 3) determine the test retest reliability and minimal detectable change (MDC) for the Tinetti POMA; and 4) explore the construct validity of the Tinetti POMA for use in people with stroke undergoing inpatient physical therapy. Study Design: This study was a prospective, longitudinal study, which followed a cohort of patients who were undergoing inpatient physical therapy post acute stroke. Methods: Participants were recruited if they had a first documented stroke and were receiving physical therapy during inpatient rehabilitation. Participants were excluded from the study if they had a history of a previous stroke, were medically unstable, were non-English speaking or were unable to walk without assistance prior to the current stroke event. Comfortable gait speed measured by a 5-meter walk test, Tinetti POMA scores and motor Functional Independence Measure (FIMTM) scores were collected at admission to and discharge from inpatient rehabilitation. To determine test re-test reliability, two trials of comfortable gait speed were administered during the same treatment session and two trials of Tinetti POMA were performed one day apart. Global Rating of Change (GROC) scores were collected at discharge from inpatient rehabilitation. A score of 6 (¡°a great deal better, an important amount¡±) on a Global Rating of Change scale and achievement of ¡Ý17 point change on the motor FIM was used to dichotomize participants into those who had important change in walking and balance ability and those who did not. Receiver operator characteristic (ROC) curves were constructed to estimate important change values for gait speed using the three anchors. Effect Size (ES) index was used to determine the responsiveness of gait speed and the Tinetti POMA, Intraclass Correlation Coefficient (ICC2,1) was used to determine test re-test reliability and MDC values for gait speed and Tinetti POMA and Spearman¡¯s Rho (rs) was used to explore the construct validity of the Tinetti POMA. Results: The participants in this study were 43 people with average age of 76¡À11 years who had experienced first documented stroke, began inpatient physical therapy at a mean of 8¡À5 days post stroke and were discharged from the hospital at an average of 38¡À11 days post stroke. The mean length of stay for all participants was 23¡À11 days. MCID of comfortable gait speed was estimated to be 0.24 m/s (AUC= 0.644 , sn/sp=66%/64%, LR+=1.83, LR-0.54) anchored to motor FIM change scores. Test re-test reliability of gait speed was ICC2,1=0.931 at admission and ICC2,1=0.987 at discharge. MDC of comfortable gait speed was 0.12 m/s at admission and 0.08 m/s at discharge. MCID of the Tinetti POMA was 7 points (AUC=0.743, sn/sp=79%/64%, LR+=2.18, LR-=0.32) anchored to motor FIM change. Test re-test reliability of the Tinetti POMA was ICC2,1 0.859 and MDC was 5 points. Tinetti POMA scores were moderately correlated to motor FIM and gait speed scores at admission (rs=0.74 and 0.67) and discharge (rs=0.60 and 0.76) to gait speed and motor FIM scores. Conclusions: People with stroke who experience a 7 point change on the Tinetti POMA during inpatient rehabilitation are likely to experience an important change in functional mobility. The Tinetti POMA demonstrates validity and reliability to measure balance ability people with stroke. More research is needed to estimate meaningful change people with sub-acute stroke using larger cohorts with similar characteristics.

Les problèmes d’équilibre associés aux déficits sensorimoteurs chez les personnes hémiparétiques après un accident vasculaire cérébral (AVC) sont un facteur de risque de chutes lors d’activités locomotrices. Cette thèse avait pour but d’approfondir les connaissances sur les capacités d’équilibre de ces personnes dans des tâches de marche et de les comparer avec celles des personnes en santé. Le premier objectif visait à quantifier la difficulté à maintenir l’équilibre dynamique (c.-à.-d. lié au déplacement du corps) et postural (c.-à.-d. lié à l’alignement des segments du corps) des personnes hémiparétiques lors de la marche sur tapis roulant. Le second objectif était de mieux comprendre les relations entre l’équilibre et les modifications du patron de marche liées aux déficits associés à l’AVC telles que la réduction de la vitesse de marche et l’asymétrie, ou liées à certaines interventions de réadaptation, telles que l’utilisation d’un tapis roulant à double courroie avec des vitesses inégales ou l’ajout d’une charge à la cheville. Les résultats ont montré que les personnes hémiparétiques avaient moins de difficulté à maintenir leur équilibre que les personnes en santé lorsqu’elles marchaient à leur vitesse confortable (étude no1). Cependant, à vitesse équivalente, la difficulté à maintenir l’équilibre était plus grande pour les personnes hémiparétiques que pour celles en santé (étude no1). L’évaluation de l’effet sur le patron de marche et l’équilibre d’une marche sur un tapis roulant avec des vitesses de courroies inégales puis égales a montré que les personnes âgées en santé avaient des capacités d’adaptation et de désadaptation, objectivées par des changements des forces de réaction du sol, similaires à celles de jeunes adultes en santé (étude no2). Toutefois, l’équilibre des personnes âgées, mesuré par la différence des forces de réaction au sol lors des phases de freinage et de propulsion, était plus affecté par les vitesses de courroie inégales que celui des jeunes adultes (étude no2). Chez les personnes hémiparétiques, une marche plus symétrique ne modifiait pas la difficulté à maintenir l’équilibre (étude no3). Toutefois, l’équilibre était plus affecté lors de l’appui sur le membre inférieur qui avait été placé sur la courroie lente lors de la marche avec les vitesses de courroies inégales (étude no3). Finalement, l’ajout d’une charge à la cheville, placée du côté non parétique puis du côté parétique, lors de la marche n’affectait pas l’équilibre dynamique des personnes hémiparétiques, mais facilitait leur équilibre postural (étude no4). En résumé, ces résultats suggèrent que les personnes hémiparétiques réduisent leur vitesse de marche pour maintenir leur équilibre. De plus, leur équilibre est affecté par le protocole de marche sur tapis roulant avec des vitesses de courroies inégales, mais il ne l’est pas parce que le patron de marche est devenu plus symétrique. Enfin, l’ajout d’une charge à la cheville reste une approche pertinente pour améliorer la marche, toutefois elle n’est pas indiquée pour entraîner l’équilibre des personnes hémiparétiques. La prise en compte de la vitesse de marche lors de l’évaluation de l’équilibre et un entraînement à des vitesses de marche plus rapides que la vitesse confortable sont des facteurs importants à considérer pour la réadaptation des personnes post-AVC. / Balance problems associated with sensorimotor impairments in individuals with hemiparesis post-stroke are a risk factor for falls during locomotion. This thesis aimed to foster knowledge on balance ability in this post-stroke population during locomotor tasks compared to healthy individuals. The first objective was to quantify difficulty in maintaining dynamic (i.e. related to body displacements) and postural (i.e. related to segment alignment) balance among individuals post-stroke walking on a treadmill. The second objective was to better understand the relationship between balance and gait pattern changes associated with stroke-related deficits such as reduced gait speed and asymmetry, or those associated with certain rehabilitation interventions such as using a split-belt treadmill with asymmetrical belt speeds or adding a load on the ankle. The results showed that individuals post-stroke had less difficulty in maintaining balance than their healthy counterparts when they walked at a self-selected speed (study #1). However, at a similar speed, the stroke group experienced greater difficulty in maintaining balance than the healthy group (study #1). Assessment of how walking on a split-belt treadmill with both asymmetrical and symmetrical belt speeds affects gait pattern and balance showed that healthy older individuals had similar ability in adapting and de-adapting, as demonstrated by changes in ground reaction forces, compared to healthy young adults (study #2). However, balance among older individuals, as measured by the difference in ground reaction forces during the braking and propulsive phases, was more affected by asymmetrical belt speeds than young adults (study #2). In individuals post-stroke, a more symmetrical gait pattern did not alter difficulty in maintaining balance (study #3). However, balance was more affected during the stance phase of the leg on the slow belt when walking with asymmetrical belt speeds (study #3). Finally, adding a load on the ankle, placed on the non-paretic side then on the paretic side, when walking did not affect dynamic balance among individuals post-stroke, but it did improve their postural balance (study #4). In summary, these results suggest that individuals post-stroke reduce their gait speed in order to maintain their balance. Moreover, the split-belt treadmill protocol does affect their balance but not as a result of their gait pattern becoming more symmetrical. Finally, adding a load on the ankle remains a relevant approach to improve gait function, however, it is not recommended to train balance in individuals post-stroke. Lastly, adding a load on the ankle is not a recommended balance training method. Gait speed when assessing balance and gait training at speeds faster than a self-selected gait speed are important factors to consider during rehabilitation of individuals post-stroke.

Abstract available through Physical Therapy.