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Balance disorders and falls are prevalent among multiple pathologies that affect the musculoskeletal or sensorineural systems. Annually, fall-related injuries put excessive economic burden on society and yet, current clinical balance assessment tools based on functional tests are inaccurate and have limited association with fall risk. Therefore, there is a growing need of an accurate balance and fall risk assessment tool for clinical use. The primary purpose of this research was to develop an accurate Center of Pressure (COP) based balance assessment tool to study postural instability and fall risk. Chapter 1 aimed at development of the COP based tool using cost effective equipment- a Wii Balance Board (WBB) and testing its accuracy and errors. The result of this study indicated that the WBB tool is reliable in assessing balance and the linearity and hysteresis errors in WBB tool are higher than force plates but it compares well in terms of cost, portability and availability. Chapter 2 aimed at assessing the relation between the radiographic parameters of balance, COP metrics, and health related quality of life in adults with spinal deformities. The results of this investigation revealed that just like radiographic parameters, COP metrics could help explain some variability in symptoms in patients with comparable extent of deformity. Chapter 3 attempted to establish a threshold value of COP metrics for binary classification of fall risk in patients with multiple sclerosis (MS). The findings of this study highlighted path length as an excellent predictor of future falls with high test accuracy, sensitivity and specificity. This dissertation concludes that the WBB tool has the potential to revolutionize balance and fall risk assessment in clinical fields such as geriatrics, rehabilitation, neurology, and orthopedics.

Quality of life (QOL) is an important aspects of overall well-being in older adults. QOL is associated with functional, physical, and psychological health; all of which can be improved with increased physical activity. A high fall risk is associated with low physical function and QOL. One in four older adults experiences a fall each year, making it necessary to focus public health interventions towards decreasing fall risk and improving QOL in older adults. Bingocize® is a health promotion program designed to promote health, health knowledge, physical activity, and social engagement among older adults. The purpose of this study was to determine the effects of the new version of Bingocize® on QOL and fall risk in community-dwelling older adults (N=36; mean age 73.63 ± 6.97). Participants were clustered and randomly assigned to (a) experimental (n=19; participating in Bingocize® program, which included the bingo game, exercise, and health education) or (b) control (n=17; only played bingo). Each group completed a 12-week intervention that consisted of two 45-60 minute sessions per week. Pre and post data assessments included the TUG, 30-second chair stand, 4-staged balance, handgrip strength, WHOQOL-BREF, PANAS, and a health knowledge quiz. A mixed design analysis of variance (ANOVA) was used to compare intervention effects. There were no significant interactions for any of the variables, with the exception of positive affect (PA) (F (1,34) = 5.66, p = 0.02, 𝜂𝑝 2 = 0.15, power = 0.64) and handgrip strength (F (1,34) = 8.31, p = 0.007, 𝜂𝑝 2 = 0.196, power = 0.80).. There was also a significant main effect for time for health knowledge. Post hoc analysis using independent samples t-tests were conducted on PA (t (33) = 2.39, p = 0.023, two-tailed) and handgrip strength (t (34) = 2.85, p = 0.007, two-tailed). Participating in the Bingocize® health promotion program can produce a meaningful and detectable change in handgrip strength and PA in community-dwelling older adults.

Introduction The consequences of falling can be fatal to elderly. The mortality, morbidity and the risk ofanxiety and depression increases following a fall. Drug prescription is a preventable fall risk,making the association between antihypertensive medications and risk of falling an importantarea of investigation. Aim Compile the results from studies which have examined the effect of initiating or changing theantihypertensive medication on fall risk in people aged 60 years or older. Methods Data sources: MEDLINE and Cochrane databases. Study selection: Original articles ofcohort-, case control-, case crossover-, cross-sectional- and randomized controlled trial type,published between January 2000 and May 2019 and written in English were included. Dataassessment: 6 studies met the criteria and were included. Study quality was assessed for eachstudy. Results Three studies found significant short-term increase in fall risk, regardless of drug type. Onestudy discovered an 18% increase in fall risk for every 5-day gap in treatment. Two studiesevaluated antihypertensive drug types separately and found contradictive results of thiazidediuretics on short-term fall risk. Calcium channel blockers showed a protective effect andbeta blockers an increased risk during the first 3 weeks after initiating treatment. Conclusions No consistent consensus was seen regarding the short-term fall risk in separateantihypertensive drug types, though most studies agree in a short-term risk increase aftergeneral antihypertensive treatment initiation or change.

Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with chronic obstructive pulmonary disease (COPD). The main objective of this thesis was to describe balance impairment and fall risk in individuals with COPD and to examine interventions for improving balance and reducing fall risk in the context of pulmonary rehabilitation. The first study of this thesis showed that falls are common in patients with COPD and that fallers are characterized by impairments in standard clinical balance measures, such as the Berg Balance Scale and Timed Up and Go. In the second study, we found that the exercise component of conventional pulmonary rehabilitation has only modest effects on balance and fall risk in COPD, highlighting the need to examine the role of balance-specific training for these patients. The third study of this thesis identified the postural control subsystems most responsible for the observed balance deficits in COPD. Compared with age-matched controls, individuals with COPD demonstrated reductions in all balance control subsystems and slower reaction times in response to external perturbations. In this study, we also showed that deficits in balance in patients with COPD were associated with peripheral muscle weakness and reduced physical activity levels. These results informed the design of the final study of this thesis, a randomized controlled trial evaluating the addition of specific balance training to pulmonary rehabilitation for improving balance in patients with COPD. Preliminary results from this study suggest that the addition of thrice weekly balance exercises to a conventional pulmonary rehabilitation program is effective for optimizing gains in measures of functional balance and fall risk. The findings from the four studies included in this thesis support the need for incorporating balance assessment and treatment for at-risk patients with COPD, as part of their comprehensive management.

Unilateral, below-knee amputees have altered gait mechanics, which can significantly affect mobility. For example, amputees often have asymmetric leg loading as well as higher metabolic cost and an increased risk of falling compared to non-amputees. Below-knee amputees lose the functional use of the ankle muscles, which are critical in non-amputee walking for providing body support, forward propulsion and leg-swing initiation. The ankle muscles also regulate angular momentum in non-amputees, which is important for providing body stability and preventing falls. Thus, compensatory mechanisms in amputee walking are developed to accomplish the functional tasks normally provided by the ankle muscles. In Chapters 2 and 3, three-dimensional forward dynamics simulations of amputee and non-amputee walking were generated to identify compensatory mechanisms and their effects on joint loading and metabolic cost. Results showed that the prosthesis provided body support, but did not provide sufficient body propulsion or leg-swing initiation. As a result, compensations by the residual leg gluteus maximus, gluteus medius, and hamstrings were needed. The simulations also showed the intact leg tibio-femoral joint contact impulse was greater than the residual leg and that the vasti and hamstrings were the primary contributors to the joint impulse on both the intact and residual legs. The amputee simulation had higher metabolic cost than the non-amputee simulation, which was primarily due to prolonged muscle activity from the residual leg gluteus maximus, gluteus medius, hamstrings, vasti and intact leg vasti and ankle muscles. In Chapter 4, whole-body angular momentum in amputees and non-amputees was analyzed. Reduced residual leg propulsion resulted in a smaller range of sagittal plane angular momentum in the second half of the gait cycle. Thus, to conserve angular momentum, reduced braking was needed in the first half of the gait cycle. Decreased residual leg braking appears to be an important mechanism to regulate sagittal plane angular momentum in amputee walking, but was also associated with a greater range of angular momentum that may contribute to reduced stability in amputees. These studies have provided important insight into compensatory mechanisms in below-knee amputee walking and have the potential to guide rehabilitation methods to improve amputee mobility. / text

OBJECTIVES: To assess whether the Minimal Chair Height Standing (MCHS) test, could effectively identify “fallers” in a population of Canadian older adults, and to compare its effectiveness with the commonly used Sit-to-Stand (STS) test. DESIGN: Cross-sectional with counter-balanced assignment of testing order. SETTING: Community centers, independent-living and assisted-living facilities. PARTICIPANTS: 167 older adults (mean age=83.6yrs), able to walk independently. MEASUREMENTS: Participants were interviewed for medical conditions, physical activity, cognitive status (Mini Mental State Examination), mobility and independence (Independent Activities of Daily Living). Height, weight and shank length were measured. Fall history was self-reported and recorded retrospectively. The main outcome measures were MCHS and STS scores. RESULTS: MCHS performance was significantly worse for fallers (37.7cm, 95% CI: 35.5-40.0cm) than non-fallers (30.3cm, 95% CI: 28.1-32.5cm). Fallers showed significantly slower times in the STS. For participants with cardiac disease and/or stroke, MCHS scores discriminated between fallers and non-fallers (p=.001), but the STS did not (p=.233). For participants with knee replacements, MCHS discriminated between fallers and non-fallers (p=.044) but the STS did not (p=.076). CONCLUSIONS: The MCHS was found to be simple, practical and feasible for use with the elderly. The current study demonstrates its effectiveness as a fall-risk screening instrument for use with Canadian older adults. Further studies should be undertaken to determine its predictive validity. / Graduate

Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with chronic obstructive pulmonary disease (COPD). The main objective of this thesis was to describe balance impairment and fall risk in individuals with COPD and to examine interventions for improving balance and reducing fall risk in the context of pulmonary rehabilitation. The first study of this thesis showed that falls are common in patients with COPD and that fallers are characterized by impairments in standard clinical balance measures, such as the Berg Balance Scale and Timed Up and Go. In the second study, we found that the exercise component of conventional pulmonary rehabilitation has only modest effects on balance and fall risk in COPD, highlighting the need to examine the role of balance-specific training for these patients. The third study of this thesis identified the postural control subsystems most responsible for the observed balance deficits in COPD. Compared with age-matched controls, individuals with COPD demonstrated reductions in all balance control subsystems and slower reaction times in response to external perturbations. In this study, we also showed that deficits in balance in patients with COPD were associated with peripheral muscle weakness and reduced physical activity levels. These results informed the design of the final study of this thesis, a randomized controlled trial evaluating the addition of specific balance training to pulmonary rehabilitation for improving balance in patients with COPD. Preliminary results from this study suggest that the addition of thrice weekly balance exercises to a conventional pulmonary rehabilitation program is effective for optimizing gains in measures of functional balance and fall risk. The findings from the four studies included in this thesis support the need for incorporating balance assessment and treatment for at-risk patients with COPD, as part of their comprehensive management.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-04-10T14:58:53Z No. of bitstreams: 1 flaviamolinatoledocouto.pdf: 5613996 bytes, checksum: 424a634369c9c4d2d49fc3e61c9434ee (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-04-11T11:38:43Z (GMT) No. of bitstreams: 1 flaviamolinatoledocouto.pdf: 5613996 bytes, checksum: 424a634369c9c4d2d49fc3e61c9434ee (MD5) / Made available in DSpace on 2017-04-11T11:38:43Z (GMT). No. of bitstreams: 1 flaviamolinatoledocouto.pdf: 5613996 bytes, checksum: 424a634369c9c4d2d49fc3e61c9434ee (MD5) Previous issue date: 2016-03-18 / O envelhecimento da população tem sido objeto de interesse de pesquisadores de diferentes áreas, sobretudo porque, nas últimas décadas, houve significativo aumento do número de pessoas idosas, tanto no mundo, em geral, quanto, especificamente, no Brasil. Concomitantemente a esse crescimento, ocorre também o aumento do número de quedas, frequentes nessa parcela da população, e os fatores relacionados ao ambiente físico aparecem como a causa mais comum nas quedas de idosos. Assim, a pesquisa busca identificar quais fatores extrínsecos ao indivíduo e relacionados ao ambiente físico da arquitetura de interiores contribuem para o risco de queda de idosos em ambientes domiciliares. O estudo se deu no campo teórico, a partir do levantamento do estado da arte, e, no campo prático, com a população-alvo, elencando-se e categorizando-se os elementos da arquitetura de interiores presentes em domicílios. Para a realização do levantamento empírico, foram selecionados, aleatoriamente, 95 idosos do Centro de Convivência do Idoso Dona Itália Franco, em Juiz de Fora (MG) e aplicadas técnicas e instrumentos de Avaliação Pós-Ocupação; em um primeiro momento, com a realização de entrevistas, e, em seguida, com o “walkthrough”, combinandose a observação sistematizada dos ambientes da habitação visitada com entrevistas. Os dados obtidos no levantamento empírico complementaram os dados teóricos da pesquisa. Por fim, os elementos do ambiente construído domiciliar foram sistematicamente listados, através da elaboração de um diagrama das categorias elencadas, evidenciando-se a complexidade da arquitetura de interiores na relação com o risco de queda da população idosa. Como produto, são apresentados os diagramas com os elementos da arquitetura de interiores diagnosticados na pesquisa como intrínsecos ao ambiente construído e extrínsecos ao indivíduo, e que se apresentaram como influenciadores do risco de queda de idosos em ambientes domiciliares, os quais estão organizados em dois grandes grupos: categorias da edificação e categorias do espaço interior. Ao final, vislumbra-se atrair novos olhares e de foco mais crítico para as incoerências presentes no ambiente físico domiciliado por idosos. Essa categorização contribui para a compreensão e elucidação dos fenômenos causais, permitindo, assim, o desenvolvimento de medidas e ações preventivas eficazes a partir da possibilidade de apropriação do conteúdo analisado por parte dos setores de planejamento do ambiente construído. / The aging of population has been object of concerns of researchers from different areas, especially because, in the last decades, there was a significant increase in the number of elderly people, both global perspective and Brazil. Concurrently with this growth, it is also occurring the increase in the number of falls, frequent in this part of the population, and the factors related to the physical environment appear as the most common cause in the falls of older people. Thus, the research seeks to identify which extrinsic factors to the individual and related to the physical environment of interior design contribute to the fall risk of older people in home environments. The study took place in the theoretical field from the survey of the state of the art and, in the practical field, with the target population, listing and categorizing the elements of the interior design present in domiciles. To carry out the empirical survey were selected, randomly, 95 elderly from the Centro de Convivência do Idoso Dona Itália Franco (Dona Itália Franco Community Center for the Elderly), in Juiz de Fora(MGBrazil)where techniques and instruments of Post-Occupancy Evaluation were used; at first, with interviews and then, with the walkthrough, combining observation of the housing environments visited with new interviews. The theoretical research data were complemented with the data from the empirical survey. Finally, the elements of the home built environment were systematically listed, through the elaboration of a diagram from the listed categories, showing the complexity of the interior design in the relation with the fall risk in the elderly population. As a product, the diagrams are presented with the elements of interior design identified in the study as intrinsic to the built environment and extrinsic to the individual, and that were presented as influencers of fall risk in elderly people in home environments, which are organized in two large groups: the edification categories and the interior space categories. At the end, the sight is to attract new looks and more critical focus to the inconsistencies present in the physical environment domiciled for the elderly. That categorization contribute to the comprehension and elucidation of the causal phenomena, allowing that way, the development of measures and effective preventive actions from the possibility of appropriation of content analyzed by part of the built environment planning sectors.

Although a great deal is known about the etiology of falls in elderly individuals, fall accidents continue to represent a significant burden to elders residing in long-term care facilities. It has been stated that 75% of deaths due to falls in the United States occur in the 13% of the population age 65 and over. The first objective of the study was to identify which fall-predictor variables acknowledged in the research literature are associated with increased fall frequency with the older population. Identifying specific predictor variables related to a high occurrence of falls in long-term care setting can assist in the redesign of tools and programs aimed to recognize fall risk, and prevent fall-related accidents and fatalities in the geriatric population. The second objective of the study was to identify which combination of predictor variables could better predict the frequency of falls. A history of falls variable was the only predictive variable that differed significantly between groups of residents who had sustained subsequent falls and those who had not. Other variables including age, mental status, day number of stay, elimination, visual impairment, confinement, blood pressure drop, gait and balance, and medication were found to not be statistically significant between groups of fallers and non-fallers. In this setting, the current design of the tool had limited accuracy and exhibited an inability to effectively discriminate between resident populations at risk of falling and those not at risk of falling. Consequently, the current fall risk assessment tool is not adequate for assessing fall risk in this clinical setting. / Master of Science