Balance differences in people with Parkinson disease with and without freezing of gait

Published in final edited form as: Gait Posture. 2015 September ; 42(3): 306–309. doi:10.1016/j.gaitpost.2015.06.007.BACKGROUND: Freezing of gait (FOG) is a relatively common and remarkably disabling impairment associated with Parkinson disease (PD). Laboratory-based measures indicate that individuals with FOG (PD+FOG) have greater balance deficits than those without FOG (PD-FOG). Whether such differences also can be detected using clinical balance tests has not been investigated. We sought to determine if balance and specific aspects of balance, measured using Balance Evaluation Systems Test (BESTest), differs between PD+FOG and PD-FOG. Furthermore, we aimed to determine if time-efficient clinical balance measures (i.e. Mini-BESTest, Berg Balance Scale (BBS)) could detect balance differences between PD+FOG and PD-FOG. METHODS: Balance of 78 individuals with PD, grouped as either PD+FOG (n=32) or PD-FOG (n=46), was measured using the BESTest, Mini-BESTest, and BBS. Between-groups comparisons were conducted for these measures and for the six sections of the BESTest using analysis of covariance. A PD composite score was used as a covariate. RESULTS: Controlling for motor sign severity, PD duration, and age, PD+FOG had worse balance than PD-FOG when measured using the BESTest (p=0.008, F=7.35) and Mini-BESTest (p=0.002, F=10.37), but not the BBS (p=0.27, F=1.26). BESTest section differences were noted between PD+FOG and PD-FOG for reactive postural responses (p<0.001, F=14.42) and stability in gait (p=0.003, F=9.18). CONCLUSIONS: The BESTest and Mini-BESTest, which specifically assessed reactive postural responses and stability in gait, were more likely than the BBS to detect differences in balance between PD+FOG and PD-FOG. Because it is more time efficient to administer, the Mini-BESTest may be the preferred tool for assessing balance deficits associated with FOG.This study was conducted with funding from the Davis Phinney Foundation, Parkinson's Disease Foundation, NIH R01 NS077959, NIH UL1 TR000448, Greater St. Louis American Parkinson Disease Association (APDA), APDA Center for Advanced PD Research at Washington University in St. Louis. The funding sources had no role in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. (Davis Phinney Foundation; Parkinson's Disease Foundation; R01 NS077959 - NIH; UL1 TR000448 - NIH; Greater St. Louis American Parkinson Disease Association (APDA); APDA Center for Advanced PD Research at Washington University in St. Louis

Improved Dynamic Postural Task Performance without Improvements in Postural Responses: The Blessing and the Curse of Dopamine Replacement

Introduction. Dopamine-replacement medications may improve mobility while not improving responses to postural challenges and could therefore increase fall risk. The purpose of this study was to measure reactive postural responses and gait-related mobility of patients with PD during ON and OFF medication conditions. Methods. Reactive postural responses to the Pull Test and performance of the Functional Gait Assessment (FGA) were recorded from 15 persons with PD during ON and OFF medication conditions. Results. Persons with PD demonstrated no significant difference in the reactive postural responses between medication conditions but demonstrated significantly better performance on the FGA when ON medications compared to OFF. Discussion/Conclusion. Dopamine-replacement medications alone may improve gait-related mobility without improvements in reactive postural responses and therefore could result in iatrogenic increases in fall risk. Rehabilitation providers should be aware of the side effects and limitations of medication treatment and implement interventions to improve postural responses

Intramuscular Adipose Tissue, Sarcopenia, and Mobility Function in Older Individuals

Objective. Intramuscular adipose tissue (IMAT) and sarcopenia may adversely impact mobility function and physical activity. This study determined the association of locomotor muscle structure and function with mobility function in older adults. Method. 109 older adults with a variety of comorbid disease conditions were examined for thigh muscle composition via MRI, knee extensor strength via isometric dynamometry, and mobility function. The contribution of strength, quadriceps lean tissue, and IMAT to explaining the variability in mobility function was examined using multivariate linear regression models. Results. The predictors as a group contributed 27–45% of the variance in all outcome measures; however, IMAT contributed between 8–15% of the variance in all four mobility variables, while lean explained only 5% variance in only one mobility measure. Conclusions. Thigh IMAT, a newly identified muscle impairment appears to be a potent muscle variable related to the ability of older adults to move about in their community

External validation of a simple clinical tool used to predict falls in people with Parkinson disease

Published in final edited form as: Parkinsonism Relat Disord. 2015 August ; 21(8): 960–963. doi:10.1016/j.parkreldis.2015.05.008.BACKGROUND: Assessment of fall risk in an individual with Parkinson disease (PD) is a critical yet often time consuming component of patient care. Recently a simple clinical prediction tool based only on fall history in the previous year, freezing of gait in the past month, and gait velocity <1.1 m/s was developed and accurately predicted future falls in a sample of individuals with PD. METHODS: We sought to externally validate the utility of the tool by administering it to a different cohort of 171 individuals with PD. Falls were monitored prospectively for 6 months following predictor assessment. RESULTS: The tool accurately discriminated future fallers from non-fallers (area under the curve [AUC] = 0.83; 95% CI 0.76–0.89), comparable to the developmental study. CONCLUSION: The results validated the utility of the tool for allowing clinicians to quickly and accurately identify an individual's risk of an impending fall.Davis Phinney Foundation, Parkinson Disease Foundation, NIH, APDA. (Davis Phinney Foundation; Parkinson Disease Foundation; NIH; APDA

Are the average gait speeds during the 10 meter and 6 minute walk tests redundant in Parkinson disease?

Published in final edited form as: Gait Posture. 2017 February ; 52: 178–182. doi:10.1016/j.gaitpost.2016.11.033.We investigated the relationships between average gait speed collected with the 10Meter Walk Test (Comfortable and Fast) and 6Minute Walk Test (6MWT) in 346 people with Parkinson disease (PD) and how the relationships change with increasing disease severity. Pearson correlation and linear regression analyses determined relationships between 10Meter Walk Test and 6MWT gait speed values for the entire sample and for sub-samples stratified by Hoehn & Yahr (H&Y) stage I (n=53), II (n=141), III (n=135) and IV (n=17). We hypothesized that redundant tests would be highly and significantly correlated (i.e. r>0.70, p<0.05) and would have a linear regression model slope of 1 and intercept of 0. For the entire sample, 6MWT gait speed was significantly (p<0.001) related to the Comfortable 10 Meter Walk Test (r=0.75) and Fast 10Meter Walk Test (r=0.79) gait speed, with 56% and 62% of the variance in 6MWT gait speed explained, respectively. The regression model of 6MWT gait speed predicted by Comfortable 10 Meter Walk gait speed produced slope and intercept values near 1 and 0, respectively, especially for participants in H&Y stages II-IV. In contrast, slope and intercept values were further from 1 and 0, respectively, for the Fast 10Meter Walk Test. Comfortable 10 Meter Walk Test and 6MWT gait speeds appeared to be redundant in people with moderate to severe PD, suggesting the Comfortable 10 Meter Walk Test can be used to estimate 6MWT distance in this population.This study was funded by the Davis Phinney Foundation, the Parkinson's Disease Foundation, and the National Institutes of Health (R01 NS077959, K12 HD055931, UL1 TR000448). The funding sources had no input related to study design, data collection, or decision to submit for publication. (Davis Phinney Foundation; Parkinson's Disease Foundation; R01 NS077959 - National Institutes of Health; K12 HD055931 - National Institutes of Health; UL1 TR000448 - National Institutes of Health

Comparative utility of the BESTest, mini-BESTest, and brief-BESTest for predicting falls in individuals with Parkinson disease: A cohort study

BACKGROUND: The newly developed Brief–Balance Evaluation System Test (Brief-BESTest) may be useful for measuring balance and predicting falls in individuals with Parkinson disease (PD). OBJECTIVES: The purposes of this study were: (1) to describe the balance performance of those with PD using the Brief-BESTest, (2) to determine the relationships among the scores derived from the 3 versions of the BESTest (ie, full BESTest, Mini-BESTest, and Brief-BESTest), and (3) to compare the accuracy of the Brief-BESTest with that of the Mini-BESTest and BESTest in identifying recurrent fallers among people with PD. DESIGN: This was a prospective cohort study. METHODS: Eighty participants with PD completed a baseline balance assessment. All participants reported a fall history during the previous 6 months. Fall history was again collected 6 months (n=51) and 12 months (n=40) later. RESULTS: At baseline, participants had varying levels of balance impairment, and Brief-BESTest scores were significantly correlated with Mini-BESTest (r=.94, P<.001) and BESTest (r=.95, P<.001) scores. Six-month retrospective fall prediction accuracy of the Brief-BESTest was moderately high (area under the curve [AUC]=0.82, sensitivity=0.76, and specificity=0.84). Prospective fall prediction accuracy over 6 months was similarly accurate (AUC=0.88, sensitivity=0.71, and specificity=0.87), but was less sensitive over 12 months (AUC=0.76, sensitivity=0.53, and specificity=0.93). LIMITATIONS: The sample included primarily individuals with mild to moderate PD. Also, there was a moderate dropout rate at 6 and 12 months. CONCLUSIONS: All versions of the BESTest were reasonably accurate in identifying future recurrent fallers, especially during the 6 months following assessment. Clinicians can reasonably rely on the Brief-BESTest for predicting falls, particularly when time and equipment constraints are of concern

Accuracy of Fall Prediction in Parkinson Disease: Six-Month and 12-Month Prospective Analyses

Introduction. We analyzed the ability of four balance assessments to predict falls in people with Parkinson Disease (PD) prospectively over six and 12 months. Materials and Methods. The BESTest, Mini-BESTest, Functional Gait Assessment (FGA), and Berg Balance Scale (BBS) were administered to 80 participants with idiopathic PD at baseline. Falls were then tracked for 12 months. Ability of each test to predict falls at six and 12 months was assessed using ROC curves and likelihood ratios (LR). Results. Twenty-seven percent of the sample had fallen at six months, and 32% of the sample had fallen at 12 months. At six months, areas under the ROC curve (AUC) for the tests ranged from 0.8 (FGA) to 0.89 (BESTest) with LR+ of 3.4 (FGA) to 5.8 (BESTest). At 12 months, AUCs ranged from 0.68 (BESTest, BBS) to 0.77 (Mini-BESTest) with LR+ of 1.8 (BESTest) to 2.4 (BBS, FGA). Discussion. The various balance tests were effective in predicting falls at six months. All tests were relatively ineffective at 12 months. Conclusion. This pilot study suggests that people with PD should be assessed biannually for fall risk

MR448: Bees and Their Habitats in Four New England States

Bees are crucial to pollination in unmanaged ecosystems and some crops, and their roles are increasingly understood in four states in the Northeastern U.S., abbreviated “NNE” in this paper: Maine (ME), Massachusetts (MA), New Hampshire (NH), and Vermont (VT). The four states have in common many native bee and plant species, forest types, and natural communities. They share drought events and risk of wildfire (Irland 2013). They are exposed to many of the same major storms (e.g., hurricanes, Foster 1988), pollution events (Hand et al. 2014), and effects ascribed to climate change (Hayhoe et al. 2008). Beekeeping enterprises (the western honey bee, Apis mellifera, an introduced species) of various sizes exist in each of the states. By including the four states in this review, we hope to better understand wild bee distributions, inspire the expansion of floral resources to support bee populations in a strategic manner, reduce use of pesticides, create pollinator corridors, and protect subtle habitat features such as ground nest sites for solitary bees and patches of native vegetation that are free of invasive plants. Our objective in this review is to synthesize from a conservation standpoint the state of knowledge regarding bees in NNE, including their diversity, and biology especially as it relates to climate change. We review foraging and nutrition, nest ecology, parasites and parasitoids, native vs. managed bees, and interactions with plants. We then turn our focus to bee habitats, and identify 15 habitat types we find useful for recognizing essential bee resources. We discuss habitat aspects including forest succession, invasive plants, land use alterations, and agriculture including impacts of pesticides, and cover economic aspects of crop-related pollination reservoirs in NNE that demonstrate cost-effectiveness at various scales. We present habitat improvement strategies including passive and active approaches, based on the literature and our experiences in NNE, and we suggest plants for pollinator plantings. Wherever pertinent throughout the text, we highlight threats to bees in our region such as pests and pathogens, pesticides, and habitat loss. Finally, we identify gaps in knowledge that could help in prioritizing directions for future research. We hope this review will be useful to anyone seeking to protect bees and their habitats.https://digitalcommons.library.umaine.edu/aes_miscreports/1029/thumbnail.jp

Breast cancer in lesbians and bisexual women: Systematic review of incidence, prevalence and risk studies

This article is made available through the Brunel Open Access Publishing Fund. © 2013 Meads and Moore; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background: The UK Parliamentary Enquiry and USA Institute of Medicine state that lesbians may be at a higher risk of breast cancer but there is insufficient information. Lesbians and bisexual (LB) women have behavioural risk-factors at higher rates compared to heterosexuals such as increased alcohol intake and higher stress levels. Conversely, breast cancer rates are higher in more affluent women yet income levels in LB women are relatively low. This systematic review investigated all evidence on whether there is, or likely to be, higher rates of breast cancer in LB women. Methods: Cochrane library (CDSR, CENTRAL, HTA, DARE, NHSEED), MEDLINE, EMBASE, PsychINFO, CAB abstracts, Web of Science (SCI, SSCI), SIGLE and Social Care Online databases were searched to October 2013. Unpublished research and specific lesbian, gay and bisexual websites were checked, as were citation lists of relevant papers. Included were studies in LB populations reporting breast cancer incidence or prevalence rates, risk model results or risk-factor estimates. Inclusions, data-extraction and quality assessment were by two reviewers with disagreements resolved by discussion. Results: Searches found 198 references. No incidence rates were found. Nine studies gave prevalence estimates - two showed higher, four showed no differences, one showed mixed results depending on definitions, one had no comparison group and one gave no sample size. All studies were small with poor methodological and/or reporting quality. One incidence modelling study suggested a higher rate. Four risk modelling studies were found, one Rosner-Colditz and three Gail models. Three suggested higher and one lower rate in LB compared to heterosexual women. Six risk-factor estimates suggested higher risk and one no difference between LB and heterosexual women. Conclusions: The only realistic way to establish rates in LB women would be to collect sexual orientation within routine statistics, including cancer registry data, or from large cohort studies

Upper limb nerve transfer surgery in patients with tetraplegia

IMPORTANCE: Cervical spinal cord injury (SCI) causes devastating loss of upper extremity function and independence. Nerve transfers are a promising approach to reanimate upper limbs; however, there remains a paucity of high-quality evidence supporting a clinical benefit for patients with tetraplegia. OBJECTIVE: To evaluate the clinical utility of nerve transfers for reanimation of upper limb function in tetraplegia. DESIGN, SETTING, AND PARTICIPANTS: In this prospective case series, adults with cervical SCI and upper extremity paralysis whose recovery plateaued were enrolled between September 1, 2015, and January 31, 2019. Data analysis was performed from August 2021 to February 2022. INTERVENTIONS: Nerve transfers to reanimate upper extremity motor function with target reinnervation of elbow extension and hand grasp, pinch, and/or release. MAIN OUTCOMES AND MEASURES: The primary outcome was motor strength measured by Medical Research Council (MRC) grades 0 to 5. Secondary outcomes included Sollerman Hand Function Test (SHFT); Michigan Hand Outcome Questionnaire (MHQ); Disabilities of Arm, Shoulder, and Hand (DASH); and 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS) scores. Outcomes were assessed up to 48 months postoperatively. RESULTS: Twenty-two patients with tetraplegia (median age, 36 years [range, 18-76 years]; 21 male [95%]) underwent 60 nerve transfers on 35 upper limbs at a median time of 21 months (range, 6-142 months) after SCI. At final follow-up, upper limb motor strength improved significantly: median MRC grades were 3 (IQR, 2.5-4; P = .01) for triceps, with 70% of upper limbs gaining an MRC grade of 3 or higher for elbow extension; 4 (IQR, 2-4; P \u3c .001) for finger extensors, with 79% of hands gaining an MRC grade of 3 or higher for finger extension; and 2 (IQR, 1-3; P \u3c .001) for finger flexors, with 52% of hands gaining an MRC grade of 3 or higher for finger flexion. The secondary outcomes of SHFT, MHQ, DASH, and SF36-PCS scores improved beyond the established minimal clinically important difference. Both early (\u3c12 months) and delayed (≥12 months) nerve transfers after SCI achieved comparable motor outcomes. Continual improvement in motor strength was observed in the finger flexors and extensors across the entire duration of follow-up. CONCLUSIONS AND RELEVANCE: In this prospective case series, nerve transfer surgery was associated with improvement of upper limb motor strength and functional independence in patients with tetraplegia. Nerve transfer is a promising intervention feasible in both subacute and chronic SCI