1,720,986 research outputs found
Reduced sway during dual task balance performance among people with stroke at 6 and 12 months after discharge from hospital
No full textBackground: cognitive motor interference has been linked to poor recovery and falls. Little is known about recovery of dual-task balance ability poststroke. Methods: in this experimental study, postural sway was examined while standing on a force plate in preferred stance, with feet together, and with eyes closed, at 6 and 12 months postdischarge from hospital. Sway was assessed in isolation and while participants performed a cognitive (shopping list) task. Results: seventy-six people with stroke (mean age 67 years; range, 21-91 years) took part. Fifty-four completed both assessments. When compared with the single task, sway during the dual-task condition was significantly lower in both the medial lateral (ML) and anterior posterior (AP) directions (both P < .0001). Sway in both directions was influenced by the difficulty of the balance task (both P < .0001). There was a trend of reduced sway at the 12-month assessment compared with the 6-month assessment: significant only in the ML direction (P = .0056). Repeat fallers swayed more than non—repeat fallers, with increases of 48% and 44% in the ML (P = .0262) and AP (P = .0134) directions, respectively. No significant variation in the dual-task reduction in sway was found: the dual-task effect was remarkably consistent over all the conditions tested, particularly in the AP direction. Conclusions: sway decreased under dual-task conditions and changed as the difficulty of the balance task changed. Stroke fallers swayed more than nonfallers and there was evidence of a reduction in sway over time, particularly in the ML directio
The analysis of continuous outcomes in multi-centre trials with small centre sizes
No full textThe standard analysis of clinical trials stratified by centre is to include centres as fixed effects, but if many centres contribute small numbers of patients, this approach results in a loss of power. Assuming no treatment by centre interaction, we used simulation to examine power and coverage of confidence intervals from three approaches to the analysis of continuous outcome in multi-centre trials: ignoring centres, including centres as fixed effects, and including them as random effects. The simulation incorporated eight sizes of centre effects; randomization in blocks of size 2 or 4; and two sample sizes, namely 100 and 200 patients per treatment arm in a parallel groups design. All simulated data sets included many centres with few subjects. The three different approaches were unbiased and had similar coverage. Fixed effects analysis was less powerful, particularly when centre effects were small. Incorporating block randomization with larger block size increased non-orthogonality in the design, contributing to loss of power. Where centre effects are small and recruitment in many centres is low, the approaches of ignoring centres or incorporating them as random effects have better performance than the traditional fixed effects analysis
Predicting fallers in a community-based sample of people with Parkinson's disease
No full textBACKGROUND: The risk of people with Parkinson's disease (PD) falling is greater than that of the general population but to date, disease-specific predictors of falling have not been identified. OBJECTIVES: To identify one or more features, which would predict individuals at risk of falling during a 3-month prospective follow-up study. METHOD: A battery of standardised tests administered in the home and the laboratory with a 3-month follow-up telephone interview. RESULTS: Sixty-three people with PD were recruited from GP practices. Eleven interview variables and six gait laboratory variables were used with subsamples (55 and 44 subjects, respectively) to fit predictive models for identifying future fallers. The number of falls in the previous year was the most important variable, without exception, to be selected as a predictor in various logistic regression models. A history of two or more falls had a sensitivity of 86.4% (95% CI 67.3-96.2%) and a specificity of 85.7% (95% CI 71.2-94.2%) in predicting falling in the next 3 months. CONCLUSION: Healthcare workers should be asking their patients with PD regularly and carefully about falling, and should consider instigating programmes of fall management for patients with PD who have fallen two or more times in the previous 12 months
A community-dwelling sample of people with Parkinson's disease: characteristics of fallers and non-fallers
No full textBackground: people with Parkinson's disease often fall. Objectives: to report the frequency of falls and characteristics of fallers and non-fallers in a community-based sample of people with Parkinson's disease. Method: we administered a battery of standardized tests in the home and the laboratory. Results: we recruited 63 people with Parkinson's disease through general practices. Forty (64%, 95% confidence interval 51–74%) had fallen in the previous 12 months. Many factors associated with falling in the general population were associated with Parkinson's disease fallers (e.g. use of multiple medication and greater physical disability). Fallers were more likely to be depressed and anxious than non-fallers. Condition-specific factors associated with falling included greater disease severity (although there were exceptions) and more marked response to levodopa treatment, including more dyskinesia and on–off phenomena. Fallers took more steps to complete a test of mobility. They also had a shorter functional reach and greater postural sway whilst completing a dual task than non-fallers. Conclusion: this community-based study confirms the high risk of falling in Parkinson's disease. Our results suggest that disease-specific factors contribute to the increased risk and that there is scope for specific therapeutic interventions
An investigation into the feasibility of comparing three management options (augmentation, conservative and water) for nulliparae with dystocia in the first stage of labour
No full textObjective: to evaluate the feasibility of a randomised controlled trial (RCT) examining the effect of three options (augmentation, conservative and water) for the management of dystocia in nulliparae. The main objectives were to explore the feasibility of trial procedures in the clinical environment, consent rates and acceptability of the management options to women, local incidence of dystocia in nulliparae and the size of the subsequent study.Design: a two part study: a pilot, RCT with follow-up through to delivery with postnatal maternal surveys, and a case review of nulliparae with dystocia.Setting: a large maternity unit in the South of England in May–July 1997 inclusive.Participants: nulliparae with dystocia in the first stage of labour who had an otherwise uncomplicated obstetric background.Interventions: women in the pilot RCT received one of three management options: labouring in a waterbirth pool, conservative management or augmentation of labour, which is the standard management of women with dystocia condition in the Unit.Findings: it is feasible to conduct an RCT of management of dystocia in the Unit. Seventy per cent (95% confidence interval 47% to 87%) of women approached agreed to participate. Conservative management was the least acceptable option to women and has been dropped from the subsequent trial. The audit provided some idea of possible differences in operative delivery and epidural rates depending on augmentation or not. A sample of 220 women should be large enough to detect moderate changes and will require a 2-year recruitment period.Conclusions: a subsequent trial is feasible and is now underway. It has the potential to provide information enabling women and practitioners to have a greater choice of care options in the presence of dystocia, or provide a good basis for an even larger trial
Hospital nurse staffing and staff-patient interactions: an observational study
No full textBackground: existing evidence indicates that reducing nurse staffing and/or skill mix adversely affects care quality. Nursing shortages may lead managers to dilute nursing team skill mix, substituting assistant personnel for registered nurses (RNs). However, no previous studies have described the relationship between nurse staffing and staff-patient interactions.Settings: six wards at two English NHS hospitals. Methods: we observed 238 hours of care (n=270 patients). Staff-patient interactions were rated using the Quality of Interactions Schedule. RN, Health Care Assistant (HCA) and patient numbers were used to calculate patient-to-staff ratios. Multilevel regression models explored the association between staffing levels, skill mix and the chance of an interaction being rated as “negative” quality, rate at which patients experienced interactions, and total amount of time patients spent interacting with staff per observed hour.Results:: 10% of the 3,076 observed interactions were rated as negative. The odds of a negative interaction increased significantly as the number of patients per RN increased (P=0.035, odds ratio of 2.82 for ≥ 8 patients/RN compared to >6 to <8 patients/RN). A similar pattern was observed for HCA staffing but the relationship was not significant (P=0.056). When RN staffing was low, the odds of a negative interaction increased with higher HCA staffing. Rate of interactions per patient hour, but not total amount of interaction time, was related to RN and HCA staffing levels. Conclusion: low RN staffing levels are associated with changes in quality and quantity of staffpatient interactions. When RN staffing is low, increases in assistant staff levels are not associated with improved quality of staff-patient interactions. Beneficial effects from adding assistant staff arelikely to be dependent on having sufficient RNs to supervise, limiting the scope for substitution
Head and pelvic movements during a dynamic reaching task in sitting: implications for physical therapists
No full textObjectives: To describe the distance reached, speed, and movement of the head and pelvis of healthy volunteers; to describe any influence of age on these variables; and to compare healthy volunteers and subjects with hemiplegia while performing a seated reaching task.Design: Age-matched, case-control study.Setting: Gait laboratory in a general hospital. Participants: A convenience sample of 53 healthy volunteers (30 women; 23 men; mean age, 57yr; range, 30[ndash ]79yr) and 5 subjects with hemiplegia (2 women, 3 men; mean age, 65yr; range, 60[ndash ]78yr) were recruited within 6 weeks poststroke.Interventions: Participants sat on a bench with feet supported and reached laterally as far as they could without falling.Main Outcome Measures: The speed, distance reached, and angular movements of the head and pelvis were recorded by using the 3-dimensional movement analysis system. Results: A significant age-related reduction in the distance reached (p [lt ] .001), velocity of the movement (p = .000), and pelvic tilt used (p [lt ] .01) was found among healthy volunteers. Comparison of data from healthy volunteers and subjects with hemiplegia showed a significant reduction in the angular movements of the heads of subjects with hemiplegia. Conclusions: The findings suggest conservation of movement with increasing age and stroke. This movement reduction could have negative effects on a subject's ability to make postural changes in response to disturbance and activity. Such information may assist therapists to gain insight into the nature of balance deficits and the adaptive behavior that could result
Recruitment to a clinical trial from the databases of specialists in Parkinson’s disease
No full textBackground: Many clinical trials involving elderly people living at home suffer from low recruitment. We report our experience of recruiting people with Parkinson's disease (PD) from specialist clinical databases, to a randomised controlled trial of personalised exercise.Methods: We aimed to recruit 200 repeat fallers with PD. Subjects were recruited through the clinical registers of specialists in PD in two NHS trusts. They had to have a confirmed diagnosis of PD, be independently mobile, live in the community, be a repeat faller, and were screened for cognitive impairment.Results: Out of 1107 patients on the registers, 457 did not meet the eligibility criteria for the trial. A further 151 were excluded for other reasons. Four hundred and ninety-nine were approached to have a home screening visit: 405 replied and 305 agreed to be screened for the trial. Of those screened, 126 were non-repeat fallers and 22 failed other eligibility criteria. Out of the remaining 157 patients, 18 (11%) decided not to participate in the trial which left 139 recruited to the trial. Seven more were recruited from a second screen of previous non-repeat fallers. In total 146 patients were recruited: 142 to the main trial and four to the initial pilot phase.Conclusion: The percentage of patients who participated in the main trial was only 13% (95% confidence interval 11% to 15%) of those on specialists’ registers, considerably less than estimated, although the proportion of fallers and repeat fallers was similar to that previously reported
The relationship between upper limb activity and impairment in post-stroke hemiplegia
No full textPurpose. To investigate the relationship between upper limb impairments and activity limitation. Method. A cross sectional, single assessment observational study in which people with hemiplegia as a result of a stroke underwent a testing procedure in an instrumented wrist rig in which the following measures of impairment were recorded: Spasticity; motor control (ability to track a moving target); muscle activation patterns during tracking; stiffness; range of active movement and isometric muscle strength. Participants also performed clinical tests of upper limb activity (Action Research Arm Test) and hyper-tonicity (Modified Ashworth Scale). Results. Seventeen people with hemiplegia whose mean age was 57 (SD 13.4) took part. Their mean upper limb activity, measured by the Action Research Arm Test, was 19.3 (SD 11.2). Statistically significant positive relationships between level of activity and the negative features of the upper motor neuron syndrome such as motor control r = 0.710 (p = 0.003), active range of movement r = 0.540 (p = 0.025) and strength into flexion r = 0.515 (p = 0.034) and extension r = 0.575 (p = 0.016) were identified, but not with the positive features, such as spasticity or the secondary features such as stiffness. Conclusions. The negative features of the upper motor neuron syndrome appear more likely to affect upper limb activity than the positive or secondary features, but findings need confirming in different study populations, preferably with larger samples
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