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Week 7 Discussion Posts
Please include reference
Discussion 1: Week 7: Terrorism in the 21st Century
Discuss how you see the “war on terrorism” as of this date. Do you think the United States
should be engaged in such a war? Give reasons for or against this war and whether or not we
are giving up our own principles to wage it.
Answer:
Discussion 2: Week 7: The Cold War and America
How did the Cold War affect the social and political climate in the United States during the
1950s? In particular, how do you explain McCarthyism and the Red Scare? Can you think of any
modern parallels to these events, when fear and paranoia threatened basic American liberties?
Elaborate.
Answer:
Discussion 3: Week 7: Applying and Sharing Evidence to Practice.
This week’s graded discussion topic relates to the following Course Outcomes (COs).
•
•
•
•
CO1 Examine the sources of evidence that contribute to professional nursing practice. (PO 7)
CO2 Apply research principles to the interpretation of the content of published research
studies. (POs 4 and 8)
CO4 Evaluate published nursing research for credibility and lab significance related to
evidence-based practice. (POs 4 and 8)
CO5 Recognize the role of research findings in evidence-based practice. (POs 7 and 8)
After the data have been analyzed, conclusions are made regarding what the findings mean.
Then, this information must be shared with your healthcare team.
1. Choose one of the articles from the Week 5 RRL assignment, and discuss the findings. Would
you apply the evidence found to your practice? Explain your answer. (I attached this article).
2. Translating research into practice is the final and most important step in the research process.
Review information you found your nursing clinical issue and explain ways in which you would
share the research-based evidence with your peers.
Answer:
[Downloaded free from http://www.ijpm.info on Friday, March 31, 2017, IP: 202.177.173.189]
Original Article
Quantitative Balance and Gait Measurement
in Patients with Frontotemporal Dementia and
Alzheimer Diseases: A Pilot Study
Selva Ganapathy Velayutham, Sadanandavalli Retnaswami Chandra1, Srikala Bharath2,
Ravi Girikamatha Shankar3
ABSTRACT
Introduction: Alzhiemers disease and Frontotemporal dementia are common neurodegenerative dementias with a
wide prevalence. Falls are a common cause of morbidity in these patients. Identifying subclinical involvement of these
parameters might serve as a tool in differential analysis of these distinct parameters involved in these conditions and
also help in planning preventive strategies to prevent falls. Patients and Methods: Eight patients in age and gender
matched patients in each group were compared with normal controls. Standardizes methods of gait and balance aseesment
were done in all persons. Results: Results revealed subclinical involvement of gait and balancesin all groups specially
during divided attention. The parameters were significantly more affected in patients. Patients with AD and FTD had
involement of over all ambulation index balance more affected in AD patients FTD patients showed step cycle, stride
length abnormalities. Discussion: There is balance and gait involvement in normal ageing as well as patients with AD and
FTD. The pattern of involvement in AD correlates with WHERE pathway involvement and FTD with frontal subcortical
circuits involvement. Conclusion: Identification the differential patterns of involvement in subclinical stage might help
to differentiate normal ageing and the different types of cortical dementias. This could serve as an additional biomarker
and also assist in initiating appropriate training methods to prevent future falls.
Key words: Alzheimer disease, balance impairment, frontotemporal dementia, gait impairment, posturography
INTRODUCTION
Alzheimer disease (AD) is a neurodegenerative
disorder characterized by progressive loss of recent
and episodic memory and other cognitive functions,
affects 35 million people worldwide. [1] Early
diagnosis is important to initiate early treatment
strategies to improve disability adjusted life years
Website:
This is an open access article distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the
work non-commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
www.ijpm.info
For reprints contact: reprints@medknow.com
Access this article online
Quick Response Code
DOI:
10.4103/0253-7176.203132
How to cite this article: Velayutham SG, Chandra SR, Bharath S,
Shankar RG. Quantitative balance and gait measurement in patients with
frontotemporal dementia and Alzheimer diseases: A pilot study. Indian J
Psychol Med 2017;39:176-82.
Departments of Neurological Rehabilitation, 1Neurology and 3Biostatistics, National Institute of Mental Health and
Neurosciences, Bengaluru, Karnataka, India, 2South Asian Division, Royal College of Psychiatrists, London, UK
Address for correspondence: Dr. Sadanandavalli Retnaswami Chandra
Faculty Block, Neurocentre, National Institute of Mental Health and Neurosciences, Bengaluru – 560 029, Karnataka, India.
E-mail: drchandrasasi@yahoo.com
176
© 2017 Indian Psychiatric Society | Published by Wolters Kluwer – Medknow
[Downloaded free from http://www.ijpm.info on Friday, March 31, 2017, IP: 202.177.173.189]
Velayutham, et al.: Gait and balance in cortical dementia
and reduce caregiver burden. The other type of
cortical dementia is frontotemporal dementia (FTD)
which manifests little more early and manifests often
with neuropsychiatric manifestations. These two
conditions are often misdiagnosed as each other or as
purely psychiatric illness which delays the diagnosis.
Morbidity and mortality are often due to secondary
factors than the disease itself. Cortical structures
are wired to subcortex by various functional circuits
and therefore there is a possibility that subcortical
signs which are easier to measure may be involved
subclinically and if any differential pattern is
observed it might help as an additional biomarker
in early specific diagnosis as AD or FTD and also
initiate appropriate treatments to delay progression
to serious disability.
Gait and balance are the product of successful
integration of various posture control mechanisms
and locomotion. Neurological disorders at any level
can compromise the biomechanics of the same as
it involves several complex mechanisms. Posture
control needs maintaining the center of mass over
the BOS all through the gait cycle. Dynamic balance
needs cerebellum, vestibular system, and unconscious
reactive reflexes such as long loop reflexes. Standing
balance needs sensory information with reference to
environment generated by vision, proprioception, and
vestibular system. Because of the frontal-subcortical
circuits breaking down in FTD and WHERE dorsal
pathway dysfunction in Ad, both these disorders are
likely to have gait and balance-related problems.
Older persons with cognitive dysfunction are especially
vulnerable for gait and balance problems resulting
in repeated falls because of the associated multiaxial
“dysfunction involving not only cognition but also,
joints, ligaments, tendons, vision, and hearing.” [2]
Patients with attention and cognitive disorders are at
risk of disequilibrium in this automatic, unconscious
act of walking due to inability to concentrate in dual
tasking.[3-14] There is evidence for abnormal equilibrium
in Ad and motor dysfunction in FTD.[15-17] This can
increase morbidity significantly in these patients.[18-22]
The changes are expected to be subclinical in the early
phase, and hence quantitative measurements will be
of great help in understanding the pattern which apart
from probably serving as a easily accessible biomarker,
might also serve in initiating rehabilitatory tools early
in the course of disease.
PATIENTS AND METHODS
Twenty-four male subjects with 50–70 years of age,
8 in each group of probable bvFTD diagnosed by
revised consensus criteria,[23] probable AD, diagnosed
by ADs association criteria,[24] and healthy volunteers as
controls. The FTD and AD groups were recruited from
Outpatient Department of Neurology and Geriatric
Clinic, controls from the community. Informed consent
was obtained from all and ethical clearance received
from the Institute Ethical Committee. Subjects with
orthopedic, visual deficit, other neurological conditions,
and cardiovascular ailments were excluded. All
demographic factors including age, gender, and height,
weight are recorded.
The balance was measured by Biodex Balance Master
Incorp., USA, using dynamic posturography, in single
and dual tasks and gait with Biodex Gait Trainer.
T h e e q u i p m e n t h a s a p o s t u ro g r a p h y – b a s e d
force platform which provides objective balance
measurements in two situations, i.e., (1) dynamic
balance and (2) limits of stability (LOS). It has a
circular platform and a display monitor kept in front
of the subject to see and get the feedback about their
status of standing. The platform becomes unstable and
the subject’s experience wobbling. The change in the
center of pressure due to this will be displayed in the
monitor as a biofeedback as the cursor moves from the
epicenter of the grid.
Each subjects “base of support” requirement for the
perturbed stand is tested, and subjects are asked to
adjust their BOS making the tilted platform to the
neutral and stable position. They can utilize the
feedback about their stand position from the display
monitor and instructed to target at the innermost circle
or epicenter of the grid. At the end, BOS is recorded
including measurement of the angle of foot deviations
and during the process.
Dynamic balance – Single task
Three trials each of 20 s duration are done. The
amount of deviation from original BOS and direction of
deviation were recorded without using handrail support.
The test results contain overall balance index (OBI),
anteroposterior index (API), i.e., amount of front to
back sway, mediolateral index (MLI), i.e., side to side
sway. Higher the score indicates poorer the balance.
Limits of stability – Single task
In the second part of balance test, the subjects ability to
come back to the original BOS after a self-initiated sway
in eight different direction, namely, (1) forward (F),
(2) backward, (3) right, (4) left, (5) forward right,
(6) forward left, (7) backward right, and (8) backward
left was tested. The maximum overall score, individual
direction score was 100 with the maximum time of
300 s. Higher the score and shorter the time taken
indicates better the balance.
Indian Journal of Psychological Medicine | Volume 39 | Issue 2 | March-April 2017
177
[Downloaded free from http://www.ijpm.info on Friday, March 31, 2017, IP: 202.177.173.189]
Velayutham, et al.: Gait and balance in cortical dementia
Procedure
The platform becomes unstable, and the subject sees a
square box in the display monitor, the subjects has to
shift the body weight toward the direction of the box so
that the cursor moves and get inside the box and hold
for 2 s. Then move to the direction where the next box
appears. The display of the boxes appears in such a way
that the subject needs to come back to the first box after
completing the individual box in a different direction.
The maximum time to complete the task is 300 s. The
result generated consists of overall balance, forward,
backward, forward right, forward left, backward right,
backward left, and time take to complete the test.
Dual task
In dual task, the subject performs dynamic balance, LOS
task along with cognitive task and repeated after a rest
period for 2 min from the single task. The cognitive task
includes digital subtraction of 3, 2, from 100 in dynamic
balance, LOS tasks, respectively.[25,26] The patients are
expected to utilize the visual feedback to obtain balance.
A safety harness protects the subject from falling.
Gait assessment
The subjects gait was measured by Biodex Gait Trainer USA
Incorp. The persons recruited had to walk for 2 min in
a sensor-based treadmill at a comfortable speed. A safety
harness was provided to protect the person from falling.
Kinematic data includes gait speed, stride and step length,
coefficient variation of the steps (CV) were gathered. After
a rest period of about 2 min, the test was administered for
the second time for a dual task where the subject counted
backward from 100 as a cognitive task[27] while walking
on a treadmill. The result contains total walking distance,
average walking speed, average step cycle, average step
length, CV of the right and left leg. Higher the score in gait
parameter indicates better gait stability, however, increased
coefficient variation of steps indicate poor gait stability.
RESULTS
The Shapiro–Wilkins test was conducted to test the
normality of the parameters. Descriptive analysis was
done for age, body mass index, education in years.
Within group analysis of single versus dual task was
analyzed with paired t-test. One-way ANOVA was
conducted to reveal the difference between groups,
followed by post hoc test with Bonferroni correction.
The mean age of FTD group = 58.37 ± 8.38; AD
group = 66.7 ± 5.5; Control group = 59.5 ± 7.03, all
the subjects were male (8 in each group), the Hindi
Mental Status Examination score of FTD and AD group
were significantly lower than the controls [Table 1].
Within group comparison of single versus dual
Dynamic balance
The OBI and API of the dynamic balance of FTD
group and control group significantly differed between
single versus dual task. However, AD group had
significant difference in mediolateral (MLI) stability
index only [Table 2 and MLI score in Figure 1].
Limits of stability
All the three group had significant difference in overall
LOS score between single vs. dual task however the
sub-component of LOS revealed FTD patients had
problem balancing on forward lateral direction and control
group had problem in forward, left direction whereas
the AD group had significant difficulty in backward
direction [Table 2 and overall LOS score in Figure 2].
Gait analysis
FTD, AD group, performed poorly in dual task gait
analysis while the control group showed no significant
worsening of gait. Ambulation index (AI) is a cumulative
score of overall gait performance which is found to be
low on dual task for both dementias [Figure 3]. In
addition, FTD group had significant reduction of step
cycle, step length especially on the right side [Table 3].
Between group comparisons
Dynamic balance – Single task
FTD group had a significant worsening of balance in
comparison with control group in all subcomponent
of dynamic balance, i.e., OBI, API, and MLI. The
Table 1: Age, body mass index, HMSE score, education of
patients with FTD and AD
FTD (n=8) AD (n=8) Control (n=8) P (ANOVA)
Age (mean±SD)
BMI
Education in years
HMSE
58.37±8.38
23.26±2.86
9.50±5.21
16.25±7.3
66.7±5.57
20.8±1.63
11.63±5.20
16.88±5.91
59.5±7.03
23.75±3.83
11±3.46
30.8±0.34
NS
NS
NS
0.000 (<0.001) NS – Not significant; SD – Standard deviation; FTD – Frontotemporal dementia; AD – Alzheimer disease; BMI – Body mass index; HMSE – Hindi Mental Status Examination 178 Figure 1: Dynamic balance showing significant mediolateral instability in Alzheimer diseases. FTD – Frontotemporal dementia; AD – Alzheimer disease Indian Journal of Psychological Medicine | Volume 39 | Issue 2 | March-April 2017 [Downloaded free from http://www.ijpm.info on Friday, March 31, 2017, IP: 202.177.173.189] Velayutham, et al.: Gait and balance in cortical dementia Table 2: Within group single task versus dual task-balance measurement Balance parameters Dynamic balance OBI Single Dual API Single Dual MLI Single Dual LOS Overall Single Dual Forward Single Dual Backward Single Dual Right Single Dual Left Single Dual Forward left Single Dual Time Single Dual FTD AD P Mean±SD 3.563±0.947 4.013±1.172 0.053* 3.363±1.112 3.675±1.248 2.400±0.507 2.925±0.638 0.031* 2.763±0.723 3.300±1.002 0.053* 2.700±0.792 2.813±0.751 1.913±0.535 2.650±0.639 0.006* 2.400±0.761 2.100±0.680 14.75±20.673 8.88±16.797 0.058* P Control Mean±SD Mean±SD 2.088±0.771 2.488±1.124 0.037* 1.488±0.522 1.425±0.423 5.38±6.323 1.63±3.852 0.037* 24.25±12.116 16±8.685 0.002* 34±16.613 15.50±10.282 0.004* 8.63±10.460 10.50±20.029 3.88±7.220 0.00±0.000 12.25±11.622 6.50±11.551 5±5.657 1.00±2.646 19.50±31.482 5.75±10.620 8.25±16.395 0.63±1.188 27.50±24.101 15.50±11.637 24.75±34.652 9.88±16.686 7±10.268 7.75±21.920 23.13±12.438 12.13±5.592 3.25±4.773 0.00±0.000 25.13±14.287 15.13±8.692 284.25±47.376 301±0.000 185.25±62.962 217.38±69.156 19.38±3.645 9±20.396 0.052* 285.38±31.332 278.25±63.944 P 0.047* 16.88±15.914 16±10.797 0.017* 0.015* *Significant (P<0.05). LOS – Limits of stability; SD – Standard deviation; FTD – Frontotemporal dementia; AD – Alzheimer disease; MLI – Mediolateral index; API – Anteroposterior index; OBI – Overall balance index Figure 2: Overall limits of stability performance between single vs dual among frontotemporal dementia, AD and Controls. All the three group performed poorly in dual task. FTD – Frontotemporal dementia; AD – Alzheimer disease Alzheimer’s group had worsening of balance in OBI, API only. There was no significant difference between FTD and AD group on all parameters of dynamic Figure 3: Ambulation index score of frontotemporal dementia, Alzheimer disease and controls. Both frontotemporal dementia and Alzheimer disease had poor score in dual task. FTD – Frontotemporal dementia; AD – Alzheimer disease balance. This denotes that both FTD and AD have a deficit in dynamic balance than control group [Table 4]. Limits of stability - Single task Alzheimer group had a significant deficit in overall LOS Indian Journal of Psychological Medicine | Volume 39 | Issue 2 | March-April 2017 179 [Downloaded free from http://www.ijpm.info on Friday, March 31, 2017, IP: 202.177.173.189] Velayutham, et al.: Gait and balance in cortical dementia Table 3: Comparison of parameters in patients with FTD and AD during single and dual tasking Gait parameters FTD Ambulation index (maximum=100) Single Dual Step cycle Single Dual Step length right Single Dual AD Control Mean±SD Mean±SD P Mean±SD P P 66.13±26.37 55.75±25.19 0.04* 63.63±18.68 56.88±17.93 0.00 (>0.1)*
78.28±27.61
85.63±6.14
NS
0.57±0.28
0.47±0.25
0.05*
0.54±0.22
0.46±0.18
NS
0.89±0.13
0.78±0.10
NS
0.32±0.17
0.37±0.22
0.02*
0.42±0.13
0.44±0.17
NS
0.45±0.17
0.42±0.11
NS
NS – Not significant; SD – Standard deviation
Table 4: Between group comparison of balance-single task
Single task
Mean±SD
Control
FTD
Dynamic balance
OBI
API
MLI
LOS
Overall
Forward
Backward right
Time
P (ANOVA)
AD
Post hoc comparison (P=0.05)*
FTD versus control
FTD versus AD
AD and control
3.56±0.94
2.76±0.72
2.40±0.76
2.40±0.50
1.91±0.53
1.48±0.52
3.36±1.11
2.70±0.79
2.08±0.77
0.037*
0.041*
0.046*
0.017*
0.023*
0.016*
NS
NS
NS
0.054*
0.034*
0.099
14.75±20.67
8.63±10.46
7.25±0.30
285±31
24.25±12.11
34±16.61
22±14.50
185±62
5.38±6.32
3.88±7.22
4.63±6.73
284±47
0.049*
0.00 (<0.001) 0.008* 0.001* 0.198 0.000* 0.012* 0.324 NS NS NS NS 0.015* 0.000* 0.004* 0.041* *Significant (P<0.05). NS – Not significant; MLI – Mediolateral index; API – Anteroposterior index; OBI – Overall balance index; LOS – Limits of stability; SD – Standard deviation Table 5: Dual task balance analysis Dual task FTD MLI LOS Backward Right FR BR Time 2.10±0.68 8.88±16.79 6.50±11.55 5.75±10.62 11.25±18.57 9.50±18.88 278±63.94 Mean±SD Control 1.42±0.42 16±8.68 16±10.79 15.50±11.63 20.25±12.45 20±15.82 217±69.15 P (ANOVA) ... Purchase answer to see full attachment

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