6/18/2015 Exploration of Timed Up and Go scores with and without a Cognitive Challenge in People with MS and a Healthy Reference Group Laura Comber, BSc, MISCP PhD Candidate Department of Clinical Therapies University of Limerick Objectives • Provide sample TUG and TUG ‐ C data for pwMS and a healthy reference group • Examine within group differences in these populations for these measures • Examine differences between these populations in these measures • Examine differences between people with MS who fall and those who do not in these measures • Present preliminary results of instrumented TUG and TUG ‐ C data from a healthy reference group 1
6/18/2015 Contents Background Methodology Results Key Points Background 2
6/18/2015 Falls in People with MS • 56% in a 3 month period (Nilsagård et al 2014) • Effect on the individual – Injurious Falls (Peterson et al 2008) – Fear of Falling (Peterson et al 2007) – Activity Curtailment (Peterson et al 2007) • Balance impairment and falls – Pooled OR 1.07 (95%CI 1.04 ‐ 1.10) (Gunn et al 2013) • Gait, Turning, Postural Transitions – Gunn et al 2014 – Matsuda et al 2012 – Nilsag å rd et al 2009 Why Choose the TUG? • Timed Up and Go – Objective/Quick to administer – Elicits dynamic activity – MS Evaluation Database to Guide Effectiveness – IMSFPRN (Cattaneo et al 2014) • Timed Up and Go ‐ Cognitive – PwMS dual tasking difficulties (Sosnoff et al 2011) – Dual task cost • Predictive Validity? 3
6/18/2015 Methodology Study Recruitment • Healthy Reference Group – University of Limerick – Undergraduate Physiotherapy Students – N=50 • People with MS – St Vincent’s University Hospital – MS Society of Ireland – N=51 Inclusion Criteria Exclusion Criteria EDSS 3.0 ‐ 6.5 Unable to provide consent Over 18 years of age Pregnant Women 4
6/18/2015 TUG Administration 3 metres • Seated on a standard armchair with back rested against chair • Permitted to use usual aid • Walk as quickly and as safely as possible to the line • Turn, walk back and sit down again • 1 Practice trial and 3 timed trials performed • TUG ‐ Cognitive : Subtracting out loud backwards in 3s from random numbers between 20 and 100 • Follow Up: Three months of prospective falls diaries • Fortnightly Text/Email Reminders Smartphone Falls Prediction • App Development – University of Limerick 2014 • Smartphone Variables – 4 Parameters in 3 Dimensions – 12 Summary Statistics – 5 Phases in 2 Conditions – 960 Variables Walk 1 “GO” Turn 1 Turn 2 Walk 2 5
6/18/2015 Statistical Analysis • Frequency analysis – Mean, Standard Deviation – Median, Interquartile Range • Tests of Normality – Skewed Data • Non ‐ Parametric Tests – Wilcoxon Signed Rank – Mann ‐ Whitney U Results 6
6/18/2015 Study Population Healthy Reference (n=50) People with MS (n=51) Mean Age 22.8±4.96 53.26±10.19 Males: Females 14:36 16:35 Mean TUG 5.78±0.78 13.55±7.59 Mean TUG ‐ C 5.98±1.0 16.44±9.83 Mean Disease N/A 13.67±8.99 Duration Walking Aid Users N/A 35/51 (69%) Retrospective N/A 22/51 (43%) Fallers Prospective Fallers N/A 9/27 (33%) Within Group TUG and TUGC Difference p<0.001 Healthy Ref PwMS Mean TUG Score (s) (n=50) (n=51) Mean TUG 5.78±0.78 13.55±7.59 Median 5.76 11.36 (IQR) (1.18) (5.94) p=0.004 Mean TUGC 5.98±1.0 16.44±9.83 Median 5.98 13.5 (IQR) (1.51) (5.79) Wilcoxon p=0.004 p<0.001 p value 7
6/18/2015 TUG Difference Healthy Ref Vs PwMS Healthy PwMS (n=50) (n=51) TUG Score (s) Mean±SD 5.78±0.78 13.55±7.59 Median 5.76 11.36 (IQR) (1.18) (5.94) Mann ‐ p<0.001 Whitney U TUGC Difference Healthy Ref Vs PwMS Healthy PwMS (n=50) (n=51) TUG ‐ C Score (s) Mean±SD 5.98±1.0 16.44±9.8 Median 5.98 13.5 (IQR) (1.51) (5.79) Mann ‐ p<0.001 Whitney U 8
6/18/2015 Dual Task Cost% Difference Healthy Ref Vs PwMS Healthy PwMS Dual Task Cost % (n=50) (n=51) Mean±SD 97.5±9.2 86.6±17.7 Median 97.16 86.66 (IQR) (8.90) (19.18) Mann ‐ p<0.001 Whitney U TUG Difference Fallers Vs Non Fallers Faller Non ‐ Faller (n=22) (n=29) TUG Score (s) Mean ±SD 13.24±4.5 13.79±9.4 Median 12.95 11.06 (IQR) (5.82) (5.14) Mann ‐ p=0.403 Whitney U Retrospective Recall 9
6/18/2015 TUGC Difference Fallers Vs Non Fallers Faller Non ‐ Faller (n=22) (n=29) TUG ‐ C Score (s) Mean ±SD 14.82±6.3 17.66±11.8 Median 13.66 12.99 (IQR) (4.31) (11.02) Mann ‐ p=0.955 Whitney U Retrospective Recall TUG Difference Fallers Vs Non Fallers Faller Non ‐ Faller (n=9) (n=18) TUG Score (s) Mean ±SD 17.46±5.2 11.77±9.7 Median 18.44 8.96 (IQR) (8.89) (3.15) Mann ‐ p=0.001 Whitney U Prospective Monitoring 10
6/18/2015 TUGC Difference Fallers Vs Non Fallers Faller (n=9) Non ‐ Faller (n=18) TUGC Score (s) Mean ±SD 25.48±12.4 13.74±9.96 Median 25.53 11.22 (IQR) (19.11) (5.38) Mann ‐ p=0.004 Whitney U Prospective Monitoring DTC% Difference Fallers Vs Non Fallers Faller Non ‐ Faller Dual Task Cost % (n=9) (n=18) Mean ±SD 80.56±32.4 85.59±12.8 Median 88.73 85.44 (IQR) (50.21) (18.39) Mann ‐ p=0.860 Whitney U Prospective Monitoring 11
6/18/2015 Preliminary Smartphone Data • 50 University Students • Mean Age 22.8±4.96 • Cognitive Challenge – Walk 1 Length (mean 0.11, p<0.001) – Go Phase (mean 0.07, p=0.004) • PwMS data collection ongoing • Creation of multivariate TUG/TUGC dataset Walk 1 “GO” Turn 2 Turn 1 Walk 2 Key Points 12
6/18/2015 Summary • Significant Differences in TUG and TUGC exist between healthy populations and pwMS • Limited sample sizes suggest significant differences exist between fallers and non ‐ fallers when prospective falls diaries are used – Research ongoing • Instrumented TUG/TUGC data may be useful in identifying pwMS at risk of falls – Research ongoing Prospective Falls Monitoring • Retrospective Vs Prospective • Falls Diaries IMSFPRN (Coote et al 2014) – 3 Months • Small sample size (n=27) • Ongoing study • ROC and AUC analysis 13
6/18/2015 Acknowledgements • Funded by Education and Health Sciences Faculty Seed Fund and MS Ireland through the Ireland Fund • Dr Susan Coote, UL Clinical Therapies • Dr Rose Galvin, UL Clinical Therapies • Pepijn Van de Ven, UL Engineering • Prof. Ailish Hannigan, UL GEMS • Dr Chris McGuigan, SVUH • Gillian Quinn, SVUH • UL MS Research Team (www.msrearch.ie ) • Study Participants Contact Information Laura.comber@ul.ie Twitter: @lauracomber 14
6/18/2015 Questions References Cattaneo, D., Jonsdottir, J. and Coote, S. (2014) 'Targeting dynamic balance in falls ‐ • prevention interventions in multiple sclerosis: recommendations from the International MS Falls Prevention Research Network', International Journal of MS Care, 16(4), 198 ‐ 202. Coote, S., Sosnoff, J. J. and Gunn, H. (2014) 'Fall incidence as the primary outcome in • multiple sclerosis falls ‐ prevention trials: recommendation from the International MS Falls Prevention Research Network', International Journal of MS Care, 16(4), 178 ‐ 184. Gunn, H., Creanor, S., Haas, B., Marsden, J. and Freeman, J. (2014) 'Frequency, • characteristics, and consequences of falls in multiple sclerosis: findings from a cohort study', Archives Of Physical Medicine And Rehabilitation, 95(3), 538 ‐ 545. Gunn, H. J., Newell, P., Haas, B., Marsden, J. F. and Freeman, J. A. (2013) 'Identification of • risk factors for falls in multiple sclerosis: a systematic review and meta ‐ analysis', Physical Therapy, 93(4), 504 ‐ 513. Matsuda, P. N., Shumway ‐ Cook, A., Ciol, M. A., Bombardier, C. H. and Kartin, D. A. (2012) • 'Understanding falls in multiple sclerosis: association of mobility status, concerns about falling, and accumulated impairments', Physical Therapy, 92(3), 407 ‐ 415. Nilsagård, Y., Denison, E., Gunnarsson, L. ‐ G. and Boström, K. (2009) 'Factors perceived as • being related to accidental falls by persons with multiple sclerosis', Disability & Rehabilitation, 31(16), 1301 ‐ 1310. 15
6/18/2015 References Nilsagård, Y., Gunn, H., Freeman, J., Hoang, P., Lord, S., Mazumder, R. and • Cameron, M. (2014) 'Falls in people with MS—an individual data meta ‐ analysis from studies from Australia, Sweden, United Kingdom and the United States', Multiple Sclerosis Journal , 95(3), 538 ‐ 545. Peterson, E. W., Cho, C. C. and Finlayson, M. L. (2007) 'Fear of falling and • associated activity curtailment among middle aged and older adults with multiple sclerosis', Multiple Sclerosis, 13(9), 1168 ‐ 1175. Peterson, E. W., Cho, C. C., von Koch, L. and Finlayson, M. L. (2008) • 'Injurious falls among middle aged and older adults with multiple sclerosis', Archives Of Physical Medicine And Rehabilitation, 89(6), 1031 ‐ 1037. Sosnoff, J. J., Boes, M. K., Sandroff, B. M., Socie, M. J., Pula, J. H. and Motl, • R. W. (2011) 'Walking and thinking in persons with multiple sclerosis who vary in disability', Archives Of Physical Medicine And Rehabilitation, 92(12), 2028 ‐ 2033. 16
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