Falls and mobility dysfunction in adults with cerebral palsy
thesis
posted on 2017-02-16, 03:10authored byMorgan, Prue
Adults with cerebral palsy (CP) are a growing population, with age-related mobility
changes, balance dysfunction, and falls relatively unexplored. This contrasts with other
populations with known vulnerabilities such as Parkinson's disease, stroke, or older
adults, where falls characteristics have been documented and clinical practice
guidelines to address falls and balance dysfunction are readily available. The studies
reported in this thesis investigated what is known about falls and mobility dysfunction
in ambulant adults with CP. Specifically, investigations of premature age-associated
mobility decline, falls and near-falls, physical, psychosocial and health-related quality
of life (HRQOL) consequences of mobility decline and falls were conducted.
Interventions to address mobility dysfunction, and perceptions of current health
services to address falls and mobility decline were also evaluated.
The research series commenced with a systematic review exploring mobility decline, revealing
it occurs in 25% or more of ambulant adults with CP. Those at higher risk of decline were
individuals with worse initial gait ability, bilateral rather than unilateral motor impairment,
older age, and higher levels of pain or fatigue. Given that balance and mobility dysfunction are
typically associated with falls in other populations, two studies investigated the perceived
causes, environmental influences, and consequences of falls or near-falls, and the association
of falls with mobility decline. These studies revealed that many adults with CP experience falls
during non-hazardous ambulation resulting in physical injuries and adverse psychosocial
consequences. In addition, those who experienced mobility decline reported poorer
satisfaction with HRQOl than those who had not. Worse physical health status and lower
levels of well-being were strongly associated with frequent falls history.
The next series of studies explored the performance of ambulant adults with CP using
standardised mobility and balance outcomes to describe falls risk, and investigated
associations between falls, gross motor performance (Gross Motor Function Classification
System- Extended and Revised, GMFCS-E&R) and these measures. Significant differences
were found in gait speed, gait endurance and standing balance between those with higher
(GMFCS-E&R levels I and II) and lower (level Ill) levels of gross motor function. Significant
differences were also found in falls risk indicators between those at higher and lower levels of
GMFCS-E&R. However, fear of falling and falls risk did not differ between those who fell and
those who did not, suggesting many ambulant adults with CP live with high fear of falling
irrespective of actual falls experienced. Furthermore, standardised falls risk assessment tools
appeared to have limited capacity to identify prospective falls frequency.
A second systematic review synthesised and appraised evidence regarding the effect of
conservative (physiotherapeutic and pharmacological) interventions on gait dysfunction in
adults with CP. Of the ten studies included in the review, around half were found to provide
low strength of evidence. Although a small between-group effect of exercise on gait speed was
found, evidence to support the efficacy of one intervention over another to improve gait was
limited. A pilot randomised controlled trial was conducted in ambulant adults with CP to
evaluate the safety, feasibility and efficacy of an eight week program of individualised balance
training on ambulatory self-confidence and balance. Results demonstrated that the
customised balance program was feasible and safe. Evidence of small to medium effects from
the balance training program in ambulatory self-confidence, postural responses, falls efficacy and fatigue were evident. Concurrent self-reported improvement also occurred. The final
study reported outcomes of a qualitative investigation into experiences with health services to
address falls and balance dysfunction. Adults with CP reported frustration and variability in the
access to and matching of health service provided with self-perceptions of service type and
need.
In conclusion, many ambulant adults with CP experience falls and mobility decline. The clinical
implications of this series of studies are considered, with recommendations for health
promotion content, physiotherapy education and clinical research to add to the growing
evidence base regarding falls and mobility dysfunction in ambulant adults ageing with CP.