Falls and mobility dysfunction in adults with cerebral palsy

Abstract

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.