Meta-analysis and GRADE profiles of exercise interventions for falls prevention in long-term care facilities

Effects of Different Exercise Interventions on Fall Risk and Gait Parameters in Frail Patients After Open Heart Surgery: A Pilot Study

Background and Objectives: Research on the effectiveness of different exercise programs on reducing fall risk and improving gait parameters among frail patients after open heart surgery is scarce. Therefore, the aim of this study was to evaluate and compare the effects of different exercise interventions on fall risk and gait parameters in frail patients after open heart surgery during inpatient rehabilitation. Materials and Methods: A prospective randomized study was conducted at Kulautuva Hospital of Rehabilitation, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, from July 2021 to November 2023. A total of 105 pre-frail and frail patients were randomized into three groups: control (CG, n = 35), intervention 1 (IG-1, n = 35), and intervention 2 (IG-2, n = 35). All three groups completed a conventional rehabilitation program that included aerobic training tailored based on each person's health status six times/week. The IG-1 additionally received multicomponent dynamic aerobic balance and strength training three times/week, and the IG-2 received a combined computer-based interactive program three times/week. The overall stability index, as an outcome of fall risk, Short Physical Performance Battery (SPPB) score, and gait parameters (geometry, stance, and timing) were assessed before and after rehabilitation. Results: Of the 105 patients, 87 completed the study. The median age of the patients was 71 years (range: 65-88); 64.76% were male. After rehabilitation, within-group comparisons showed a significant improvement in the overall stability index, SPPB, and all phase gait parameters in all groups. Of all geometry gait parameters, none of the groups showed a significant improvement in step width, and foot rotation was significantly reduced only in the IG-2. All timing gait parameters improved in the CG and IG-2 after rehabilitation, while in the IG-1, only gait speed was significantly improved. Between-group comparisons after rehabilitation revealed significant differences in the overall stability index among the groups and in all phase gait parameters except for stance phase between the IG-1 and the IG-2. The greatest significant difference was documented for the double stance phase between the IG-1 and the IG-2, and the smallest was recorded for the single limb support phase. Significantly greater differences in step time and stride time were found in the IG-1 and the IG-2 than in the CG. Conclusions: All applied interventions were effective in reducing fall risk based on the overall stability index. However, interactive exercise interventions decreased fall risk based on the overall stability index by one-fifth as compared to the conventional rehabilitation program. The incorporation of interactive exercise interventions in rehabilitation resulted in improved double stance phase, stride time, and step time parameters, but did not have any effect on gait speed as compared to other exercise interventions.

Person-focused interventions for fall risk assessment, fall prevention and fall injury prevention in long-term care facilities: a scoping review

OBJECTIVE

Falls are a significant concern in long-term care facilities (LTCFs) as fall-related injuries can result in functional impairment, disability and death. Older adults living in LTCFs are at greater risk for falls than those in the community. Using scoping review methodology, we aimed to synthesise evidence examining intervention effects of person-focused interventions for risk assessment and prevention in LTCFs in order to identify evidence-based practices in LTCFs.

METHODS

We included three databases (Ovid-Medline, CINAHL and EMBASE) to identify original research from 2007 to 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guideline. From the initial search, we identified 988 articles. Following the removal of duplicates, title and abstract screening, and full-text review against inclusion/exclusion criteria, 20 studies remained for analysis. Then, we conducted a narrative synthesis to summarise the included studies.

RESULTS

Identified evidence-based interventions for fall prevention include (1) exercise programmes (eg, high-intensity functional exercise, aerobic exercise, short stick exercises, etc); (2) multifactorial programmes; and (3) other interventions (eg, lavender olfactory stimulation). Outcomes of included studies included the number of falls, fall rate, risk of falls and fear of falls before and after interventions.

CONCLUSION

Overall, most studies reported significant effects of person-focused interventions in LTCFs. Available evidence supports that well-designed person-focused interventions can reduce falls and fear of falls for individuals in LTCFs.

Effectiveness of fall prevention interventions in residential aged care and community settings: an umbrella review

INTRODUCTION

Preventing falls is a priority for aged care providers. Research to date has focused on fall prevention strategies in single settings (e.g., residential aged care (RAC) or community settings). However, some aged care providers deliver care, including fall prevention interventions, across RAC and community settings. We conducted an umbrella review to identify what type of fall prevention interventions had the greatest impact on falls outcomes in RAC and community settings.

METHODS

Five databases were searched for systematic reviews of falls prevention randomised control trials in older adults living in the community or RAC. Data extracted included systematic review methods, population characteristics, intervention characteristics, setting details (RAC or community), and fall-related outcomes (falls, people who have had a fall, fall-related hospitalisations, and fall-related fractures). Review quality was appraised using the Assessment of Multiple Systematic Reviews-2 tool.

RESULTS

One-hundred and six systematic reviews were included; 63 and 19 of these stratified results by community and RAC settings respectively, the remainder looked at both settings. The most common intervention types discussed in reviews included 'exercise' (61%, n = 65), 'multifactorial' (two or more intervention types delivered together) (26%, n = 28), and 'vitamin D' (18%, n = 19). In RAC and community settings, 'exercise' interventions demonstrated the most consistent reduction in falls and people who have had a fall compared to other intervention types. 'Multifactorial' interventions were also beneficial in both settings however demonstrated more consistent reduction in falls and people who fall in RAC settings compared to community settings. 'Vitamin D' interventions may be beneficial in community-dwelling populations but not in RAC settings. It was not possible to stratify fall-related hospitalisation and fall-related fracture outcomes by setting due to limited number of RAC-specific reviews (n = 3 and 0 respectively).

CONCLUSION

'Exercise' interventions may be the most appropriate falls prevention intervention for older adults in RAC and community settings as it is beneficial for multiple fall-related outcomes (falls, fall-related fractures, and people who have had a fall). Augmenting 'exercise' interventions to become 'multifactorial' interventions may also improve the incidence of falls in both settings.

Effects of Physical Activity on Physical and Mental Health of Older Adults Living in Care Settings: A Systematic Review of Meta-Analyses

Previous studies included in meta-analyses have highlighted the effects of physical activity on the physical and psychological health of older adults living in care settings. We conducted a systematic review of meta-analyses, of institutionalized older adults, to evaluate and conduct a narrative synthesis of the results of these meta-analyses. A literature search was conducted in three databases (PubMed, Web of Science, and Cochrane Library) until 22 March 2023. After screening the identified articles with the PRISMA criteria filters, we included 11 meta-analyses in this systematic review. Higgins' (2013) assessment tool of the meta-analyses demonstrates that the studies were of good quality although future meta-analyses need to provide more information on the treatment of missing data. A summary of the results of these meta-analyses shows that physical activity reduces the rate of falls, mobility issues, functional dependence, and depression, and improves health status. Future studies need to focus on new ways to promote and adapt physical activities to increase the participation of older adults in care settings.

The Effect of a Standing Intervention on Falls in Long Term Care: a Secondary Analysis of a Randomized Controlled Trial

Background

Older adults in long term care (LTC) spend over 90% of their day engaging in sedentary behaviour. Sedentary behaviour may exacerbate functional decline and frailty, increasing the risk for falls. The purpose of this study is to explore the impact of a 22-week standing intervention on falls among LTC residents at 12-month follow-up.

Methods

This was a planned secondary analysis of the Stand if You Can randomized controlled trial. The original trial randomized 95 participants (n = 47 control; n = 48 intervention) to either a sitting control or a supervised standing intervention group (100 minutes/week) for 22 weeks. Falls data were available to be collected over 12 months post-intervention for 89 participants. The primary outcome was a hazard of fall (Yes/No) during the 12-month follow-up period.

Results

A total of 89 participants (average age 86 years ± 8.05; 71.9% female) were followed for 12-months post-intervention. Participants in the intervention group (n=44) had a significantly greater hazard ratio of falls (2.01; 95% CI = 1.11 to 3.63) than the control group (n=45) when accounting for the history of falls, frailty status, cognition level, and sex.

Conclusion

Participants who received a standing intervention over 22 weeks were twice as likely to fall 12 months after the intervention compared with the control group. However, the prevalence of falls did not surpass what would be typically observed in LTC facilities. It is imperative that future studies describe in detail the context in which falls happen and collect more characteristics of participants in the follow-up period to truly understand the association between standing more and the risk of falls.

Walking aids and complicated orthopedic diseases are risk factors for falls in hemodialysis patients: an observational study

BACKGROUND

Aging and an increased fall risk have been demonstrated in hemodialysis patients at home and in a facility. However, studies investigating the cause of falls to prevent fractures in dialysis rooms are scarce. This study aimed to explore the related factors for accidental falls statistically in dialysis facilities for future fall prevention.

METHODS

This study included 629 hemodialysis patients with end-stage renal disease. The patients were divided into two groups: the fall and non-fall groups. The main outcome was the presence or absence of falls in the dialysis room. Univariate and multivariate logistic analyses were performed; multivariate analysis was conducted using covariates significantly correlated in the univariate analysis.

RESULTS

A total of 133 patients experienced falling accidents during the study period. The multivariate analysis indicated that the use of walking aid (p < 0.001), orthopedic diseases (p < 0.05), cerebrovascular disease, and age were significantly correlated with falls.

CONCLUSIONS

In the dialysis clinic, patients who use walking aids and have complicated orthopedic or cerebrovascular conditions are at a high risk of falling in the dialysis room. Therefore, establishing a safe environment may help prevent falls, not only for these patients but also among other patients with similar conditions.

Implementation strategies to support fall prevention interventions in long-term care facilities for older persons: a systematic review

BACKGROUND

Falls are common among older people in long-term care facilities (LTCFs). Falls cause considerable morbidity, mortality and reduced quality of life. Of numerous interventional studies of fall prevention interventions in LTCFs, some reduced falls. However, there are challenges to implementing these interventions in real-world (non-trial) clinical practice, and the implementation techniques may be crucial to successful translation. This systematic review thus aimed to synthesise the evidence on implementation strategies, implementation outcomes and clinical outcomes included in fall prevention intervention studies.

METHODS

A systematic search of six electronic databases (PubMed, CINAHL, EMBASE, PsycINFO, SCOPUS, Web of Science) and eight grey literature databases was conducted, involving papers published during 2001-2021, in English or Arabic, targeting original empirical studies of fall prevention interventions (experimental and quasi-experimental). Two seminal implementation frameworks guided the categorisation of implementation strategies and outcomes: the Expert Recommendations for Implementing Change (ERIC) Taxonomy and the Implementation Outcomes Framework. Four ERIC sub-categories and three additional implementation strategies were created to clarify overlapping definitions and reflect the implementation approach. Two independent researchers completed title/abstract and full-text screening, quality appraisal assessment, data abstraction and coding of the implementation strategies and outcomes. A narrative synthesis was performed to analyse results.

RESULTS

Four thousand three hundred ninety-seven potential papers were identified; 31 papers were included, describing 27 different fall prevention studies. These studies used 39 implementation strategies (3-17 per study). Educational and training strategies were used in almost all (n = 26), followed by evaluative strategies (n = 20) and developing stakeholders' interrelationships (n = 20). Within educational and training strategies, education outreach/meetings (n = 17), distributing educational materials (n = 17) and developing educational materials (n = 13) were the most common, with 36 strategies coded to the ERIC taxonomy. Three strategies were added to allow coding of once-off training, dynamic education and ongoing medical consultation. Among the 15 studies reporting implementation outcomes, fidelity was the most common (n = 8).

CONCLUSION

This is the first study to comprehensively identify the implementation strategies used in falls prevention interventions in LTCFs. Education is the most common implementation strategy used in this setting. This review highlighted that there was poor reporting of the implementation strategies, limited assessment of implementation outcomes, and there was no discernible pattern of implementation strategies used in effective interventions, which should be improved and clearly defined.

TRIAL REGISTRATION

This systematic review was registered on the PROSPERO database; registration number: CRD42021239604.

Implementation strategies supporting fall prevention interventions in a long-term care facility for older persons: a systematic review protocol

INTRODUCTION

Falls are common among older people in long-term care facilities (LCFs). Falls lead to significant morbidity, mortality and reduced quality of life among residents. Fall prevention interventions have been shown to reduce falls in LCFs. However, this may not always translate to effectiveness in real-world situations. We will conduct a systematic review (SR) to identify the implementation strategies used in fall prevention interventions in LCF, describing the effectiveness of strategies in terms of key implementation outcomes and fall reduction.

METHODS AND ANALYSIS

The search will include scientific papers in electronic databases, including PubMed, CINAHL, Embase, PsycINFO, Scopus and Web of Science, and published theses. The SR will consider all original research that empirically evaluated or tested implementation strategies to support fall prevention interventions in LCF, published in English or Arabic between 1 January 2001 and 31 December 2021, where data are presented on the implementation strategy (eg, audit and feedback, champions) and/or implementation outcome (eg, fidelity). Clinical trials, quasi-experimental studies and quality improvement studies will be eligible for inclusion. Two researchers will complete abstract screening, data abstraction and quality assessments independently. The screening process will be presented using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. Data will be extracted into a standardised table, including the country, year, authors, type of study, primary clinical outcome (falls rate and/or risk reduction as available), implementation strategy and implementation outcomes. Implementation strategies will be defined and categorised using the Expert Recommendation for Implementing Change Taxonomy. Implementation outcomes will be defined and categorised using the Implementation Outcomes Taxonomy, and clinical outcomes of the intervention effectiveness for falls preventions will be reported as formulated in each study, with a final narrative synthesis of data.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study, and the results will be disseminated via peer-reviewed journals and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42021239604.

Effects of an individualized and progressive multicomponent exercise program on blood pressure, cardiorespiratory fitness, and body composition in long-term care residents: Randomized controlled trial

This study analyzed the effects of an individualized and progressive multicomponent exercise program on blood pressure, cardiorespiratory fitness, and body composition in long-term care residents. This was a single-blind, multicenter, randomized controlled trial performed in 10 long-term care settings and involved 112 participants. Participants were randomly assigned to a control group or an intervention group. The control group participated in routine activities; the intervention group participated in a six-month individualized and progressive multicomponent exercise program focused on strength, balance, and walking recommendations. The intervention group maintained peak VO₂, oxygen saturation, and resting heart rate, while the control group showed a significant decrease in peak VO₂ and oxygen saturation and an increase in resting heart rate throughout the six-month period. Individualized and progressive multicomponent exercise programs comprising strength, balance, and walking recommendations appear to be effective in preventing cardiorespiratory fitness decline in older adults living in long-term care settings.

Accuracy of Kinovea software in estimating body segment movements during falls captured on standard video: Effects of fall direction, camera perspective and video calibration technique

Falls are a major cause of unintentional injuries. Understanding the movements of the body during falls is important to the design of fall prevention and management strategies, including exercise programs, mobility aids, fall detectors, protective gear, and safer environments. Video footage of real-life falls is increasingly available, and may be used with digitization software to extract kinematic features of falls. We examined the validity of this approach by conducting laboratory falling experiments, and comparing linear and angular positions and velocities measured from 3D motion capture to estimates from Kinovea 2D digitization software based on standard surveillance video (30 Hz, 640x480 pixels). We also examined how Kinovea accuracy depended on fall direction, camera angle, filtering cut-off frequency, and calibration technique. For a camera oriented perpendicular to the plane of the fall (90 degrees), Kinovea position data filtered at 10 Hz, and video calibration using a 2D grid, mean root mean square errors were 0.050 m or 9% of the signal amplitude and 0.22 m/s (7%) for vertical position and velocity, and 0.035 m (6%) and 0.16 m/s (7%) for horizontal position and velocity. Errors in angular measures averaged over 2-fold higher in sideways than forward or backward falls, due to out-of-plane movement of the knees and elbows. Errors in horizontal velocity were 2.5-fold higher for a 30 than 90 degree camera angle, and 1.6-fold higher for calibration using participants’ height (1D) instead of a 2D grid. When compared to 10 Hz, filtering at 3 Hz caused velocity errors to increase 1.4-fold. Our results demonstrate that Kinovea can be applied to 30 Hz video to measure linear positions and velocities to within 9% accuracy. Lower accuracy was observed for angular kinematics of the upper and lower limb in sideways falls, and for horizontal measures from 30 degree cameras or 1D height-based calibration.

Perceptions of Rehabilitation Managers on Implementation of the Home-Based Older Person Upstreaming Prevention (HOP-UP) Program: A Retrospective Qualitative Analysis

Introduction

The purpose of this study was to identify themes and concepts derived from responses of physical therapy clinical leaders related to implementing a prevention-focused, home-based older-adult program known as HOP-UP-PT (Home-Based Older Person Upstreaming Prevention Physical Therapy) into their clinical operations.

Methods

Following Institutional Review Board approval, a retrospective qualitative analysis of transcribed interviews obtained by six undergraduate students participating in the Oakland University Ideas to Business Program (I2B) was conducted. Students interviewed nine local physical therapy clinical managers throughout Michigan using 12 questions developed by content experts. Questions aimed to ascertain the perceived opportunities and barriers to implementing HOP-UP-PT into each respondent's practice setting, clinic demographics, and suggested price point of a prevention-focused continuing education. Interview data was analyzed using the constant comparative method to identify themes and concepts.

Results

Sixty-seven percent of respondents (n=6) reported practicing in an outpatient setting; 56% of respondents (n=5) indicated 50% or more of their clients were 65 years and older; and 67% of respondents (n=6) suggested a price point of $200-$500 for an eight-hour HOP-UP-PT training course. Three concepts (community involvement and partnership, administrative barriers to an innovative delivery model, and foundational physical therapy [PT] skills utilized in a novel approach) and eight themes (community altruism, referral source expansion, integrated community relationships, current payment methodology challenges, favorability of clinic setting and type, minimal additional training required, willingness to pay for certification training, and prevention-focused or upstream mindset) were identified.

Conclusion

Physical therapy clinical managers identified a willingness to expand current rehabilitation models and incorporate prevention-focused care delivery into the existing care delivery approach. However, barriers and opportunities must be addressed in advance of a program roll-out to achieve optimal outcomes and cost savings within the healthcare system.

Meta-analysis and GRADE profiles of exercise interventions for falls prevention in long-term care facilities

AIMS

To provide a comprehensive collection of evidence on the effectiveness of exercise interventions to prevent falls and support clinical decision-making.

DESIGN

A systematic literature review and meta-analysis of randomized controlled trails were performed by combining trials from published systematic reviews and more recent ones from a separate literature search.

DATA SOURCES

The literature search was performed using PubMed, CINAHL, Cochrane Databases, and Google Scholar dating January 2007 - March 2018.

REVIEW METHODS

Comparable studies were pooled using the random-effects model. The GRADE approach was used to judge the evidence.

RESULTS

Exercises with a balance component or with technical devices reduced falls significantly, however, with low confidence in the evidence. The evidence indicated that exercises conducted longer than 6 months were beneficial. In frail residents, exercise interventions seemed to have substantially negative effects on falls.

CONCLUSIONS

Exercise interventions with technical devices, those with a balance component, and those performed longer than 6 months are recommended in long-term care settings. Frail residents need special attention when performing exercises due to their increased risk of falling.

IMPACT

Exercises with a balance component and exercises carried out with technical devices have beneficial effects, whereas exercises performed longer than 6 months are more effective than short-term performances. No significant reduction or decrease in the number of falls was found for exercise in cognitively impaired residents. In frail residents, however, the number of fall events increased substantially as a result of exercise interventions. The results of this review are useful for clinical decision-makers in long-term care facilities with regard to the planning and performance of exercise interventions for residents.