Effect of a Matter of Balance programme on avoidance behaviour due to fear of falling in older adults

Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community

BACKGROUND

Fear of falling (FoF) is a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing. It is a common condition amongst older adults and may occur independently of previous falls. Cognitive behavioural therapy (CBT), a talking therapy that helps change dysfunctional thoughts and behaviour, with and without exercise, may reduce FoF, for example, by reducing catastrophic thoughts related to falls, and modifying dysfunctional behaviour.

OBJECTIVES

To assess the benefits and harms of CBT for reducing FoF in older people living in the community, and to assess the effects of interventions where CBT is used in combination with exercise.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2023), MEDLINE Ovid (from 1946 to 11 January 2023), Embase Ovid (from 1980 to 11 January 2023), CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) (from 1982 to 11 January 2023), PsycINFO (from 1967 to 11 January 2023), and AMED (Allied and Complementary Medicine from 1985 to 11 January 2023). We handsearched reference lists and consulted experts for identifying additional studies.

SELECTION CRITERIA

This review included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs assessing CBT with and without exercise interventions compared to control groups with sham-treatment, or treatment as usual. We defined CBT as a collaborative, time-limited, goal-oriented, and structured form of speaking therapy. Included studies recruited community-dwelling older adults, with a mean population age of at least 60 years minus one standard deviation, and not defined by a specific medical condition.

DATA COLLECTION AND ANALYSIS

Two review authors used standard methodological procedures expected by Cochrane. For continuous data, as assessed by single- or multiple-item questionnaires, we report the mean difference (MD) with 95% confidence interval (CI) when studies used the same outcome measures, and standardised mean difference (SMD) when studies used different measures for the same clinical outcome. For dichotomous outcomes, we reported the treatment effects as risk ratios (RR) with 95% CIs. We measured the primary outcome, FoF, immediately, up to, and more than six months after the intervention. We analysed secondary outcomes of activity avoidance, occurrence of falls, depression, and quality of life when measured immediately after the intervention. We assessed risk of bias for each included study, using the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We selected 12 studies for this review, with 11 studies included for quantitative synthesis. One study could not be included due to missing information. Of the 11 individual studies, two studies provided two comparisons, which resulted in 13 comparisons. Eight studies were RCTs, and four studies were cluster-RCTs. Two studies had multiple arms (CBT only and CBT with exercise) that fulfilled the inclusion criteria. The primary aim of 10 studies was to reduce FoF. The 11 included studies for quantitative synthesis involved 2357 participants, with mean ages between 73 and 83 years. Study total sample sizes varied from 42 to 540 participants. Of the 13 comparisons, three investigated CBT-only interventions while 10 investigated CBT with exercise. Intervention duration varied between six and 156 hours, at a frequency between three times a week and monthly over an eight- to 48-week period. Most interventions were delivered in groups of between five and 10 participants, and, in one study, up to 25 participants. Included studies had considerable heterogeneity, used different questionnaires, and had high risks of bias. CBT interventions with and without exercise probably improve FoF immediately after the intervention (SMD -0.23, 95% CI -0.36 to -0.11; 11 studies, 2357 participants; moderate-certainty evidence). The sensitivity analyses did not change the intervention effect significantly. Effects of CBT with or without exercise on FoF may be sustained up to six months after the intervention (SMD -0.24, 95% CI -0.41 to -0.07; 8 studies, 1784 participants; very low-certainty evidence). CBT with or without exercise interventions for FoF probably sustains improvements beyond six months (SMD -0.28, 95% CI -0.40 to -0.15; 5 studies, 1185 participants; moderate-certainty of evidence). CBT interventions for reducing FoF may reduce activity avoidance (MD -2.57, 95% CI -4.67 to -0.47; 1 study, 312 participants; low-certainty evidence), and level of depression (SMD -0.41, 95% CI -0.60 to -0.21; 2 studies, 404 participants; low-certainty evidence). We are uncertain whether CBT interventions reduce the occurrence of falls (RR 0.96, 95% CI 0.66 to 1.39; 5 studies, 1119 participants; very low-certainty evidence). All studies had a serious risk of bias, due to performance bias, and at least an unclear risk of detection bias, as participants and assessors could not be blinded due to the nature of the intervention. Downgrading of certainty of evidence also occurred due to heterogeneity between studies, and imprecision, owing to limited sample size of some studies. There was no reporting bias suspected for any article. No studies reported adverse effects due to their interventions.

AUTHORS' CONCLUSIONS

CBT with and without exercise interventions probably reduces FoF in older people living in the community immediately after the intervention (moderate-certainty evidence). The improvements may be sustained during the period up to six months after intervention (low-certainty evidence), and probably are sustained beyond six months (moderate-certainty evidence). Further studies are needed to improve the certainty of evidence for sustainability of FoF effects up to six months. Of the secondary outcomes, we are uncertain whether CBT interventions for FoF reduce the occurrence of falls (very low-certainty evidence). However, CBT interventions for reducing FoF may reduce the level of activity avoidance, and may reduce depression (low-certainty evidence). No studies reported adverse effects. Future studies could investigate different populations (e.g. nursing home residents or people with comorbidities), intervention characteristics (e.g. duration), or comparisons (e.g. CBT versus exercise), investigate adverse effects of the interventions, and add outcomes (e.g. gait analysis). Future systematic reviews could search specifically for secondary outcomes.

Using an academic-community partnership model to deliver evidence-based falls prevention programs in a metropolitan setting: A community case study

Background

Prevention is an effective approach for mitigating the negative health outcomes associated with falls in older adults. The Administration for Community Living (ACL) has sponsored the implementation of evidence-based falls prevention programs (EBFPPs) across the United States through cooperative agreement grants to decrease the health and economic burden of falls. Marymount University received two of these grants to deliver three EBFPPs into the northern Virginia region. This community case study describes the development of a collaboration between a university and community-based organizations to adopt and implement multiple evidence-based programming in an area where none previously existed.

Methods

Through an academic-community partnership, EBFPPs were introduced to and implemented by senior-focused organizations. Target adopters were senior and community centers, multi-purpose senior services organizations, recreational organizations, and residential facilities serving older adults. The three EBFPPs were (1) Stay Active and Independent for Life (SAIL), (2) a Matter of Balance (MOB) and (3) Otago Exercise Program (OEP). Key interdependent project elements included: (1) fostering ongoing community organization collaboration, (2) introducing programs in the community, (3) growing and sustaining delivery sites, (4) preparing trained program leaders, and (5) building community demand for the programs.

Results

From August 2016–June 2022, 5,857 older adults participated in one of the three EBFPPs. SAIL classes were offered at 33 sites and MOB workshops at 31 with over 70% of them occurring at community or senior centers. OEP was offered at 4 sites. Factors that influenced the implementation of these programs included having: key advocates at host organizations, programs embedded into site workflows, sufficient capacity and workforce, engaged invested partners, and flexibility in working with a complex set of agencies and systems with different administrative structures.

Conclusion

By connecting academic faculty with various community members from multiple sectors, new initiatives can be successfully implemented. Results from this ACL-funded project indicate that using an academic-community partnership model to build relationships and capacity for ongoing delivery of health promotion programming for older adults is feasible and effective in delivering EBFPPs. In addition, academic-community partnerships can develop a strong network of invested partners to foster continued support of fall prevention activities.

Student coaching in a rural community fall prevention program: An exploratory study

Falls are a significant cause of disability internationally. The purpose of this exploratory study was to examine the effectiveness of a community fall prevention program, Stepping On (SO), using nine student physical therapists and program faculty in a rural setting. A mixed-methods design was utilized. Students partnered with older adults to master exercises, demonstrate floor recovery techniques, and manage community navigation in line with program fidelity. A descriptive survey assessed program outcomes. Students participated in a follow-up focus group to discuss perspectives on their role in the program. One hundred and seventeen community-dwelling older adults (mean age: 75.2 ± 8.5) completed the program. Participants who lived alone were likely to limit their activities because of fear of falling (p = .045). Following SO most subjects (87.7%) described having a better understanding of falls and their causes, with a plan to arise from the floor (82.6%). Focus group themes underscored students' opportunity to facilitate, reinforce safety during mobility activities, and motivate participants. Furthermore, an increased awareness of other professions' contribution to fall prevention was noted. Following a community fall prevention program, older adults have a better understanding of fall prevention and plan for floor recovery. In turn, student coaching skills are reinforced.

A Collaborative Implementation Strategy to Increase Falls Prevention Training Using the Age-Friendly Health Systems Approach

Falls in the home and in community environments are the leading cause of injuries and long-term disabilities for the aging population. The purpose of this study was to examine outcomes of a partnership among an academic institution, government agency, community organizations, and emergency management services to implement a falls prevention training program using an Age-Friendly Health Systems approach. In this prospective study, partners identified gaps in services and targeted and non-targeted delivery areas for implementation of an evidence-based falls prevention intervention addressing the 4Ms of Age-Friendly Health Systems—Mobility, Medications, Mentation, and What Matters. Descriptive statistics were calculated for program implementation and participant demographic variables, and paired t-test analysis compared scores for self-assessed general health and falls efficacy prior to and after program participation. Twenty-seven falls prevention classes were implemented, with over half (52%) in targeted areas. A total of 354 adults aged 50 and older participated, with N = 188 participants (53%) completing the program by attending at least five of eight sessions. Of completers, 35% resided in targeted areas. The results showed a statistically significant improvement in falls efficacy by program completers in targeted and non-targeted areas. However, there was no statistically significant difference in self-rated health. Overall, the findings of this study indicate that collaboration to deliver falls prevention training can be effective in reaching at-risk older adults. By mobilizing collaborative partnerships, limited resources can be allocated towards identifying at-risk older adults and improving community-based falls prevention education.

Translation, Cross-Cultural Adaptation, and Measurement Properties of the Brazilian-Portuguese Version of the Fear of Falling Avoidance Behavior Questionnaire in Older Adults

The aim of this study was to translate and culturally adapt the Fear of Falling Avoidance Behavior Questionnaire (FFABQ) into Brazilian-Portuguese (FFABQ-B), and to examine its reliability and validity in Brazilian older adults. The FFABQ-B was translated and tested in 10 Brazilian older adults. We assessed 52 community-dwellers, 68.7 (±6.2) years, using the FFABQ-B, BERG Balance Scale, Activities-specific Balance Confidence Scale, Falls Efficacy Scale, 6-Minute Walk Test, Timed Up and Go test, and activity monitor. Internal consistency, test-retest reliability, construct validity, and floor and ceiling effects were analyzed. The FFABQ-B had adequate internal consistency (Cronbach's α = .90) and test-retest reliability (intraclass correlation coefficient = .81; 95% confidence interval [.68, .90]). The FFABQ-B was associated with 6-Minute Walk Test, Timed Up and Go, BERG Balance Scale, physical activity time (p < .05), Activities-specific Balance Confidence scale, and Falls Efficacy Scale (p < .001). The FFABQ-B is both reliable and valid to assess avoidance behavior in activities and participation due to fear of falling in Brazilian community-dwelling older adults.

A theoretical framework for addressing fear of falling avoidance behavior in Parkinson's disease

Postural instability in Parkinson's disease (PD) is associated with several downstream consequences that ultimately lead to a greater risk of falling. Among the prominent downstream consequences is fear of falling (FOF), which is both common and problematic in PD. It can lead to a vicious cycle of FOF avoidance behavior that results in more sedentary behavior, physical deconditioning, and weakening of already impaired balance systems. This, in turn, may make the person with PD more susceptible to a future fall even with benign daily tasks. While FOF activity avoidance can be adaptive (appropriate), it can also be maladaptive (inappropriate or exaggerated). When this adaptive and maladaptive FOF avoidance behavior is contextualized to gait/balance performance, it provides a theoretical framework that can be used by clinicians to match patterns of behavior to a concordant treatment approach. In the theoretical framework proposed in this perspective, four different patterns related to FOF avoidance behavior and gait/balance performance are suggested: appropriate avoiders, appropriate non-avoiders, inappropriate avoiders, and inappropriate non-avoiders. For each of the four FOF avoidance behavior patterns, this paper also provides suggested treatment focuses, approaches and recommendations.

A Survey-Based Assessment of "Matter of Balance" Participant Fall-Related Experience

BACKGROUND

Falls are a substantial cause of injury in older adults, which can be attributed to progressive lack of physical activity, associated comorbidities, social isolation, and chronic health conditions. Fall prevention courses are designed to educate participants on fall safety and increase activity levels and social engagement.

OBJECTIVE

The purpose of this study was to evaluate the perceived effectiveness of a nationally recognized fall prevention course on self-reported fall frequency and lifestyle habits.

METHODS

This was a single-group pretest-posttest study of a convenience sample of older adults enrolled in a group fall prevention program, A Matter of Balance, in a community setting between March 2019 and March 2020. Questionnaires were distributed at the first and final sessions of the course to evaluate participant perceptions of the program and its impact on their fall history, exercise habits, and social engagement. Comparisons were made using Wilcoxon rank sum tests.

RESULTS

A total of 40 class members agreed to participate, with 29 (73%) completing both the presurvey and the postsurvey. Responses indicated no change in the number of falls or participants following an established exercise routine. However, of those who fell prior to the course, 75% reported a reduction in falls. In addition, the participants reported an overall increase in weekly exercise frequency. In those who reported fear of falling, 71% reported a reduction in fear following the course.

CONCLUSIONS

The participants in this study self-reported a decrease in fall rate, a decrease in fear of falling, and an increase in exercise frequency. The course is not fall protective but can be considered an adjunct to fall prevention measures that include medical, medication, visual, and environmental management.

The effects of the Otago Exercise Programme on actual and perceived balance in older adults: A meta-analysis

Objective

Falls are serious issues in older populations. Balance problems are a major cause of falls and may lead to fear of falling and decreased balance confidence. The Otago Exercise Programme (OEP) is an effective fall prevention program that benefits balance function and fear of falling. The primary aim of the meta-analysis was to investigate the effectiveness of the OEP intervention on actual balance performance (i.e., static, dynamic, proactive or reactive balance) and perceived balance ability (i.e., balance confidence or fear of falling) for older adults; the secondary aim was to examine which OEP protocol most improves balance in older adults.

Methods

A systematic electronic review search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines to identify randomized controlled trials (RCTs) investigating the effects of the OEP on actual balance performance and perceived balance ability in healthy older adults, and examining which OEP training protocol and intervention format most improves balance.

Results

A total of 12 RCTs were included in the analyses. The OEP exerted significant effects on static balance (Hedges’s g = 0.388; 95% confidence interval [CI] = 0.131 to 0.645), dynamic balance (g = -0.228; 95% CI = -0.352 to -0.1.4), proactive balance (g = 0.239; 95% CI = 0.061 to 0.416) and perceived balance (g = -0.184; 95% CI = -0.320 to -0.048) in older adults. Subgroup analysis indicated that the group format for the OEP was more effective for improving static (p = 0.008), dynamic (p = 0.004) and perceived balance (p = 0.004) than was the individual format. Sessions of >30 minutes were more effective in improving static (p = 0.007) and perceived balance (p = 0.014) than were sessions of ≤30 minutes. However, the effects of the OEP on balance were unrelated to the types of control group, training frequency and training period.

Discussion

The OEP is helpful for improving actual balance including static, dynamic, and proactive balance; enhancing confidence in balance control; and reducing fear of falling in older adults. In particular, administrating the OEP in a group setting in >30-minute sessions may be the most appropriate and effective exercise protocol for improving balance.

COVID-19 event strength, psychological safety, and avoidance coping behaviors for employees in the tourism industry

The impact of COVID-19 on the emotions or behaviors of employees in tourism enterprises would be worthwhile for investigation since COVID-19 has harmed not only people's health and lives but also most tourism enterprises. By identifying the effect of COVID-19 event strength on avoidance coping behaviors, the behaviors isolated from customers unlikely beneficial for tourism enterprises, we not only revealed that COVID-19 event strength indirectly affects avoidance coping behaviors through either the fear of external threat or psychological safety, but also disclosed that supervisor safety support would moderate the effect of psychological safety on such coping behaviors. We argue that understanding potential causes, such as the fear of external threat and psychological safety, and identifying possible solutions, like supervisor safety support, may be key factors for restarting tourism enterprises successfully under the severe impact of the COVID-19 pandemic.

Matter of Balance Classes Through Physical Therapist Fall Risk Assessment

BACKGROUND

Falls remain the leading cause of injury-related death for 65 years and older. Matter of Balance is a well-documented community-based program designed to reduce participants' fear of falling. However, Matter of Balance classes' effect on physical measures remains less well studied.

OBJECTIVE

The objective of this study was to evaluate the effects of the Matter of Balance program on balance, strength, and fall risk.

METHODS

This is a single-group pretest-posttest evaluation of balance and strength in community participants enrolled in 8-week Matter of Balance classes. Physical therapist assessments of the Functional Reach Test and five times sit-to-stand test at week 1 and week 8 were compared.

RESULTS

A total of 33 class participants were studied. The average improvement in the Functional Reach Test was M = 1.33 (SD = 1.6) inches and the five times sit-to-stand test was M = -3.24 (SD = 3.42) seconds; p < .05.

CONCLUSIONS

Matter of Balance classes resulted in improvement in both balance and strength. This study's findings support Matter of Balance classes' efficacy as a community-based program that can reduce a participant's physical risk for falls.

Screening Gait Performance, Falls, and Physical Activity among Benedictine and Trappist Monks

Background and Objective:

Physical performance in older men has been reported in analyses with veterans and in disease-based cohort research. Studies examining gait performance among older monks, however, are narrow. The purpose of this study was to analyze the impact of a recent fall on gait ability in a cohort of Benedictine and Trappist monks in 4 US monastic communities. The second aim was to analyze physical activity and a recent fall as predictive markers of 2 constructs of gait performance.

Methods:

In this cross-sectional study, 53 Benedictine and Trappist monks over 60 (x = 74.7 ± 7.6; range: 61-94 years) completed a basic sociodemographic and fall history profile, the Timed Up and Go (TUG) Test, Dynamic Gait Index (DGI) and the Physical Activity Scale for the Elderly (PASE).

Results:

Demographic profiles revealed that 10% of participants had fallen over the past 3 months; in addition, those who had fallen were more likely to limit activities because of fear of falling (P = .005). Monks who had fallen over the past 3 months demonstrated significantly poorer TUG (12.6 ± 2.1 vs 10.5 ± 1.8; P = .01) and DGI (17.2 ± 5.3 vs 22.3 ± 2.3; P < .001) scores. There was a significant association between physical activity and both the TUG (–0.55; P < .001) and DGI (64; P < .001). Multiple regression models demonstrated that physical activity and a fall in the past 3 months predicted 24% of the variance in the TUG (P < .001) and 46% of the variance in the DGI (P < .001).

Conclusions:

Gait performance is linked to a recent fall episode among older monks. Predictive determinants of functional mobility (TUG) and superimposing tasks on the gait cycle (DGI) include recent fall history and physical activity. Appropriate health promotion activities can be aligned with these lifestyle attributes in monastic communities.

Construct validity and reliability of the modified gait efficacy scale for older adults

PURPOSE

To perform a cross-cultural adaptation of the mGES into Dutch and investigate its construct validity, internal consistency, test-retest reliability and floor and ceiling effects in a large cohort of community-dwelling older adults.

MATERIALS AND METHODS

We translated the British version of the mGES into Dutch, back into English, and had a native English speaker review the final version. Next, we included 223 community-dwelling older adults from the 'Veilig in Beweging Blijven' (VIBE) cohort (69.8 [67.6-74.3] years old, 155 (69.5%) female), who filled out both the mGES and the Falls Efficacy Scale-International (FES-I) twice, with a month in between. Construct validity was assessed by Spearman's correlation between the scores on the mGES and the FES-I. Internal consistency was assessed with Cronbach's alpha and test-retest reliability was assessed with the intra class correlation coefficient (ICC(2,1)).

RESULTS

Construct validity (rho = -0.81, p < 0.001), internal consistency (α = 0.95), and test-retest reliability (ICC(2,1)=0.90, 95%CI = [0.87-0.92]) were all excellent. Ceiling effect was observed in 44 (19.7%) participants which suggest caution when evaluating the mGES for fit and confident older adults.

CONCLUSION

The Dutch mGES is a valid and reliable tool to assess confidence in walking and is suggested as a tool for evaluating self-efficacy after interventions aimed at improving gait.IMPLICATIONS FOR REHABILITATIONAssessment and rehabilitation of gait may be affected by self-efficacy of walking performance.We show that the Dutch translation of the modified gait efficacy scale is a valid and reliable tool for assessing self-efficacy of walking.A ceiling effect was observed that was associated with muscle strength and symptoms of depression.The results of the present study underline the use of the modified gait efficacy scale in the assessment and evaluation of self-efficacy of walking in rehabilitation.

Systematic review and meta-analysis of fear of falling and fall-related efficacy in a widely disseminated community-based fall prevention program

BACKGROUND

Fear of falling restricts mobility and increases fall risk among older adults. Fall-related efficacy (i.e. the confidence to perform activities without falling), a construct related to fear of falling, has also been associated with active living and fall prevention. This study statistically synthesized the program effects of A Matter of Balance Volunteer Lay Leader (AMOB/VLL) model, designed to improve fall-related efficacy and promote daily activities among community-dwelling older adults.

METHODS

Research articles and doctoral dissertations that examined the effect of the AMOB/VLL on fear of falling and fall-related efficacy were searched from multiple databases. A random effects model was used to compute mean weighted effect sizes, 95 % CIs, and heterogeneity (I2). Bias was examined through a funnel plot and Egger's test. Factors associated with heterogeneity were also explored.

RESULTS

Seventeen AMOB/VLL studies involving 3,860 participants were identified. The pooled effects of the 13 studies with sufficient information for effect size calculation, were -0.29 (95 % CI: -0.40, -0.19) for fear of falling and 0.51 (95 % CI: 0.42, 0.60) for fall-related efficacy. Effect sizes differed partially due to outcome measures of fall-related efficacy. Covariate adjustment and study quality were not associated with differences in effect sizes. No substantial evidence of asymmetry and publication bias was found.

CONCLUSION

This study provides evidence supporting AMOB/VLL as an effective intervention for reducing fear of falling and improving fall-related efficacy. A greater consistency in outcome measures is needed to optimally capture changes in fear of falling and fall-related efficacy among community-dwelling older adults.

Effects of the Matter of Balance Program on Self-Reported Physical Activity in Community-Dwelling Older Adults

Objective: To (a) evaluate effects of the Matter of Balance (MOB) program on self-reported physical activity (PA) in older adults as measured by the program’s activity (MOB-PA) measure and the Rapid Assessment of Physical Activity, Part 1 (RAPA1) and (b) for a separate Community cohort, explore correlations between MOB-PA and RAPA1 scores and step counts obtained using accelerometry. Methods: Community-dwelling older adults recruited from upcoming MOB classes and from in-person contacts comprised MOB (N = 56) and Community (N = 23) cohorts, respectively. For the MOB cohort, paired t tests were computed for baseline and follow-up MOB-PA and RAPA1 scores. For the Community cohort, Pearson’s correlations between self-reported PA and step counter measures were calculated. Results: Self-reported PA did not change following MOB participation. The MOB-PA had substantial ceiling effects, which weakened relationships with step counter data. Discussion: No evidence was found that MOB participation increased PA. The MOB-PA may not be appropriate for measuring activity levels.