Are interventions effective in improving the ability of older adults to rise from the floor independently? A mixed method systematic review

Exercise and Sports Science Australia updated position statement on exercise for preventing falls in older people living in the community

BACKGROUNDS

Falls affect a significant number of older Australians and present a major challenge to health care providers and health systems with over 380 older Australians hospitalised for a fall each day.

OBJECTIVES

This statement seeks to inform and guide exercise practitioners and health professionals in safe and effective prescription of exercise to prevent falls amongst community-dwelling older people.

EXERCISE PRESCRIPTION TO PREVENT FALLS

Exercise is crucial for preventing falls in older age. Research evidence has identified that programmes which include functional balance and muscle strength training are the most effective in preventing falls. It is also important for exercise to be progressively challenging, ongoing and of sufficient dose to maximise its benefits in reducing falls. Additional (non-exercise) interventions are necessary for people with complex medical conditions, recent hospitalisation and/or particular risk factors not improved by exercise. People at a higher risk of falls may need greater support to undertake safe and effective fall prevention exercise.

SUMMARY

Global guidelines for fall prevention and management recommend that all older adults should receive advice about exercise to prevent falls. Qualified exercise professionals are well placed to prescribe and supervise functional balance and muscle strength training to older people with varied functional abilities, including those with co-morbidities.

Floor-hugging Intervention: A Perspective on Floor Exposure and After-Fall Contingency Intervention

The fear of falling is a pressing public health issue, yet current interventions often fall short in addressing it effectively. As a result, there is a need for innovative interventions that go beyond symptom relief to address the underlying causes. From this standpoint, we propose that limited exposure to floors and a lack of post-fall contingencies may contribute to the uncertainty that amplifies the fear of falling, particularly in fall prone populations. We explore the theoretical underpinnings of this hypothesis and propose a framework based on the Uncertainty and Anticipation model to elucidate potential connections. Building upon this, we introduce the Floor-hugging intervention-a two-part strategy designed to confront these challenges. Firstly, we propose gradual exposure to different floor scenarios through guided imagery to diminish fear by familiarizing individuals with such situations. Secondly, we advocate for the adoption of evidence-based ways to get up from the floor for developing after fall contingencies. We delve into the theoretical framework supporting our approach and its potential to reduce the fear of falling while improving physical, social, and psychological well-being. Additionally, we outline prospective outcome measures to comprehensively assess the impact of the intervention across biopsychosocial domains. This perspective aims to stimulate discussion on the potential role of floor exposure and post-fall strategies in reducing the fear of falling, while also advocating for innovative interventions to empower and protect fall-prone populations.

Floor-to-Stand Performance Among People Following Stroke

OBJECTIVES

Studies have examined floor-to-stand performance in varied adult populations both quantitatively and qualitatively. Despite an elevated risk of falls and inability to independently return to stand after a fall, few have examined the ability to stand from the floor in patients recovering from stroke. There were 2 objectives of the study: to identify the relationships between floor-to-stand performance using a timed supine-to-stand test (TSS) and physical performance measures of gait, balance, and balance confidence among persons in the subacute phase after stroke; and to analyze descriptive strategies used in the completion of the TSS.

METHODS

A cross-sectional design was implemented. Fifty-eight adults (mean age = 59.2 [standard deviation (SD) = 13.9] years; 34 [58.6%] men) who were in the subacute phase after ischemic or hemorrhagic stroke and who could stand from the floor with no more than supervision completed the TSS and physical performance assessments.

RESULTS

The median time to complete the TSS in our sample was 13.0 (interquartile range = 15.5) seconds. TSS time was significantly correlated with physical performance tests, including the Timed "Up & Go" Test (ρ = 0.70), gait speed (ρ = -0.67), Dynamic Gait Index (ρ = -0.52), and Activities-Specific Balance Confidence Scale (ρ = -0.43). Thirty-two percent of the variance in TSS time was attributed to Timed "Up & Go" Test time and the use of the quadruped position to transition to standing. Participants who used a gait device were more likely to use a chair during rise to stand.

CONCLUSION

The TSS demonstrates concurrent validity with physical performance measures.

IMPACT

Findings serve to improve functional mobility examination after stroke and to formulate effective treatment interventions to improve floor-to-stand performance.

Implementation and Core Components of a Multimodal Program including Exercise and Nutrition in Prevention and Treatment of Frailty in Community-Dwelling Older Adults: A Narrative Review

Increasing disability-free life expectancy is a crucial issue to optimize active ageing and to reduce the burden of evitable medical costs. One of the main challenges is to develop pragmatic and personalized prevention strategies in order to prevent frailty, counteract adverse outcomes such as falls and mobility disability, and to improve quality of life. Strong evidence reports the effectiveness of exercise interventions to improve various physical parameters and muscle function that are cornerstones of frailty. Other findings also suggest that the interactions between nutrition and physical exercise with or without health behavior promotion prevent the development of frailty. Multimodal programs, including structured exercise, adequate dietary intervention and health behavior promotion, appear increasingly consensual. However, in order for implementation in real-life settings, some pitfalls need to be addressed. In this perspective, structuring and tailoring feasible, acceptable and sustainable interventions to optimize exercise training responses are essential conditions to warrant short, medium and long-term individual benefits. The different components of exercise programs appear to be fairly consensual and effective. However, specific composition of the programs proposed (frequency, intensity, type, time, volume and progressiveness) have to be tailored to individual characteristics and objectives in order to improve exercise responses. The intervention approaches, behavioral strategies and indications for these programs also need to be refined and framed. The main objective of this work is to guide the actions of healthcare professionals and enable them to widely and effectively implement multimodal programs including exercise, nutrition and behavioral strategies in real-life settings.

Factors associated with unrecovered falls among older adults

This cross-sectional exploratory study investigated factors associated with unrecovered falls among older patients with a history of falls in the previous year participating in a clinical trial on fall prevention by asking them about their inability to get up independently after the fall. Participants' sociodemographic, clinical, functional (ADL/IADL, TUG, chair-stand test, hand grip, risk of falling) and fall location were investigated. We conducted a multivariate regression analysis adjusted for covariates to identify the main factors associated with unrecovered falls. Out of 715 participants (mean age: 73.4 years; 86% women), 51.6% (95% IC; 47.9 - 55.3%) experienced unrecovered falls. Depressive symptoms, ADL/IADL limitation, mobility limitation, undernutrition, and outdoor falls were associated with unrecovered falls. While assessing the risk of falling, professionals should consider preventive strategies and preparedness procedures for those who are more likely to experience unrecovered falls, such as training to get up from the floor, alarms, and support services.

Rising From the Floor in Persons With Parkinson's Disease

Although considerable research has targeted fall prevention among older adults with Parkinson's disease (PD), less is known about their ability to rise from the floor. The aim of the current exploratory study was to examine the relationship between floor rise and physical performance tests. A cross-sectional design was used. Twenty community-dwelling older adults with PD (mean age = 74.8 years, SD = 9.5 years) performed a standardized floor rise test and physical performance assessments in a structured task circuit. Mean time to rise from the floor was 14.9 seconds (SD = 7.6 seconds). Fourteen (70%) participants used a quadruped strategy to rise to stand. Supine-to-stand performance time was significantly correlated with all physical performance measures. Findings serve as a catalyst for nursing and rehabilitation professionals to examine floor rise ability, prevent adverse effects of a critical fall, and instruct fall recovery techniques in clinical settings. [Journal of Gerontological Nursing, 49(1), 50-54.].

Assessing the fidelity of the independently getting up off the floor (IGO) technique as part of the ReTrain pilot feasibility randomised controlled trial for stroke survivors

PURPOSE

Hemiparesis and physical deconditioning following stroke lead to an increase in falls, which many individuals cannot get up from. Teaching stroke survivors to independently get off the floor (IGO) might mitigate long-lie complications. IGO was taught as part of a community-based, functional rehabilitation training programme (ReTrain). We explore the feasibility of teaching IGO and assess participant's level of mastery, adherence, and injury risk.

MATERIALS AND METHODS

Videos of participants (n = 17) performing IGO at early, middle, and late stages of the ReTrain programme were compared to a manualised standard. A visual, qualitative analysis was used to assess technique mastery, adherence, and injury risk.

RESULTS

Most participants (64%) achieved independent, safe practice of IGO. A good (73%) level of adherence to IGO and low incidence of risk of injury (6.8%) were observed. Deviations were made to accommodate for non-stroke related comorbidities.

CONCLUSIONS

IGO was successfully and safely practised by stroke survivors including those with hemiparesis. Trainers should be aware of comorbidities that may impede completion of IGO and modify teaching to accommodate individual need. Further research should assess if IGO can be utilised by individuals who have other disabilities with unilateral impairments and whether IGO has physical, functional and economic benefit.Implications for rehabilitationFalls are common in stroke survivors, and many are unable to get up despite being uninjured, leading to long-lie complications or ambulance call-outs but non-conveyance to hospital.Teaching the independently getting up off the floor (IGO) technique to stroke survivors was possible for those with or without hemiparesis, and remained safe despite modifications to accommodate an individual's needs.Individual assessment is needed to check if a stroke survivor is suitable for learning IGO including, but not limited to, their ability to safely get to the floor and to temporarily stand (without support) at the end of the technique.

Using Treatment Fidelity Measures to Understand Walking Recovery: A Secondary Analysis From the Community Ambulation Project

OBJECTIVES

Physical therapist intervention studies can be deemed ineffective when, in fact, they may not have been delivered as intended. Measurement of treatment fidelity (TF) can address this issue. The purpose of this study was to describe TF of a home-based intervention, identify factors associated with TF, and examine whether components of TF were associated with the outcome of change in 6-minute walk distance (∆6MWD).

METHODS

This is a secondary analysis of community-dwelling hip fracture participants who completed standard therapy and were randomly assigned to the active intervention (Push). Push was 16 weeks of lower extremity strengthening, function, and endurance training. TF was defined as delivery (attendance rate, exercise duration) and receipt (progression in training load, heart rate reserve [HRR] during endurance training, and exercise position [exercise on floor]). The outcome was ∆6MWD. Independent variables included baseline (demographic and clinical) measures. Descriptive statistics were calculated; linear and logistic regressions were performed.

RESULTS

Eighty-nine participants were included in this analysis; 59 (66%) had attendance of 75% or greater. Participants walked for 20 minutes or more for 78% of sessions. The average training load increased by 22%; the mean HRR was 35%; and 61 (69%) participants exercised on the floor for at least 75% of sessions. Regression analyses showed that a higher body mass index and greater baseline 6MWD were related to components of TF; 4 out of 5 components of TF were significantly related to ∆6MWD. The strongest TF relationship showed that those who exercised on the floor improved by 62 m (95% CI = 31-93 m) more than those who did not get on the floor.

CONCLUSIONS

Measures of TF should extend beyond attendance rate. This analysis demonstrates how measures of TF, including program attendance, progression in training load, endurance duration, and exercising on the floor were significantly related to improvement in 6MWD in participants post hip fracture.

IMPACT

This careful analysis of treatment fidelity assured that the intervention was delivered and received as intended. Analysis of data from a large trial with participants after hip fracture showed that regular attendance, frequent endurance training for 20 minutes, increases in lower extremity training loads, and exercising on the floor were associated with improvements in the outcome of 6-minute-walk distance. The strongest association with improvement was exercising on the floor.

Research Screener: a machine learning tool to semi-automate abstract screening for systematic reviews

BACKGROUND

Systematic reviews and meta-analyses provide the highest level of evidence to help inform policy and practice, yet their rigorous nature is associated with significant time and economic demands. The screening of titles and abstracts is the most time consuming part of the review process with analysts required review thousands of articles manually, taking on average 33 days. New technologies aimed at streamlining the screening process have provided initial promising findings, yet there are limitations with current approaches and barriers to the widespread use of these tools. In this paper, we introduce and report initial evidence on the utility of Research Screener, a semi-automated machine learning tool to facilitate abstract screening.

METHODS

Three sets of analyses (simulation, interactive and sensitivity) were conducted to provide evidence of the utility of the tool through both simulated and real-world examples.

RESULTS

Research Screener delivered a workload saving of between 60 and 96% across nine systematic reviews and two scoping reviews. Findings from the real-world interactive analysis demonstrated a time saving of 12.53 days compared to the manual screening, which equates to a financial saving of USD 2444. Conservatively, our results suggest that analysts who scan 50% of the total pool of articles identified via a systematic search are highly likely to have identified 100% of eligible papers.

CONCLUSIONS

In light of these findings, Research Screener is able to reduce the burden for researchers wishing to conduct a comprehensive systematic review without reducing the scientific rigour for which they strive to achieve.

Knowledge, skills and attitudes of older people and staff about getting up from the floor following a fall: a qualitative investigation

Background

Falls are the most common reason for ambulance callouts resulting in non-conveyance. Even in the absence of injury, only half of those who fall can get themselves up off the floor, often remaining there over an hour, increasing risk of complications.

There are recognized techniques for older people to learn how to get up after a fall, but these are rarely taught. The aim of this study was to develop an understanding of attitudes of older people, carers and health professionals on getting up following a fall.

Methods

A qualitative focus group and semi-structured interviews were conducted with 28 participants, including community-dwelling older people with experience of a non-injurious fall, carers, physiotherapists, occupational therapists, paramedics and first responders. Data were transcribed and analysed systematically using the Framework approach. A stakeholder group of falls experts and service users advised during analysis.

Results

The data highlighted three areas contributing to an individual’s capability to get-up following a fall: the environment (physical and social); physical ability; and degree of self-efficacy (attitude and beliefs about their own ability). These factors fell within the wider context of making a decision about needing help, which included what training and knowledge each person already had to manage their fall response.

Staff described how they balance their responsibilities, prioritising the individual’s immediate needs; this leaves limited time to address capability in the aforementioned three areas. Paramedics, routinely responding to falls, only receive training on getting-up techniques from within their peer-group. Therapists are aware of the skillset to breakdown the getting-up process, but, with limited time, select who to teach these techniques to.

Conclusion

Neither therapists nor ambulance service staff routinely teach strategies on how to get up, meaning that healthcare professionals largely have a reactive role in managing falls. Interventions that address the environment, physical ability and self-efficacy could positively impact on peoples’ capability to get up following a fall. Therefore, a more proactive approach would be to teach people techniques to manage these aspects of future falls and to provide them easily accessible information.

Impact of the backward chaining method on physical and psychological outcome measures in older adults at risk of falling: a systematic review

BACKGROUND

Being unable to "get up from the floor" is a risk factor and predictor of serious fall-related injuries in older age; however, floor-rise training (FRT) is not widely used. The backward chaining method (BCM) is a success-oriented, step-by-step form of FRT. This systematic review aimed to evaluate the impact of BCM on physical and psychological outcome measures, and its clinical application.

METHODS

Studies were identified through systematic searching of five databases. Criteria for inclusion were: use of BCM as a treatment method, outcome measures related to falls, and participants aged 60 + years. Study quality was evaluated using the Mixed Methods Appraisal Tool and PEDro scale, if applicable.

RESULTS

Seven studies with a total of 446 participants (mean age 82.4 ± 5.3 years) were identified. Emerging evidence shows that BCM significantly improves the ability to get up unassisted from the floor, as well as mobility with reduced fall incidence in older people. Furthermore, it can potentially reduce fear of falling. Reporting on feasibility and acceptance of BCM was limited. Study quality varied widely.

CONCLUSIONS

BCM provides a promising intervention in fall-related recovery strategies for older adults and is most effective when offered to older adults at risk of falling. Considering the small number of included studies and the varying methodological quality, these findings should be evaluated accordingly. The growing evidence regarding the benefits of BCM, yet the lack of adoption into standard care, highlights the need for further research and clinical application of this intervention approach.