Effects of gait adaptability training on falls and fall-related fractures in older adults: a systematic review and meta-analysis

Exercise as a falls prevention strategy in the care of older people

Older people who sustain a fall may experience a range of adverse outcomes, such as distress, injury and loss of independence. Falls increase the risk of frailty and frailty increases the risk of falls. Regular exercise is a pillar of falls prevention and can have extensive benefits for older people's health, well-being and ability to undertake activities they enjoy. As part of the multidisciplinary team, nurses have a pivotal role in implementing exercise-based falls prevention strategies for older people and in encouraging their patients to exercise. This article discusses exercise as a falls prevention strategy in hospital and in the community and supports nurses to develop their knowledge and confidence in promoting exercise in older people.

Differences of gait adaptability behavior between young and healthy older adults during a locomotor pointing task in virtual reality

BACKGROUND

Gait adaptability training programs to prevent falls in healthy older adults can be proposed in virtual reality. The development of training programs requires the characterization of the target population.

RESEARCH QUESTION

Before proposing an innovative training program to develop gait adaptability behavior of healthy older adults in fully immersive virtual reality, we had to compare gait adaptability behavior between healthy older adults and young adults in virtual reality.

METHODS

Twenty healthy older adults (with no fall history) and twenty young adults performed a goal-directed locomotion task in a totally secure virtual reality set-up. Gait adaptability behavior was investigated via a set of measures taking into account gait speed, pointing accuracy, and the evolution of the relationship between the participant and the environment through both inter-trial and trial-by-trial analyses. Mann-Whitney tests and linear regressions were performed to determine potential age differences.

RESULTS

The results reveal some common and specific strategies in gait adaptability behavior between healthy older and young adults. In both populations, successive gait adjustments depend on the state of the agent-environment system. However, older adults walked more slowly than young adults (p < .001) with a greater coupling at the end of the target approach (p = .003).

SIGNIFICANCE

In the context of fall prevention in healthy older adults, fully immersive VR appears as a relevant tool to propose relevant gait training programs to improve gait adjustments.

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.

[Reactive dynamic balance in the geriatric setting : Possibilities for evaluation and quantification in functionally heterogeneous persons]

BACKGROUND

Most falls in older persons occur during walking and are often due to maladaptation in response to gait perturbations. Therefore, the assessment of reactive dynamic balance is highly relevant for determining the individual risk of falling and could enable an early initiation of interventions.

OBJECTIVE

The methods available for perturbation of gait and for evaluating the corresponding reaction patterns are critically discussed in order to approach the assessment of reactive dynamic balance.

MATERIAL AND METHODS

A diagnostic protocol for perturbation of gait on a treadmill was developed based on the literature. The application of the protocol to map reactive dynamic balance as comprehensively as possible is presented.

RESULTS

After the initial determination of the individually preferred gait speed over ~ 6 min, the participant's gait is disrupted with 9 different types of perturbations over a time period of ~ 4:30 min. The evaluation options include spatiotemporal parameters and their variability, the margin of stability and the Lyapunov exponent.

CONCLUSION

Dynamic reactive balance is a promising and specific parameter for quantifying the risk of falling in older persons. The comprehensive evaluation of the documented parameters is currently insufficient because there are no established methods or references. The development of a unified method for the sensitive determination of reactive dynamic balance is essential for its use in assessment of the risk of falling in the clinical context and for measuring the success of training.

The 'Bermuda Triangle' of orthostatic hypotension, cognitive impairment and reduced mobility: prospective associations with falls and fractures in The Irish Longitudinal Study on Ageing

BACKGROUND

Orthostatic hypotension (OH), cognitive impairment (Cog) and mobility impairment (MI) frequently co-occur in older adults who fall. This study examines clustering of these three geriatric syndromes and ascertains their relationship with future falls/fractures in a large cohort of community-dwelling people ≥ 65 years during 8-year follow-up.

METHODS

OH was defined as an orthostatic drop ≥ 20 mmHg in systolic blood pressure (from seated to standing) and/or reporting orthostatic unsteadiness. CI was defined as Mini Mental State Examination ≤ 24 and/or self-reporting memory as fair/poor. MI was defined as Timed Up and Go ≥12 s. Logistic regression models, including three-way interactions, assessed the longitudinal association with future falls (explained and unexplained) and fractures.

RESULTS

Almost 10% (88/2,108) of participants had all three Bermuda syndromes. One-fifth of participants had an unexplained fall during follow-up, whereas 1/10 had a fracture. There was a graded relationship with incident unexplained falls and fracture as the number of Bermuda syndromes accumulated. In fully adjusted models, the cluster of OH, CI and MI was most strongly associated with unexplained falls (odds ratios (OR) 4.33 (2.59-7.24); P < 0.001) and incident fracture (OR 2.51 (1.26-4.98); P = 0.045). Other clusters significantly associated with unexplained falls included OH; CI and MI; MI and OH; CI and OH. No other clusters were associated with fracture.

DISCUSSION

The 'Bermuda Triangle' of OH, CI and MI was independently associated with future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.

Relation of gait measures with mild unilateral knee pain during walking using machine learning

Gait alterations in those with mild unilateral knee pain during walking may provide clues to modifiable alterations that affect progression of knee pain and osteoarthritis (OA). To examine this, we applied machine learning (ML) approaches to gait data from wearable sensors in a large observational knee OA cohort, the Multicenter Osteoarthritis (MOST) study. Participants completed a 20-m walk test wearing sensors on their trunk and ankles. Parameters describing spatiotemporal features of gait and symmetry, variability and complexity were extracted. We used an ensemble ML technique ("super learning") to identify gait variables in our cross-sectional data associated with the presence/absence of unilateral knee pain. We then used logistic regression to determine the association of selected gait variables with odds of mild knee pain. Of 2066 participants (mean age 63.6 [SD: 10.4] years, 56% female), 21.3% had mild unilateral pain while walking. Gait parameters selected in the ML process as influential included step regularity, sample entropy, gait speed, and amplitude dominant frequency, among others. In adjusted cross-sectional analyses, lower levels of step regularity (i.e., greater gait variability) and lower sample entropy(i.e., lower gait complexity) were associated with increased likelihood of unilateral mild pain while walking [aOR 0.80 (0.64-1.00) and aOR 0.79 (0.66-0.95), respectively].

How to tackle the global challenge of falls?

Worldwide, falls and accompanying injuries are increasingly common, making their prevention and management a critical global challenge. The wealth of evidence to support interventions to prevent falls has recently (2022) been distilled in the first World Falls Guideline for Prevention and Management for Older Adults. The core of falls prevention includes (i) risk assessment and stratification; (ii) general recommendations on optimising physical function and mobility for all and (iii) offering a holistic, multidomain intervention to older adults at high risk of falls, in which the older adult's priorities, beliefs and resources are carefully considered. In recent decades, sustainable and adequately resourced falls prevention has proved challenging, although evidence suggests that suboptimal implementation of falls prevention is ineffective. Future research should focus on understanding the most successful approaches for implementation. To further optimise falls prevention, recent developments include technological innovation to identify and prevent falls, including exergaming. Further work is warranted to understand how to best incorporate the concepts of frailty and sarcopenia in falls prevention and management. This themed collection includes key articles in the field of falls prevention, covering several topics including risk factors, effective interventions, older adult's views, implementation issues and future perspectives.

Total knee arthroplasty improves gait adaptability in osteoarthritis patients; a pilot study

Background

Gait adaptability is of utmost importance for keeping balance during gait in patients with knee osteoarthritis, also after total knee arthroplasty (TKA). The aims of this explorative study are: (1) assess the effect of age, knee osteoarthritis and TKA on gait adaptability; (2) assess changes in gait adaptability pre-to post-TKA and (3) their relation to functional outcomes.

Methods

Gait adaptability was measured using a Target Stepping Test (TST) in knee osteoarthritis patients before (preTKA) and 12 months after TKA (postTKA) and compared to asymptomatic old (AsOld) and young adults (AsYng). TST imposed an asymmetrical gait pattern with projected stepping targets at high walking speed. Gait adaptability was determined through stepping accuracy on the targets. The Oxford Knee Score (OKS) and Timed-Up-and-Go test (TUG) measured patients' physical function.

Results

12 preTKA, 8 postTKA, 18 AsYng, 21 AsOld were tested. Age showed no effect on TST-stepping accuracy. PreTKA showed worse TST-stepping accuracy compared to AsYng and AsOld (7.7; 6.2 cm difference). PostTKA showed an improvement of 52% in TST-stepping accuracy compared to preTKA (3.2 cm).Higher stepping accuracy preTKA predicted higher stepping accuracy post-TKA. In addition, low preTKA stepping accuracy predicted more improvement postTKA. Pre-to post-TKA improvement of stepping accuracy was related to improvement on the TUG (Beta = 0.17, p = 0.024), but not to OKS.

Conclusions

Gait adaptability is improved following TKA in knee osteoarthritis patients and no longer significantly worse than asymptomatic adults. The relation of gait adaptability to function is shown by its relation to the TUG and shows to have predictive value pre-to post-TKA.

Association between heart failure severity and mobility in geriatric patients: an in-clinic study with wearable sensors

BACKGROUND

Individuals with heart failure (HF) frequently experience limitations in mobility, but specific aspects of these limitations are not well understood. This study investigated the association of HF severity, based on the New York Heart Association (NYHA) classes, with digital mobility outcomes (DMOs) and handgrip strength in older inpatients with HF.

METHODS

For this explorative analysis, hospital admission and discharge data from an ongoing, prospective cohort study were used. The sample included older participants with HF and a sub-sample of heart-healthy individuals. Participants were equipped with a wearable inertial measurement unit (IMU) system during mobility performance (balancing, sit-to-stand transfer, walking). We analyzed the association between 17 DMOs and HF severity with multiple linear regression models.

RESULTS

The total sample included 61 older participants (65-97 years of age, 55.7% female). Of all DMOs, only sway path in a semi-tandem stance position (m/s²) showed a relevant association with NYHA classes (admission: β = -0.28, P = 0.09; discharge: β = -0.39, P = 0.02). Handgrip strength showed a trend towards a significant association (admission: β = -0.15, P = 0.10; discharge: β = -0.15, P = 0.19).

CONCLUSIONS

This is to our best knowledge the first analysis on the association of HF severity and IMU-based DMOs. Sway path and handgrip strength may be the most promising parameters for monitoring mobility aspects in treatment of HF.

Validation of an immersive virtual reality device accepted by seniors that preserves the adaptive behavior produced in the real world

Falls in the elderly are a major societal issue. Virtual reality appears as a relevant tool to propose gait training programs to prevent the occurrence of falls. The use of a head-mounted display allows overground walking during fully immersive virtual training sessions. Our long-term ambition is to develop gait training programs with a head-mounted display to propose enjoyable and personalized training content for the elderly. Before proposing these programs, several methodological precautions must be taken. The first concerns the supposed similarity of the adaptive behavior produced in the real world and in virtual reality. The second concerns the acceptance of the virtual reality device before and after use. Twenty older adults performed a locomotor pointing task in three conditions including a real-world condition, a virtual-world condition consisting in a replica of the real-world condition, and a virtual condition in which the locomotor pointing task was performed in a different context. From feet positions in relation to the position of a target, gait adaptability behavior was investigated. In line with previous studies, step adjustments (needed and produced) were investigated through a combination of inter-trial and trial-by-trial analyses. The results highlighted that participants adopted the same gait adaptability behavior whatever the type of environment (real vs. virtual). Gait analyses suggested the use of a generic control mechanism based on information-movement coupling. We also demonstrated that older adults accepted the virtual reality device before and after use. With these methodological locks removed, it is now possible to design training programs in virtual reality to prevent falls in the elderly.

Three days of beam walking practice improves dynamic balance control regardless of the use of haptic anchors in older adults

Balance deficits during walking increase the risk of falls in older adults. Providing haptic information through anchors improves dynamic balance control, but the benefits of practicing with anchors during walking need to be evaluated. We investigated the effect of practice with haptic anchors in the beam walking task in older adults. Twenty-five older adults participated in this study divided into 0% (G0, practice without the anchors) and 50% (G50, practice with the haptic anchors in 50% of the trials) groups. With the anchors, participants held in each hand a cable with a mass of 0.125 kg affixed to the end of the cable that contacted the ground. They walked and kept the anchors in contact with the ground such that they dragged them. Participants increased the distance walked on the beam and reduced the trunk angular acceleration after training, but this effect was independent of the anchors. The use of haptic anchors during beam walking training did not significantly affect older adults' performance and dynamic balance control. Both groups showed improvements in the post-test and 24-hr retention conditions, indicating that older adults can learn to adapt their gait to more challenging contexts.

Effects of treadmill slip and trip perturbation-based balance training on falls in community-dwelling older adults (STABILITY): study protocol for a randomised controlled trial

INTRODUCTION

Falls among older adults are most frequently caused by slips and trips and can have devastating consequences. Perturbation-based balance training (PBT) have recently shown promising fall preventive effects after even small training dosages. However, the fall preventive effects of PBT delivered on a treadmill are still unknown. Therefore, this parallel-group randomised controlled trial aims to quantify the effects of a four-session treadmill-PBT training intervention on falls compared with treadmill walking among community-dwelling older adults aged 65 years or more.

METHODS AND ANALYSIS

140 community-dwelling older adults will be recruited and randomised into either the treadmill-PBT or the treadmill walking group. Each group will undergo three initial training sessions within a week and an additional 'booster' session after 26 weeks. Participants in the treadmill-PBT group will receive 40 slip and/or trip perturbations induced by accurately timed treadmill belt accelerations at each training session. The primary outcome of interest is daily life fall rates collected using fall calendars for a follow-up period of 52 weeks. Secondary outcomes include physical, cognitive and social-psychological fall-related risk factors and will be collected at the pre-training and post-training test and the 26-week and 52-week follow-up tests. All outcomes will be analysed using the intention-to-treat approach by an external statistician. A Poisson's regressions with bootstrapping, to account for overdispersion, will be used to compare group differences in fall rates.

ETHICS AND DISSEMINATION

The study protocol has been approved by the North Denmark Region Committee on Health Research Ethics (N-20200089). The results will be disseminated in peer-reviewed journals and at international conferences.

TRIAL REGISTRATION NUMBER

NCT04733222.