Exercise- and strategy-based physiotherapy-delivered intervention for preventing repeat falls in people with Parkinson's: the PDSAFE RCT

BACKGROUND

People with Parkinson's disease are twice as likely to experience a fall as a healthy older person, often leading to debilitating effects on confidence, activity levels and quality of life.

OBJECTIVE

To estimate the effect of a physiotherapy programme for fall prevention among people with Parkinson's disease.

DESIGN

A multicentre, pragmatic, investigator-masked, individually randomised controlled trial (RCT) with prespecified subgroup analyses.

SETTING

Recruitment from NHS hospitals and clinics and community and social services in eight English regions with home-based interventions.

PARTICIPANTS

A total of 474 people with Parkinson's disease (i.e. Hoehn and Yahr scale stages 1-4) were recruited: 238 were assigned to a physiotherapy programme and 236 were assigned to usual care. Random allocation was 50 : 50.

INTERVENTIONS

All participants received routine care; the usual-care group received an information digital versatile disc (DVD) and a single advice session at trial completion. The intervention group had an individually tailored, progressive, home-based fall avoidance strategy training programme with balance and strengthening exercises: PDSAFE.

MAIN OUTCOME MEASURES

The primary outcome was the risk of repeat falling, collected by self-report monthly diaries between 0 and 6 months after randomisation. Secondary outcomes included near-falls, falls efficacy, freezing of gait (FoG), health-related quality of life, and measurements taken using the Mini-Balance Evaluation Systems Test (Mini-BESTest), the Chair Stand Test (CST), the Geriatric Depression Scale, the Physical Activity Scale for the Elderly and the Parkinson's Disease Questionnaire.

RESULTS

PDSAFE is the largest RCT of falls management among people with Parkinson's disease: 541 patients were screened for eligibility. The average age was 72 years, and 266 out of 474 (56%) participants were men. Of the 474 randomised participants, 238 were randomised to the intervention group and 236 were randomised to the control group. No difference in repeat falling within 6 months of randomisation was found [PDSAFE group to control group odds ratio (OR) 1.21, 95% confidence interval (CI) 0.74 to 1.98; p = 0.447]. An analysis of secondary outcomes demonstrated better balance (Mini-BESTest: mean difference 0.95, 95% CI 0.24 to 1.67; p = 0.009), functional strength (CST: p = 0.041) and falls efficacy (Falls Efficacy Scale - International: mean difference 1.6, 95% CI -3.0 to -0.19; p = 0.026) with near-falling significantly reduced with PDSAFE (OR 0.67, 95% CI 0.53 to 0.86; p = 0.001) at 6 months. Prespecified subgroup analysis (i.e. disease severity and FoG) revealed a PDSAFE differing effect; the intervention may be of benefit for people with moderate disease but may increase falling for those in the more severe category, especially those with FoG.

LIMITATIONS

All participants were assessed at primary outcome; only 73% were assessed at 12 months owing to restricted funding.

CONCLUSIONS

PDSAFE was not effective in reducing repeat falling across the range of people with Parkinson's disease in the trial. Secondary analysis demonstrated that other functional tasks and self-efficacy improved and demonstrated differential patterns of intervention impact in accordance with disease severity and FoG, which supports previous secondary research findings and merits further primary evaluation.

FUTURE WORK

Further trials of falls prevention on targeted groups of people with Parkinson's disease are recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN48152791.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 36. See the NIHR Journals Library website for further project information. Sarah E Lamb is funded by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) at Oxford Health NHS Foundation Trust, the NIHR Oxford Biomedical Research Centre at the Oxford University Hospitals NHS Foundation Trust and CLAHRC Oxford. Victoria A Goodwin is supported by the NIHR Collaborations for Leadership in Applied Health Research and Care in the South West Peninsula (PenCLAHRC). Lynn Rochester is supported by the NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University. The research was also supported by the NIHR Newcastle Clinical Research Facility Infrastructure funding. Helen C Roberts is supported by CLAHRC Wessex and the NIHR Southampton Biomedical Research Centre.

Participant expectations and experiences of a tailored physiotherapy intervention for people with Parkinson's and a history of falls

Purpose: People with Parkinson's are twice as likely to fall as older people within the general population. This longitudinal qualitative study was part of a larger programme of research including a randomised controlled trial to test the effectiveness of a tailored physiotherapy intervention. Specific qualitative aims focused on a subsample of trial participants in the intervention arm of the trial, and comprised the following:To explore the expectations of participants about the intervention.To investigate participants' experiences of the intervention, and its perceived impacts.To understand the facilitators and barriers to engagement.Methods: Two semi-structured interviews were completed with a theoretical sample of people with Parkinson's from the intervention arm, initially after randomisation but before the intervention commenced, and then again six months later.Results: Forty-two participants out of a large clinical trial were interviewed initially, with 37 agreeing to a second interview at six months. Prior experience of rehabilitation plus information accessed through the trial consent procedure informed participants' realistic expectations. Most found the level of the intervention acceptable, and perceived a range of benefits. However, views about equipment provided were more equivocal. The biggest barriers to participation were time and motivation, whilst social support facilitated engagement with the intervention.Conclusions: This study is the first to capture expectations about participation in a programme of exercises and strategies. It highlights that previous challenges to engagement in physical exercises and activities are not a barrier to future participation and provides new insights into the role of equipment and technology in programmes of physical activity for people with Parkinson's. The challenge of ensuring that programmes of exercise and strategies become an embedded feature of everyday life is highlighted, particularly alongside busy social engagements and leisure pursuits.Implications for rehabilitationFor people with Parkinsons, a programme of exercises and strategies has the potential to reduce the risk of falls amongst those with a history of falling.Adherence to such programmes can prove challenging for a variety of reasons, even when participants have realistic expectations about the commitment and effort needed.Clear explanations about the role of equipment and technology within such programmes could enhance adherence.In order to further individualise programmes of exercise for people with Parkinsons, choice regarding social support, reminders and integration into everyday activities should be explored.

Self-management of a musculoskeletal condition for people from harder to reach groups: a qualitative patient interview study

Background: This study recorded the functional health literacy levels of people with musculoskeletal (MSK) conditions from harder to reach groups and explored their experiences in engaging with health care professionals to self-manage their MSK condition.Methods: We recruited participants, identified by key health and social care contacts as likely to have lower health literacy levels, and used semi-structured interviews to collect data. Thematic analysis was used to identify the main key themes arising from the transcribed interviews.Results: Eighteen participants were identified and recruited from harder to reach community populations, 10 were scored as having inadequate functional health literacy on the Short Form Rapid Estimate of Adult Literacy Measure. Three themes were identified in relation to participants' experiences of MSK self-management approaches: engaging with health care services; interpreting the health care providers' message; and facilitating participation in MSK self-management.Conclusions: Our findings indicate that people with a MSK condition, from harder to reach groups, experience multi-morbidity, find health care systems complicated and hear from health care professionals that their MSK condition cannot be cured. People interpreted that a lack of cure meant that nothing could be done to help their MSK pain. Engaging with self-management strategies was not seen as a priority for our participants. Strategies to simplify health communication, more time to process health information and supportive social networks helped our participants to understand and manage their MSK health on a day-to-day basis. Implications for RehabilitationMSK conditions are long term and prevalent in the UK with substantial impact on people's daily life.Currently self-management strategies for MSK conditions are poorly communicated and many patients believe that nothing can be done to help their MSK pain.Good clinician communication that supports self-management is needed so that key messages can be effectively understood and used by patients with a range of literacy skills.Health services need to be even more accessible to help all individuals from a range of backgrounds better self-manage their MSK conditions.

Multicentre, randomised controlled trial of PDSAFE, a physiotherapist-delivered fall prevention programme for people with Parkinson's

OBJECTIVE

To estimate the effect of a physiotherapist-delivered fall prevention programme for people with Parkinson's (PwP).

METHODS

People at risk of falls with confirmed Parkinson's were recruited to this multicentre, pragmatic, investigator blind, individually randomised controlled trial with prespecified subgroup analyses. 474 PwP (Hoehn and Yahr 1-4) were randomised: 238 allocated to a physiotherapy programme and 236 to control. All participants had routine care; the control group received a DVD about Parkinson's and single advice session at trial completion. The intervention group (PDSAFE) had an individually tailored, progressive home-based fall avoidance strategy training programme with balance and strengthening exercises. The primary outcome was risk of repeat falling, collected by self-report monthly diaries, 0-6 months after randomisation. Secondary outcomes included Mini-BESTest for balance, chair stand test, falls efficacy, freezing of gait, health-related quality of life (EuroQol EQ-5D), Geriatric Depression Scale, Physical Activity Scale for the Elderly and Parkinson's Disease Questionnaire, fractures and rate of near falling.

RESULTS

Average age is 72 years and 266 (56%) were men. By 6 months, 116 (55%) of the control group and 125 (61.5%) of the intervention group reported repeat falls (controlled OR 1.21, 95% CI 0.74 to 1.98, p=0.447). Secondary subgroup analyses suggested a different response to the intervention between moderate and severe disease severity groups. Balance, falls efficacy and chair stand time improved with near falls reduced in the intervention arm.

CONCLUSION

PDSAFE did not reduce falling in this pragmatic trial of PwP. Other functional tasks improved and reduced fall rates were apparent among those with moderate disease.

TRIAL REGISTRATION NUMBER

ISRCTN48152791.

Nursing and allied health professionals' views about using health literacy screening tools and a universal precautions approach to communication with older adults: a qualitative study

Purpose: Health literacy describes individuals' abilities to access, understand and use health information. Lower health literacy is associated with poor health outcomes, is more common among older adults and impacts on the effectiveness of rehabilitation/self-management interventions. This research explored nursing and allied healthcare professionals' views about identifying and responding to older adults' health literacy needs.Methods: Qualitative focus groups were conducted with a purposive sample of 22 UK nursing and AHPs working with older adults. Focus groups were audio-recorded, transcribed verbatim and analyzed using framework approach.Results: Participants used a variety of practices to identify older patients' health literacy levels, but primarily relied on subtle cues. Participants lacked knowledge and confidence in identifying and addressing health literacy needs. Participants expressed concerns about patient reactions and described practical barriers to using recommended health literacy strategies.Conclusions: Participants recognized the importance of addressing patients' health literacy needs, but do not routinely use health literacy strategies, lack confidence and have reservations about recommended health literacy strategies. This impacts on healthcare professionals' abilities to support patients to self-manage and participate in rehabilitation. Health literacy education for health professionals should consider barriers to using health literacy strategies and be tailored to accommodate variation in teams and professions.Implications for rehabilitationRehabilitation professionals need to standardise their practice to health literacy, using strategies which can be easily integrated into routine practice.To meet older adults' health literacy needs, rehabilitation professionals should use clear and accessible tailored communication, build trust, assess understanding and involve patients' social networks.Rehabilitation professionals would benefit from further education regarding health literacy to build their knowledge/confidence and address their concerns about implementing health literacy strategies.Professional education regarding health literacy needs to accommodate variation between individuals and teams.

Duration of intravenous antibiotic therapy for children with acute osteomyelitis or septic arthritis: a feasibility study

BACKGROUND

There is little current consensus regarding the route or duration of antibiotic treatment for acute osteomyelitis (OM) and septic arthritis (SA) in children.

OBJECTIVE

To assess the overall feasibility and inform the design of a future randomised controlled trial (RCT) to reduce the duration of intravenous (i.v.) antibiotic use in paediatric OM and SA.

DESIGN

(1) A prospective service evaluation (cohort study) to determine the current disease spectrum and UK clinical practice in paediatric OM/SA; (2) a prospective cohort substudy to assess the use of targeted polymerase chain reaction (PCR) in diagnosing paediatric OM/SA; (3) a qualitative study to explore families' views and experiences of OM/SA; and (4) the development of a core outcome set via a systematic review of literature, Delphi clinician survey and stakeholder consensus meeting.

SETTING

Forty-four UK secondary and tertiary UK centres (service evaluation).

PARTICIPANTS

Children with OM/SA.

INTERVENTIONS

PCR diagnostics were compared with culture as standard of care. Semistructured interviews were used in the qualitative study.

RESULTS

Data were obtained on 313 cases of OM/SA, of which 218 (61.2%) were defined as simple disease and 95 (26.7%) were defined as complex disease. The epidemiology of paediatric OM/SA in this study was consistent with existing European data. Children who met oral switch criteria less than 7 days from starting i.v. antibiotics were less likely to experience treatment failure (9.6%) than children who met oral switch criteria after 7 days of i.v. therapy (16.1% when switch was between 1 and 2 weeks; 18.2% when switch was > 2 weeks). In 24 out of 32 simple cases (75%) and 8 out of 12 complex cases (67%) in which the targeted PCR was used, a pathogen was detected. The qualitative study demonstrated the importance to parents and children of consideration of short- and long-term outcomes meaningful to families themselves. The consensus meeting agreed on the following outcomes: rehospitalisation or recurrence of symptoms while on oral antibiotics, recurrence of infection, disability at follow-up, symptom free at 1 year, limb shortening or deformity, chronic OM or arthritis, amputation or fasciotomy, death, need for paediatric intensive care, and line infection. Oral switch criteria were identified, including resolution of fever for ≥ 48 hours, tolerating oral food and medicines, and pain improvement.

LIMITATIONS

Data were collected in a 6-month period, which might not have been representative, and follow-up data for long-term complications are limited.

CONCLUSIONS

A future RCT would need to recruit from all tertiary and most secondary UK hospitals. Clinicians have implemented early oral switch for selected patients with simple disease without formal clinical trial evidence of safety. However, the current criteria by which decisions to make the oral switch are made are not clearly established or evidence based.

FUTURE WORK

A RCT in simple OM and SA comparing shorter- or longer-course i.v. therapy is feasible in children randomised after oral switch criteria are met after 7 days of i.v. therapy, excluding children meeting oral switch criteria in the first week of i.v. therapy. This study design meets clinician preferences and addresses parental concerns not to randomise prior to oral switch criteria being met.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Positioning Children's Voice in Clinical Trials Research: A New Model for Planning, Collaboration, and Reflection

Following the United Nations Convention on the Rights of the Child, there has been considerable growth in research with children about health and services that affect them. Creative methods to engage with children have also been developed. One area where progress has been slower is the inclusion of children's perspectives in qualitative research in the context of clinical trials or feasibility studies. Addressing this gap, this article discusses experiences of, and reflections on, the process of researching children's views as part of a clinical feasibility study. The article considers what worked well and highlights remaining dilemmas. A new continuum of children's engagement in research is presented, designed to assist researchers to make explicit the contingent demands on their research, and to suggest a range of techniques from within the broader fields of health, childhood studies, and education research that could be used to forward qualitative research in clinical contexts.

Factors associated with alcohol reduction in harmful and hazardous drinkers following alcohol brief intervention in Scotland: a qualitative enquiry

Background

Alcohol Brief Intervention (ABI) uses a motivational counselling approach to support individuals to reduce excessive alcohol consumption. There is growing evidence on ABI’s use within various health care settings, although how they work and which components enhance success is largely unknown. This paper reports on the qualitative part of a mixed methods study. It explores enablers and barriers associated with alcohol reduction following an ABI. It focuses on alcohol’s place within participants’ lives and their personal perspectives on reducing consumption. There are a number of randomised controlled trials in this field though few ABI studies have addressed the experiences of hazardous/harmful drinkers. This study examines factors associated with alcohol reduction in harmful/hazardous drinkers following ABI.

Methods

This qualitative study was underpinned by a realist evaluation approach and involved semi-structured interviews with ten harmful or hazardous alcohol drinkers. Participants (n = 10) were from the intervention arm of a randomised controlled trial (n = 124). All had received ABI, a 20 min motivational counselling interview, six months previously, and had reduced their alcohol consumption. Interviews were recorded, transcribed verbatim and thematically analysed.

Results

Participants described their views on alcohol, its’ place in their lives, their personal perspectives on reducing their consumption and future aspirations.

Conclusions

The findings provide an insight into participants’ views on alcohol, ABI, and the barriers and enablers to change. Participants described a cost benefit analysis, with some conscious consideration of the advantages and disadvantages of reducing intake or abstaining from alcohol. Findings suggest that, whilst hospital admission can act as a catalyst, encouraging individuals to reflect on their alcohol consumption through ABI may consolidate this, turning this reflective moment into action. Sustainability may be enhanced by the presence of a ‘significant other’ who encourages and experiences benefit. In addition having a purpose or structure with activities linked to employment and/or social and leisure pursuits offers the potential to enhance and sustain reduced alcohol consumption.

Trial registration

Trial registration number TRN NCT00982306 September 22nd 2009.

The Effectiveness of Sensory Integration Therapy to Improve Functional Behaviour in Adults with Learning Disabilities: Five Single-Case Experimental Designs

This paper describes a research project using a single-case experimental design (A-B-A), which aimed to explore the impact of sensory integration therapy (SIT) on level of engagement and maladaptive behaviour (measured through timed scores) and function (using Goal Attainment Scaling, GAS) for five learning disabled adults with tactile sensory modulation disorder.

Each phase lasted 4 weeks and consisted of 24 measurements in total. Individually tailored SIT was given twice weekly for 4 weeks during the intervention phase (B), immediately prior to each individual's participation in his or her prescribed horticulture task. The changes between phases in engagement, maladaptive behaviours and function scores, measured as the difference between baselines and intervention, were analysed visually and statistically for each participant.

The intervention produced significant improvements in engagement for participant four, with a highly significant deterioration in scores for all five participants on withdrawal of SIT. All the participants' maladaptive behaviour decreased significantly on the introduction of SIT. Although there was no significant change to GAS scores for four participants, participant four's score improved significantly with SIT. The withdrawal of SIT resulted in a highly significant deterioration in GAS scores for participants one, two, four and five. This study may be the first to suggest that SIT is effective in improving functional performance in adults with a learning disability with a tactile sensory modulation disorder.

Falling from Grace or into Expert Hands? Alternative Accounts about Falling in Older People

Falls in older people are a priority area for both research and clinical intervention in the United Kingdom. There is, however, currently an absence of research exploring the meaning and interpretation of a fall.

Semi-structured interviews were conducted with 20 therapists and with eight older people with fractured hips. The therapists' accounts appeared to draw on a ‘risk discourse’ which constructed a fall as a predictable and preventable event, highlighting individual patient characteristics as causative factors and suggesting that therapists were more knowledgeable about this subject. The accounts of the older inpatients, conversely, made use of a ‘moral discourse’, in which commendable personal qualities and competencies were emphasised.

It is suggested that this work has implications for therapy in that many falls prevention initiatives and health promotion materials may be falsely premised on an acceptance of vulnerability by older people.

Writing up Rigour: Representing and Evaluating Good Scholarship in Qualitative Research

Qualitative research is a mode of inquiry with which many occupational therapists engage and which some claim is particularly suited to researching the complexity and richness of occupational therapy practice.

This paper, written as part of a research series in this journal, has a dual purpose: first, to encourage qualitative researchers to identify their own ontology and use recognised strategies for ensuring high quality work which are consistent with their own world-view of research and, secondly, to consider how best to represent those strategies within their written accounts of their research.

Three researcher positions ranged along a continuum are proposed – realist, subtle realist and relativist – and alternative criteria for each of these positions are suggested. Occupational therapy and health examples are used to illuminate each of these traditions.

It is hoped that the paper will assist qualitative researchers both to clarify their own position along the research continuum and remain coherent within it and to identify the key features relating to quality and rigour that they should consider including in papers submitted for publication.

College of Occupational Therapists: Research and Development Strategy

The role of research in occupational therapy has been widely debated over the last two years within the profession. The outcome has been the production, by the Research and Development Committee, of the Research and Development Strategy for the College of Occupational Therapists. The strategy addresses how the College of Occupational Therapists can help to support occupational therapists as research consumers, as participants in research and as proactive researchers.

Networking between Therapists Interested in Research: How to Set up a Support Group

A local initiative in Southampton attempted to address therapy researchers' needs for networking support and information. A multidisciplinary research support group meets every 2 months to share ideas and experiences of research. This article outlines information about the group: Its development, role and possible future directions. It is hoped that therapists interested or involved in research might feel inspired to consider doing the same in other locations.

Older People's Views about Community Falls Prevention: An Australian Perspective

Although targets have been set for the establishment of falls prevention services, little is known about the views of older people in respect of such initiatives. The purpose of this study was to investigate the perspectives of the older participants in a community group falls prevention programme in Australia and to explore their views about the most and least useful aspects of the programme, using methods deriving from a grounded theory approach.

Semi-structured interviews were carried out with nine women and two men who had attended a falls prevention programme. The multifaceted intervention comprised seven weekly meetings of 2 hours each. The key principle underpinning the programme was enhancement of self-efficacy.

Four themes were identified through qualitative analysis: identity (focusing on participants as active elders); the salience of interventions (or the meaning attributed to different programme components); the social experience (the views about group interaction); and the consequences of participation. The participants were very positive about their experience of the programme and described a range of psychological and physical outcomes.

A decrease in the likelihood of a fall did not feature prominently in these interviews. It may be more meaningful to older people to embed falls prevention within a wider context of wellbeing and independence.

Determining priorities for research to improve fundamental care on hospital wards

PLAIN ENGLISH SUMMARY

The aim of this project was to find out the priorities for research that could improve fundamental care. 'Fundamental care' covers all aspects of basic care in hospital wards, such as helping with core physical needs, building positive relationships and keeping patients safe.By setting the priorities with patients, carers, the public and health care professionals, research can look at the issues that really matter to people who are receiving or delivering care in hospital wards.Previously, prioritisation exercises have started with a menu of options and asked people to choose from that list. They have also been focused on specific health conditions. Traditionally, there has been little opportunity for patients, carers and the public to contribute to identifying the issues to be prioritised.To develop the priorities for research, we started by exploring what is meant by 'fundamental care', looking at patient and carer accounts and academic and policy reports. Patients, carers, staff, and members of the public were consulted via surveys, interviews and group discussions to share experiences and issues.A list of 15 topics was identified based on what was most commonly mentioned by patients, carers and healthcare professionals as well as what was practical for the CLAHRC Wessex team to research. A workshop with patients, carers and healthcare professionals was held, to decide the top 5 areas.The five priority areas identified were:Nurse staffingIndividualised patient careStaff communicationStaff attitudes and relationships with patientsInformation about care/communication.

ABSTRACT

Background The provision of high quality fundamental care in hospitals is a top priority for the NHS. Recent reports and investigations highlight that at times care has fallen below standard. It is unclear what research should be prioritised to improve care. The aim of this work is to involve patients/carers/public, clinicians and other stakeholders to identify issues that are priorities for research which could improve fundamental care in hospital. Methods Patient and public involvement was integral to this project, with a patient leader/service user being a member of the core team who designed and executed this research. After consideration of existing priority setting approaches, we developed an inclusive approach which consisted of six main phases: 1) Development of a conceptual framework of fundamental care, based on reports and literature 2) Consultation with a wide range of stakeholders through a survey, focus groups and interviews 3) Identifying themes from the responses to the consultation phase (76 themes identified) 4) Analysis to identify the 15 topics most frequently cited 5) Prioritisation of the top 15 themes through a half day workshop, which led to a shortlist of five themes 6) Development of the top 5 themes into research areas. Results Three hundred forty stakeholders (29 % of whom were patients/carers/public) completed the consultation survey. Analysis of the survey responses and of focus groups and interviews led us to identify 15 high scoring themes. We presented these at the prioritisation workshop, attended by 39 participants (23 of whom patients/carers/public). After a voting exercise, the 5 top research priorities which emerged were: nurse staffing; individualised patient care; staff communication; staff attitudes and relationships with patients; and information about care. Conclusions We involved a range of stakeholders in identifying topics for research to improve fundamental care and asked them to prioritise these. The process provided a means of reaching consensus as to the important issues for future research to focus on to improve fundamental care on hospital wards.

A feasibility study to prevent falls in older people who are sight impaired: the VIP2UK randomised controlled trial

BACKGROUND

Published evaluations of successful interventions to prevent falls in people with sight impairment (SI) are limited. The aim of this feasibility study is to optimise the design and investigation of home safety (HS) and home exercise (HE) programmes to prevent falls in older people with SI.

METHODS

A community-based feasibility study in north-west England comprising a three-arm randomised controlled trial (RCT) allocated participants to (1) a control group receiving usual care and social visits, (2) an experimental group receiving the HS programme and (3) an experimental group receiving the HS + HE programme. Participants were community-dwelling, aged 65 years and older and sight impaired. Primary outcome data on falls were collected continuously over 6 months. Secondary outcomes on physical activity (self-report and instrumented) and adherence were collected at baseline and 3 and 6 months for HE and at 6 months for the HS programme. Costs for the HS and HS + HE groups were calculated from logs of time spent on home visits, telephone calls and travel. The research assistant and statistician were blinded to group allocation.

RESULTS

Altogether, 49 people were recruited over a 9-month period (randomised: 16 to control, 16 to HS, 17 to HS + HE). The interventions were implemented over 6 months by an occupational therapist at a cost per person (pounds sterling, 2011) of £249 (HS) and £674 (HS + HE). Eighty-eight percent (43/49) completed the trial and 6-month follow-up. At 6-month follow-up, 100 % reported partially or completely adhering to HS recommendations but evidence for adherence to HE was equivocal. Although self-reported physical activity increased, instrumented monitoring showed a decrease in walking activity. There were no statistically significant differences in falls between the groups; however, the study was not powered to detect a difference.

CONCLUSION

It is feasible and acceptable for an occupational therapist to deliver HS and HE falls prevention programmes to people with SI living independently in the community. Future studies could access Local Authority Registers of people with SI to improve recruitment rates. Further research is required to identify how to improve adherence to HE and to measure changes in physical activity before conducting a definitive RCT.

TRIAL REGISTRATION

ISRCTN53433311 , registered on 8 May 2014.

Giving hope, ticking boxes or securing services? A qualitative study of respiratory physiotherapists' views on goal-setting with people with chronic obstructive pulmonary disease

OBJECTIVE

To explore respiratory physiotherapists' views and experiences of using goal-setting with people with chronic obstructive pulmonary disease in rehabilitation settings.

PARTICIPANTS

A total of 17 respiratory physiotherapists with ⩾12 months current or previous experience of working with patients with chronic obstructive pulmonary disease in a non-acute setting. Participants were diverse in relation to age (25-49 years), sex (13 women), experience (Agenda for Change bands 6-8) and geographic location.

METHOD

Data were collected via face-to-face qualitative in-depth interviews (40-70 minutes) using a semi-structured interview guide. Interview locations were selected by participants (included participants' homes, public places and University). Interviews followed an interview guide, were audio-recorded and transcribed verbatim.

DATA ANALYSIS

Data were analysed using thematic analysis; constant comparison was made within and between accounts, and negative case analysis was used.

RESULTS

Three themes emerged through the process of analysis: (1) 'Explaining goal-setting'; (2) 'Working with goals'; and (3) 'Influences on collaborative goal-setting'. Goal-setting practices among respiratory physiotherapists varied considerably. Collaborative goal-setting was described as challenging and was sometimes driven by service need rather than patient values. Lack of training in collaborative goal-setting at both undergraduate and postgraduate level was also seen as an issue.

CONCLUSION

Respiratory physiotherapists reflected uncertainties around the use of goal-setting in their practice, and conflict between patients' goals and organisational demands. This work highlights a need for wider discussion to clarify the purpose and implementation of goal-setting in respiratory rehabilitation.

Commissioning of self-management support for people with long-term conditions: an exploration of commissioning aspirations and processes

OBJECTIVES

To explore how self-management support (SMS) is considered and conceptualised by Clinical Commissioning Groups (CCGs) and whether this is reflected in strategic planning and commissioning. SMS is an essential element of long-term condition (LTC) management and CCGs are responsible for commissioning services that are coordinated, integrated and link into patient's everyday lives. This focus provides a good test and exemplar for how commissioners communicate with their local population to find out what they need.

DESIGN

A multisite, quasi-ethnographic exploration of 9 CCGs.

SETTING

National Health Service (NHS) CCGs in southern England, representing varied socioeconomic status, practice sizes and rural and urban areas.

DATA COLLECTION/ANALYSIS

Content analysis of CCG forward plans for mention of SMS. Semistructured interviews with commissioners (n=10) explored understanding of SMS and analysed thematically. The practice of commissioning explored through the observations of Service User Researchers (n=5) attending Governing Body meetings (n=10, 30 hours).

RESULTS

Observations illuminate the relative absence of SMS and gateways to active engagement with patient and public voices. Content analysis of plans point to tensions between local aspirations and those identified by NHS England for empowering patients by enhancing SMS services ('person-centred', whole systems). Interview data highlight disparities in the process of translating the forward plans into practice. Commissioners reference SMS as a priority yet details of local initiatives are notably absent with austerity (cost-containment) and nationally measured biomedical outcomes taking precedence.

CONCLUSIONS

Commissioners conceptualise locally sensitive SMS as a means to improve health and reduce service use, but structural and financial constraints result in prioritisation of nationally driven outcome measures and payments relating to biomedical targets. Ultimately, there is little evidence of local needs driving SMS in CCGs. CCGs need to focus more on early strategic planning of lay involvement to provide an avenue for genuine engagement, so that support can be provided for communities and individuals in a way people will engage with.

Evaluating equipment for people with disabilities: user and technical perspectives on basic commodes

Disabled people often do not use the equipment supplied to them. Past work indicates that there are many reasons for this, including the low priority given to user views by the designers and manufacturers of such equipment. A number of different methodologies have been used to evaluate equipment. This paper describes an evaluation of basic commodes, a project funded by the Medical Devices Agency, Department of Health, in which both a user survey and technical tests were employed.

A sample of 18 basic commodes, divided into four categories, was evaluated by 40 users, a questionnaire being administered to determine user views. A series of 13 technical tests was also carried out.

The results showed that the preferred commodes as indicated by the users did not necessarily perform well in the technical tests, with at least one of the products having potentially serious design faults. It is suggested that users, therapists and engineers each have an essential contribution to make in the evaluation of equipment for disabled people.

Effectiveness of Alcohol Brief Intervention in a General Hospital: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to examine the effectiveness of an alcohol brief intervention (ABI) on alcohol consumption in hazardous or harmful drinkers compared with screening alone within a general hospital setting.

METHOD

Following screening, 124 hazardous or harmful drinkers (103 men, ages 18-80 years, score of 3-12 on the Fast Alcohol Screening Test [FAST]) admitted to medical and orthopedic wards during the 13-month recruitment period were randomized to receive an ABI or control. The intervention group received an ABI where they were supported to set their own personalized alcohol reduction goals, and both groups received a health information leaflet. Retrospective alcohol consumption for 7 days was reported for the week, before hospital admission and 6 months after it.

RESULTS

Demographics and clinical characteristics at baseline showed no statistical differences between the two groups on all variables except FAST score, which was higher in the intervention group (p ≤ .05). A reduction of 85 grams of alcohol per week (95% CI [162.46, 7.54]) was observed between groups in favor of the intervention group based on changes from baseline. However, there was no significant difference between groups for absolute grams of alcohol per week at 6 months. A significant mean difference in favor of the intervention group (U = 1,537, p = .043) was observed for weekly heavy drinking episodes.

CONCLUSIONS

Our results suggest screening with delivery of ABI for harmful/hazardous drinkers in a general hospital is beneficial in reducing alcohol consumption compared with screening alone.

Rehabilitation professionals' perceptions of the use of new visualisation software tools with people with stroke

PURPOSE

The envisage programme of research was funded to explore and evaluate the use of visualisation software tools using biomechanical data within rehabilitation. Three work packages were developed to evaluate the impact of the tools within stroke rehabilitation. The research presented here aimed at exploring the perceptions of rehabilitation therapists about the use of the visualisation software tools in the context of future randomised controlled trials and stroke rehabilitation practice.

METHODS

Sixteen therapists working in a range of stroke rehabilitation contexts participated in semi-structured interviews. Interview questions explored their current practice, and the perceived impact of the new visualisation technologies on their workplace environment and practice. Framework analysis was used to analyse the textual data.

RESULTS

In general, the stroke therapists were enthusiastic about the potential application of the visualisation software tools. Three themes were identified through qualitative framework analysis: potential uses of the visualisation tools; integration within current service provision; and trial involvement.

CONCLUSIONS

The study highlights important contextual considerations which may impact significantly on the success of novel technologies in stroke rehabilitation. Normalisation process theory was proposed as a useful process evaluation methodology to optimise both trial evaluation and future service implementation. Implications for Rehabilitation There is limited research exploring the use of visual software technologies featuring biomechanical data within stroke rehabilitation. The perspectives of stroke rehabilitation therapists about the potential of such tools are useful both in terms of planning trial evaluations, and implementation. Therapists were generally positive about the contribution of visual software tools in stroke rehabilitation, but highlighted a number of practical constraints which required addressing. Normalisation process theory provides a useful process evaluation methodology which can support both trial evaluation and implementation of such novel technologies within stroke rehabilitation.

A critical review of the effectiveness of environmental assessment and modification in the prevention of falls amongst community dwelling older people

Introduction

The potential of environmental assessment and modification to reduce falls has recently received attention within the gerontology literature. Research investigating the clinical effectiveness of this intervention in falls prevention reports conflicting results. Discrepancies are due to variation in the risk profile of study participants and the health care background of the person providing the environmental intervention or the intensity of the intervention provided.

Method

The purpose of this paper is to compare and contrast two systematic reviews, which include meta-analyses, of environmental interventions for falls prevention in community dwelling older people, using the critical appraisal skills programme tool for systematic reviews.

Findings

Both reviews found that: environmental assessment and modification was effective in falls prevention; intervention was effective with high but not low risk participants; and that high intensity environmental assessment was effective, whereas low intensity intervention was not. Environmental interventions which were delivered by occupational therapists were deemed high intensity, probably because their underpinning theoretical frameworks focus on the impact of the environment on function.

Conclusion

We discuss possible reasons why occupational therapist led environmental assessment and modification is clinically effective in falls prevention, for people at high risk of falls, whereas non occupational therapist led intervention is not.

A pilot randomised controlled trial to compare changes in quality of life for participants with early diagnosis dementia who attend a 'Living Well with Dementia' group compared to waiting-list control

OBJECTIVES

The aim of this paper is to report a pilot study in which participants who had recently received a diagnosis of dementia were randomised to either a 10-week group intervention or a waiting-list control.

METHOD

Memory clinic staff with limited previous experience of group therapy were trained to lead a 10-week group therapy intervention called 'Living Well with Dementia'. Fifty-eight participants, all of whom had received a diagnosis of Alzheimer's disease, vascular or Lewy body dementia within the previous 18 months, were randomised to receive either the intervention or treatment as usual (waiting-list control). Data collection occurred at baseline, within two weeks after the intervention finished and at 10-week follow-up.

RESULTS

The study met its recruitment targets, with a relatively low attrition rate for the intervention arm. The acceptability of the intervention and research methods was examined qualitatively and will be reported on elsewhere. For the primary outcome, measure of quality of life in Alzheimer's disease (QoL-AD), and secondary outcome, self-esteem, there was some evidence of improvement in the intervention group compared to the control group. There was, also, evidence of a reduction in cognitive functioning in the treatment group compared to the control. Such reported differences should be treated with caution because they are obtained from a pilot and not a definitive study.

CONCLUSION

This pilot study succeeded in collecting data to inform a future definitive cost effectiveness clinical trial of Living Well with Dementia group therapy.

A multi-centre, randomised controlled trial of the effectiveness of PDSAFE to prevent falls among people with Parkinson's: study protocol

Background

Falls amongst people with Parkinson’s (PwP) result in significant disability and reduced quality of life. There is emerging evidence that exercise-based and physiotherapeutic interventions are of benefit for improving fall risk factors, such as balance. However, the benefit, in terms of preventing falls, is mixed. The development of effective interventions has been identified as the highest research priority for this population.

The aim of this trial is to establish the effectiveness and cost-effectiveness of a novel, home-based physiotherapy programme, compared with usual care, on falls amongst PwP.

Methods/Design

A UK multi-centre, community-based, single blind, randomised controlled trial with twelve month follow-up, and nested economic evaluation and qualitative studies will be undertaken. Six hundred PwP who live in their own home, have had one or more falls in the previous year and an MMSE score of ≥24 will be recruited. Those living in care homes and those needing assistance from another person to walk indoors will not be eligible.

The intervention is a physiotherapist delivered, individually tailored and progressive, home-based programme (PDSAFE) comprising task orientated movement strategy training, functional lower limb strengthening and balance training, of six months duration. Unsupervised daily home exercises and strategies will be practised and supported using technology. Control participants will receive usual care.

Data collection will include falls, cognitive state, balance and mobility, fear of falling, freezing of gait, mood, quality of life, carer quality of life and resource use. Data will be collected at baseline, three, six and twelve months. Longitudinal semi-structured interviews will be undertaken with forty participants to explore the expectations and experiences of participants.

The primary outcome is risk of repeat falling at six months post-randomisation.

Discussion

The aims of this trial are to establish the effectiveness and cost-effectiveness of a novel, home-delivered physiotherapy intervention (PDSAFE) compared with usual care on risk of falling for PwP who have a history of falling. PDSAFE is a novel intervention that builds upon the existing literature and targeting known risk factors, being the first study that uses a novel delivery modus (technology) in conjunction with traditional physiotherapeutic approaches.

Trial registration

Current Controlled Trials ISRCTN48152791

The causes of falls: views of older people with visual impairment

Background

Sight impairment increases with age and, compared with the general older population, older people with sight impairment are more likely to fall. There is a growing body of evidence on the views and perceptions of older people about falls, but little is published on the views of older people with sight impairment.

Objective

To explore what older people with sight impairment believe to be the causes of falls.

Design

A qualitative design was used, incorporating focus groups and interviews in which participants discussed falls and falls prevention. Framework analysis was employed to identify themes arising from participants' discussions of the causes of falls.

Setting and participants

Fifty‐four community dwelling men and women with sight impairment, aged 65 and over, were recruited from across Greater Manchester, UK.

Results

Five types of factors were identified that were believed to cause falls: (i) health issues and changes in balance caused by ageing; (ii) cognitive and behavioural factors; (iii) the impact of sight impairment on getting around the home; (iv) the impact of sight impairment on negotiating the environment away from home; and (v) unexplained falls.

Discussion and conclusions

Older people with sight impairment reported many researched risk factors previously identified by older people without sight impairment but also described many perceived risks unique to people with sight impairment. There are few interventions to prevent falls aimed at older people with sight impairment, and the results of this study allow further tailoring of such interventions based on views of older people with sight impairment.

Understanding the Lived Experience of People with Multiple Sclerosis and Dysexecutive Syndrome

Introduction:

While evidence suggests that people with multiple sclerosis experience executive function impairment, there is a lack of understanding as to what this means for people within their occupational lives. This study attempted to explore the meanings constructed by individual participants who live with multiple sclerosis and dysexecutive syndrome on a daily basis.

Method:

Ten community-dwelling adults, diagnosed with clinically definite/probable multiple sclerosis and having performed within the ‘Impaired’ category of the Behavioural Assessment of Dysexecutive Syndrome, were invited to participate in semi-structured interviews. The data were analysed using interpretative phenomenological analysis.

Findings:

The reported changes in the occupational lives of the participants contributed to significant alterations in the roles they inhabited. There was a substantial cost to personal identity as the participants withdrew from former roles or perceived themselves to be failing within their existing roles, leading to a loss of self-worth and self-esteem.

Conclusion:

It is evident from the findings of this study that the actual cognitive deficits did not represent the main issue for people within their everyday lives; rather, the putative consequences of executive dysfunction were of much greater concern for them.

The circumstances and impact of injuries on adults with learning disabilities

Introduction:

People with learning disabilities experience higher rates of injury compared to the general population, but little is known about the circumstances and perceived impact of these injuries on people with learning disabilities themselves.

Method:

Content analysis was conducted from interviews with 113 adults with learning disabilities who had at least one injury in a 12-month period. Qualitative interviews were conducted with ten adults with learning disabilities (and their carers where appropriate) who had experienced serious or frequent injury or frequent falls with or without injury in a 12-month period.

Findings:

The most commonly reported contributory factors for injuries and/or falls were related to physical health status (for example, epilepsy) and the environment (for example, walking/banging into furniture or stairs/steps). In terms of perceived impact, the development of fear of walking outdoors unsupported or fear of crossing a road were highlighted. The non-use and misuse of assistive technology was also highlighted as a concern.

Conclusion:

These findings demonstrate that occupational therapists have a key role to play in tailoring injury and fall prevention strategies and interventions for people with learning disabilities. In particular, environmental assessment and monitored use of assistive technology is important.

Effectiveness of musculoskeletal education interventions in people with low literacy levels: a systematic review

Objective

To conduct a systematic review to assess the effectiveness of patient education interventions delivered or directed by health professionals for people with musculoskeletal conditions who also have lower levels of literacy.

Methods

Electronic databases were searched from 1946 to May 2012. Randomized controlled trials with primary interventions designed specifically for individuals with musculoskeletal conditions and lower levels of literacy were eligible for inclusion. The quality of the study was determined by assessing method of randomization, allocation concealment, creation and maintenance of comparable groups, blinding of patients and providers, control of confounding, and the validity and reliability of outcome measures.

Results

Of the 2,440 studies located using the search strategy, 6 studies met the inclusion criteria. Three public health community studies and 3 rheumatology clinic-based studies delivered educational programs to people with musculoskeletal conditions who also had lower levels of literacy. Three moderate quality studies suggest that musculoskeletal educational interventions had a small short-term effect on knowledge and 2 moderate quality studies suggest musculoskeletal interventions had a small effect on self-efficacy (although results on self-efficacy were conflicting in 1 of these studies). Only 1 moderate quality study showed a small effect on anxiety and 1 on self-perceived health and well-being in people with lower literacy.

Conclusion

High quality evidence is lacking on the effectiveness of musculoskeletal education interventions for people with lower literacy levels. Research programs that test the effectiveness of patient education interventions for arthritis must recruit and engage people with lower levels of literacy.

Characteristics of outdoor falls among older people: a qualitative study

Background

Falls are a major threat to older people’s health and wellbeing. Approximately half of falls occur in outdoor environments but little is known about the circumstances in which they occur. We conducted a qualitative study to explore older people’s experiences of outdoor falls to develop understanding of how they may be prevented.

Methods

We conducted nine focus groups across the UK (England, Wales, and Scotland). Our sample was from urban and rural settings and different environmental landscapes. Participants were aged 65+ and had at least one outdoor fall in the past year. We analysed the data using framework and content analyses.

Results

Forty-four adults aged 65 – 92 took part and reported their experience of 88 outdoor falls. Outdoor falls occurred in a variety of contexts, though reports suggested the following scenarios may have been more frequent: when crossing a road, in a familiar area, when bystanders were around, and with an unreported or unknown attribution. Most frequently, falls resulted in either minor or moderate injury, feeling embarrassed at the time of the fall, and anxiety about falling again. Ten falls resulted in fracture, but no strong pattern emerged in regard to the contexts of these falls. Anxiety about falling again appeared more prevalent among those that fell in urban settings and who made more visits into their neighbourhood in a typical week.

Conclusions

This exploratory study has highlighted several aspects of the outdoor environment that may represent risk factors for outdoor falls and associated fear of falling. Health professionals are recommended to consider outdoor environments as well as the home setting when working to prevent falls and increase mobility among older people.

Environmental and behavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people

BACKGROUND

Impairment of vision is associated with a loss of function in activities of daily living. Avoidance of physical activity and consequent reduced functional capacity is common in older people with visual impairment and an important risk factor for falls. Indeed, the rate of falls and fractures is higher in older people with visual impairment than age-matched visually normal older people. Depression and anxiety is common in older people with vision impairment and leads to further restriction of activity, reduced social contact and reduced quality of life. Possible mechanisms to reduce activity restriction and therefore improve mobility and activity include environmental and behavioural interventions delivered by a number of health professionals, including occupational therapists.

OBJECTIVES

The objective of this review was to assess the effectiveness of environmental and behavioural interventions in reducing activity limitation and improving quality of life amongst visually impaired older people.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to November 2012), EMBASE (January 1980 to November 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to November 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to November 2012), OT Seeker (inception to November 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 9 November 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled trials (Q-RCTs) that compared environmental interventions, behavioural interventions or both, versus control (placebo control or no intervention or usual care), and trials comparing different types of environmental or behavioural interventions, in older people (aged 60 and over) with irreversible visual impairment living independently or in residential settings. To be eligible for inclusion the primary aim of studies must be reducing physical activity limitation and must include a measure of physical activity. Secondary outcome measures included falls, fear of falling, quality of life.

DATA COLLECTION AND ANALYSIS

Two authors independently read abstracts retrieved by the search to identify eligibility and study quality. We contacted study authors for additional information.

MAIN RESULTS

Our searches found no RCTs or Q-RCTs that met the eligibility criteria for this review.

AUTHORS' CONCLUSIONS

We are unable to reach any conclusion about the effectiveness of environmental or behavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people, as no eligible studies were found. However a number of studies reviewed included only the secondary outcome measures of this review. Although behavioural interventions delivered by occupational therapists have been shown to reduce the rate of falls, we are unable to conclude if this is due to reduced activity restriction (increased mobility) or reduced activity (lessening exposure to risk). There are inconclusive and conflicting results from trials evaluating the effectiveness of behavioural and environmental interventions aimed at improving quality of life. Further research is necessary (such as ongoing Dutch and UK trials considering the effectiveness of orientation and mobility training on activity restriction, physical activity, falls, fear of falling and quality of life in older adults with low vision, and the effect of an occupational therapist delivering home safety modification, coping strategies and exercise with older people with low vision) before any conclusions can be reached.

The Elizabeth Casson Memorial Lecture 2012: The Effectiveness, Impact and Legacy of Occupational Therapy

The Elizabeth Casson Memorial Lecture 2012, given on 13 June at the 36th Annual Conference and Exhibition of the College of Occupational Therapists, held at the Scottish Exhibition and Conference Centre, Glasgow.

Exercise for improving balance in older people

BACKGROUND

In older adults, diminished balance is associated with reduced physical functioning and an increased risk of falling. This is an update of a Cochrane review first published in 2007.

OBJECTIVES

To examine the effects of exercise interventions on balance in older people, aged 60 and over, living in the community or in institutional care.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE and EMBASE (to February 2011).

SELECTION CRITERIA

Randomised controlled studies testing the effects of exercise interventions on balance in older people. The primary outcomes of the review were clinical measures of balance.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed risk of bias and extracted data from studies. Data were pooled where appropriate.

MAIN RESULTS

This update included 94 studies (62 new) with 9,917 participants. Most participants were women living in their own home.Most trials were judged at unclear risk of selection bias, generally reflecting inadequate reporting of the randomisation methods, but at high risk of performance bias relating to lack of participant blinding, which is largely unavoidable for these trials. Most studies only reported outcome up to the end of the exercise programme.There were eight categories of exercise programmes. These are listed below together with primary measures of balance for which there was some evidence of a statistically significant effect at the end of the exercise programme. Some trials tested more than one type of exercise. Crucially, the evidence for each outcome was generally from only a few of the trials for each exercise category. 1. Gait, balance, co-ordination and functional tasks (19 studies of which 10 provided primary outcome data): Timed Up & Go test (mean difference (MD) -0.82 s; 95% CI -1.56 to -0.08 s, 114 participants, 4 studies); walking speed (standardised mean difference (SMD) 0.43; 95% CI 0.11 to 0.75, 156 participants, 4 studies), and the Berg Balance Scale (MD 3.48 points; 95% CI 2.01 to 4.95 points, 145 participants, 4 studies).2. Strengthening exercise (including resistance or power training) (21 studies of which 11 provided primary outcome data): Timed Up & Go Test (MD -4.30 s; 95% CI -7.60 to -1.00 s, 71 participants, 3 studies); standing on one leg for as long as possible with eyes closed (MD 1.64 s; 95% CI 0.97 to 2.31 s, 120 participants, 3 studies); and walking speed (SMD 0.25; 95% CI 0.05 to 0.46, 375 participants, 8 studies).3. 3D (3 dimensional) exercise (including Tai Chi, qi gong, dance, yoga) (15 studies of which seven provided primary outcome data): Timed Up & Go Test (MD -1.30 s; 95% CI -2.40 to -0.20 s, 44 participants, 1 study); standing on one leg for as long as possible with eyes open (MD 9.60 s; 95% CI 6.64 to 12.56 s, 47 participants, 1 study), and with eyes closed (MD 2.21 s; 95% CI 0.69 to 3.73 s, 48 participants, 1 study); and the Berg Balance Scale (MD 1.06 points; 95% CI 0.37 to 1.76 points, 150 participants, 2 studies).4. General physical activity (walking) (seven studies of which five provided primary outcome data). 5. General physical activity (cycling) (one study which provided data for walking speed). 6. Computerised balance training using visual feedback (two studies, neither of which provided primary outcome data). 7. Vibration platform used as intervention (three studies of which one provided primary outcome data).8. Multiple exercise types (combinations of the above) (43 studies of which 29 provided data for one or more primary outcomes): Timed Up & Go Test (MD -1.63 s; 95% CI -2.28 to -0.98 s, 635 participants, 12 studies); standing on one leg for as long as possible with eyes open (MD 5.03 s; 95% CI 1.19 to 8.87 s, 545 participants, 9 studies), and with eyes closed ((MD 1.60 s; 95% CI -0.01 to 3.20 s, 176 participants, 2 studies); walking speed (SMD 0.04; 95% CI -0.10 to 0.17, 818 participants, 15 studies); and the Berg Balance Scale ((MD 1.84 points; 95% CI 0.71 to 2.97 points, 80 participants, 2 studies).Few adverse events were reported but most studies did not monitor or report adverse events.In general, the more effective programmes ran three times a week for three months and involved dynamic exercise in standing.

AUTHORS' CONCLUSIONS

There is weak evidence that some types of exercise (gait, balance, co-ordination and functional tasks; strengthening exercise; 3D exercise and multiple exercise types) are moderately effective, immediately post intervention, in improving clinical balance outcomes in older people. Such interventions are probably safe. There is either no or insufficient evidence to draw any conclusions for general physical activity (walking or cycling) and exercise involving computerised balance programmes or vibration plates. Further high methodological quality research using core outcome measures and adequate surveillance is required.