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The Effectiveness of Multifactorial Interventions Incorporating Exercise to Reduce Falls in Older Adults.. Huck, Kerri 2010

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The Effectiveness of Multifactorial Interventions Incorporating Exercise to Reduce Falls in Older Adults in Acute and Sub-acute Hospital Settings A Systematic Review & Meta-Analysis Meghan Curle Alex Fell Kerri Huck Amy Neufeld Karen Waddington Dr. Maureen Ashe, Supervisor Outline  Background  Objective  Methods  Results  Discussion  Conclusions  Implications & Dissemination Plans Background Falls The prevalence of falling:  Rises progressively after middle age  Highest among individuals > 80 years old  50% of women and 33% of men 85+ fall annually  Serious activity-limiting injuries  2/3 due to falls, ½ = fractures1  Nationally:  Falls are the 3rd leading cause of chronic disability2  Falls account for 86% of injurious admissions in 65+3 Fall-related injuries in older adults will increase almost threefold in the next 50 years4  Fall associated injuries in older people = ~$20.2 billion Projected to reach $32.4 billion by 20205 (USA)  Total direct health care cost due to falls = $180 million in BC in 1 year (1998)6  Illness & injuries leading to hospitalization accounted for 50% to 80% of disabilities post discharge7  Direct costs do not include long term consequences! Fall Consequences on Health Care Falls Prevention Today What we know:  Effective interventions to prevent falls are available in the community8  Otago program, Tai Chi, Osteofit, WaterWorks®, JointWorks®  ↑ balance = ↓ falls8  Minimal research done in acute & sub-acute settings9 Operational Definitions Fall10 Any event in which the participant unexpectedly comes to rest on the ground, floor or other lower surface. Exercise11  The prescription of a physical activity program  Involves voluntary muscle contraction / body movement  Aim of:  Relieving symptoms,  Improving function, or  Improving, retaining or slowing the deterioration of health Operational Definitions Multifactorial Interventions12  Interventions of two or more sub-domains  Linked to individual’s risk profile  Unlike multiple interventions, not all participants in a program receive the same combination of sub-domains. Acute & Sub-acute and/or Rehabilitation12  Acute, post-acute, rehabilitative, or preventive medical care  Periodic or temporary in nature  Administered in a hospital for the treatment of  Injury,  Illness, or  During recovery from surgery Acute and Sub-acute Settings  Usual Care  May include:  Physiotherapy  Occupational therapy  Available for consultation  Dietician  Dependent on ward/hospital  Teamwork between health professionals  Dependent on hospital/ward  Individual care planning  Does not include:  Routine analysis of fall risk  Specific education regarding falls for patients or staff Fall Prevention: The Role of Exercise  Muscle weakness develops with acute illness  Can be recoverable with exercise13  Loss of muscle strength  5% per day with bed rest in younger adults14  Proportionally greater in the lower limbs14  Due to effects of aging muscle loss will likely be ↑ in the older adult  Deficiency in muscle strength is a key factor associated with falls15,16  Preservation of strength           key to prevent functional decline & maintain independence Falls In Hospital Settings  Rehabilitation Setbacks  Injury sustained & resulting fear-avoidance behaviours  High risk for falls in institution ↑ potential of catastrophic disability17  Fall related injuries result in:  Increased dependence on health care staff  Potential increased LOS  Increased cost of patient care Objective Assess the effectiveness of multifactorial interventions incorporating exercise in preventing falls in older adults while in acute and sub-acute hospital settings. Rationale for Review  Limited research to address in-patient falls  Thorough analysis of all research investigating this topic  Summary of current interventions  Facilitates dissemination to enhance standards of care Methods Inclusion/Exclusion Criteria Participants  65+ years old, male or female  With or without history of falls  Acute or sub-acute care facility Intervention  Program vs. Standard Care  Aim to reduce fall frequency or risk of falls  Exercise Outcome  Falls and/or # of fallers Study Type  RCT including low levels of concealment Studies were excluded if:  Specific to neurological populations  Intervention following a neurological treatment model to reduce falls Search Strategy  Electronic Databases up to 19 April 2009  CINAHL (from 1982)  CIRRIE (from 1990)  Clinical Trials Registry  Cochrane DSR  EBM  EMBASE (from 1980)  MEDLINE (from 1950)  NARIC Rehab Data  PEDro  Web of Science  Non-peer reviewed  Grey Matters  PROQUEST  Broad search of Randomized Control Trials (RCTs)  Updates received via email from EMBASE and MEDLINE  New publications from ongoing trials via Clinical Trials Registry  Primary search terms (Key words & MeSH)  “hospital”; “acute care”; “subacute care”; “rehabilitation”; “exercise”; “physical activity”; “fall prevention”; “accidental fall”; and “accident prevention” Study Identification  Identified by title, abstract, & full-text review  All studies independently screened by 2 reviewers Consensus Full text screen Abstracts Titles Search Results  Agreement via consensus or through third party adjudication at all levels  Citation screen  Literature accepted at full-text level  Systematic reviews that incorporated fall-based interventions Methodological Quality Assessment  Studies were scored by 2 independent reviewers  PEDro scale (Score: 0 < 10)  Designed for RCTs assessing PT interventions18  Rates the quality of studies by fulfillment of 11 specific criteria  Sackett’s Level of Evidence (Level: I > V)  Enables assignment of study outcome strength19  Agreement reached via consensus or third party specific to each criterion  All inclusive review Data Extraction  Data extracted via standardized form  Study characteristics  Participants  Interventions  Outcome measures  Study analysis  Study results Pilot Rater Rater Rater Rater Rater Rater Rater Data Extraction Discussion Compiled Results Rater Rater  Piloted x5 to ensure interrater reliability  Data extracted by 2 reviewers  Results compared via discussion  Results compiled to identify study trends Data Analysis  Qualitative analysis  Performed via tabulation  Meta-analysis  Falls per days at risk  Sensitivity analysis  Influence of effective sample size of cluster RCT Meta-analysis  Random effects meta-analysis (falls/bed days)  Revman 5.0 software20  Mantel-Haenszel test  Compared risk ratios from 4 studies  2 studies excluded  Missing data  Study authors contacted  Not all information retrieved Results Article Selection Subjects  Study Characteristics Individual Study Overview Methodological Quality  Qualitative Results  Quantitative Results Article Selection Studies Retrieved for Data Abstraction N = 6 Excluded by Full-text N = 71 Total Studies Retrieved N = 2535 Excluded by Title / Abstract N = 2458 Studies Retrieved for Full-text Analysis N = 77 Studies Retrieved from Citations N = 1381 Studies Retrieved from Databases N = 1153 Studies Included for Review N = 6 Subjects  5038 total participants  1958 Male  3080 Female  Admission diagnosis  Orthopedic  Geriatric management  Elective joint replacement  Stroke/Neurological  Other disabling impairment  Co-morbidities:  Arthritis  Dementia  Depression  Diabetes  Heart disease  Hip fracture  Stroke Male Female Study Characteristics  Locations  Australia (4)  Sweden (1)  England (1)  Hospital settings  Acute and rehabilitation elderly care wards  General medicine wards  Post-op geriatric wards & geriatric units  Orthopedic wards  Mean LOS (SD)  8.2 (2.7) to 38 (40.6) days 7 months 36 months S tudy Duration Individual Study Overview Cumming et al. (2008)9  Cluster RCT  Interventions 50 hrs/wk per ward 3 year study period  Outcome Measures Total falls # of Injurious falls (including fractures)  Clinically Relevant Results  Intervention showed no effect on outcomes Exercise – Balance & Functional Education – Patient & Family Staffing – RN & PT 25hrs/wk Usual Care VS. Donald et al. (2000)21  Interventions 2x/day 7 month study period  Outcome Measures  Incidence of falls Fall risk Strength (Hip flexor, Ankle DF)  Clinically Relevant Results Lower incidence of falls in intervention group Carpet flooring had higher incidence of falls vs. vinyl Exercise – Strength 3x10 reps Enviro – Carpet / Vinyl flooring Usual Care 1-2x/day Mobility – T/F, Walking, Balance VS. Haines et al. (2004)22         Interventions Additional 105 min, 5x/week 9 month study period  Outcome Measures  Incidence of falls Fall related injuries Number of patient falls  Clinically Relevant Results Fall incidence ↓ 30% with intervention  Injurious falls ↓ by 28% in intervention group Exercise – Functional & Tai Chi Education – 30 min, 2x/wk (≤ 4) Usual Care 2hrs/day Mobility & Balance – PT & OT VS. Haines et al. (2007)23  Interventions Additional 105 min, 5x/week 9 month study period  Outcome Measures Rate of falls (/1000 patient days) Balance, strength & mobility  Clinically Relevant Results ↓ fall rate in intervention vs. usual care (10:21) No difference in strength, step balance or mobility  Improved Functional Reach Test in intervention group Exercise – Functional & Tai Chi Education – 30 min, 2x/wk (≤ 4) Usual Care 2hrs/day Mobility & Balance – PT & OT VS. Jones et al. (2006)24  Interventions Additional 160 min over LOS 10 month study period  Outcome Measures Adverse events (including falls) LOS  Clinically Relevant Results Adverse events ↓ 5.6% intervention vs. 2.6% control ↓ LOS in intervention group PT – 100min + 160min group ex Strength & Function Usual Care Includes PT  ~90 min over LOS VS. Stenvall et al. (2007)25  Interventions 2x/wk 31 month study period  Outcome Measures  Incidence of falls # of falls / injurious falls LOS  Clinically Relevant Results ↓ fall incidence in intervention group ↓ minor & serious injurious falls in the intervention group  ↓ mean LOS in intervention group (28:38 control) Exercise – ADL & Fall focused Team Collaboration – Care Plan Usual Care Mobility & Exercise – by PT VS. Methodological Quality of Studies Primary Author Title PEDro Score Sackett’s Level of Evidence Cumming (2008) Cluster randomized trial of a targeted multifactorial Intervention to prevent falls among older people in the hospital 6 I Donald (2000) Preventing falls on an elderly care rehabilitation ward 6 II Haines (2004) Effectiveness of targeted falls prevention programme in sub-acute hospital setting: RCT 6 II Haines (2007) Additional exercise for older sub-acute hospital inpatients to prevent falls: benefits and barriers to implementation and evaluation 5 II Jones (2006) An RCT of an exercise intervention to reduce functional decline and health service utilization in the hospitalized elderly 6 II Stenvall (2006) A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture 9 II Methodological Quality  Mean quality score  6.3/10 (range 5-9)  Agreement between raters (ICC)  0.796 (95%CI -0.466 to 0.972)  “Good reliability”26  Criteria  Random allocation (6 studies)  Allocation concealment (4 studies)  Partial blinding (1 study)  Staff unaware of study nature  Blinding of assessors (2 studies)  Intention to treat (5 studies) 0 1 2 3 4 5 6 7 8 9 10 Number of Studies PEDro S core (/ 10) Qualitative Results  Fall Outcomes  Falls and / or Fallers  Self reported  Healthcare verbal communication  Healthcare documentation  Targeted interventions  Population homogeneity23,25  LOS  Extended LOS = Better intervention outcomes25 Quantitative Results  Heterogeneity (I2 =84%)  Risk ratio 0.59 (95%CI 0.32 to 1.07)  40% reduction in fall rate  Statistically  Meta-analysis not exclusive of no effect  Limited to 4 studies  Excluded Studies  Jones24 unable to report total days at risk  Haines22 (2007 was population of interest)  Sensitivity analysis  Cluster RCT9 effective sample size = no change  Clinically  Effectiveness of 2 studies warrants attention Discussion Length of Stay Exercise Appropriateness Program Delivery Methods Socialization Follow-Up Study Weight Limitations Discussion 1. LOS  Effective interventions reduced LOS24,25  Homogeneity and ↑ LOS with high risk populations allowed results of intervention to be seen25  ↓ intervention timeframes or ↑ medical acuity may limit the effectiveness of interventions9,21-23 1. Exercise appropriateness  Screening is necessary  Potential fallers  Those that may benefit from exercise  Optimizing allocation of resources Discussion 1. Program delivery methods  Tailor interventions to specific individual risk factors  Enhances proper exercise execution & program compliance vs. group exercise8 1. Socialization  Exercise intervention hours = ↑ socialization  No comparison to rule out socialization / therapist contact time Discussion 1. Follow-Up  Patients not followed post-discharge  Importance  Enables assessment of fall rates 2° to inpatient intervention  Long term program evaluation = long term effect on falling  Patient re-admission data 1. Study weight  Large sample size (Cumming9 = 32%)  Conclusions based on a potentially skewed result Limitations  6 studies = small body of research to draw conclusions  Potential for publication bias  Small RCTs with no effect may not be published  Identified positive results potentially misrepresentative  Lack of large RCTs utilizing exercise interventions  Subjectivity of self reported falls  May affect accuracy and validity of data due to ↓ mental states  ↑ awareness of falling with knowledge of the intervention  Diversity may have led to variation in outcomes  English & French literature only This review of multifactorial interventions including exercise to prevent inpatient falls in older adults displayed a 40% reduction in fall rate.  Clinically significant reduction:  Further supports falls prevention research  Potentially generalizable to acute and/or sub-acute settings  Consider:  Disparity in the literature  Clinically relevant reduction in fall rates identified  How this knowledge can benefit the growing high-risk older adult population Conclusion Clinical Recommendations Future Research Implications Clinical Recommendations  Fall prevention programs need to be:  Targeted  Patient specific  Multifactorial  Collaborative team effort Due to variation in scope of practice / procedures between hospitals, health authority & country  Appropriate time frames to optimize results Implications for Research  Follow up post-discharge  Evaluate long term effects of multifactorial inpatient falls interventions  Future studies  Large RCTs needed  Development of optimal screening tool for falls  Optimum exercise intervention not yet identified  Publish in Journal of Clinical Rehabilitation  Widely available to health care practitioners  Promote awareness   Audio-cast available  PABC Website  Multidisciplinary In-services Peer-Reviewed Journal PABC Website & Podcast In-services Systematic Review Symposium    2009 Dissemination Plans Acknowledgements We would like to thank:  Dr. Maureen Ashe - Supervisor  Dr. Penny Brasher - Biostatistician Advisor  Charlotte Beck - UBC Reference Librarian  Dr. Darlene Reid - UBC PT Faculty  Dr. Elizabeth Dean - UBC PT Faculty Thank-you References 1. Wilkins K. Health care consequences of falls for seniors. Health  Reports  (Statistics Canada, Catalogue 82-003) 1999; 10(4): 47-55. Cited July 15, 2008. Available  from 2. Statistics Canada. Causes of death, 1995 (Catalogue 84-208-XPB) Ottawa: Minister of Industry, 1997. 3. Canadian Institute for Health Information (CIHI). Fact Sheet: Ontario Trauma Registry, Hospital Injury Admissions, 1996/97 c1996-2009 [updated June 15, 2009; cited July 17, 2008]. Available from 4. Hall SE, Hendrie DV. A prospective study of the costs of falls in older adults living in the community. Australian and New Zealand Journal of Public Health. 2003;27(3):343-351. 5.  Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. J Forensic Sci. 1996;41:733-46. 6. British Columbia. Ministry of Health Planning.  Prevention of Falls and Injuries among the Elderly: A Special Report of the Provincial Health Officer . 2004; Available from . 7. Gill TM, Allore HG, Holfrod TR, Guo Z. Hospitalizations, restricted activity, and the development of disability among older persons. JAMA. 2004;292(17):2115-2124. 8. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for  preventing falls in elderly people [Cochrane review] In: The Cochrane Collaboration, Issue 2, 2003. Oxford: John Wiley & Sons, Ltd. 9. Cumming RG, Sherrington C, Lord SR, Simpson JM, Vogler C, Cameron ID & Naganathan V. Cluster randomized trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ, 2008;336(5):758-760. 10. Wolf S, Barnhart H, Kutner N, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of tai chi and computerized balance training. J Am Geriatr Soc. 1996 May;44(5):489-97. 11. Taylor NF, Dodd KJ, Shields N, Bruder A. Therapeutic exercise in physiotherapy practice is beneficial: a summary of systematic reviews 2002-2005. Aust J Physiother. 2007;53(1):7-16. 12. ProFane: Prevention of Falls Network Europe [homepage on the internet]. C2000 [2007; cited July 20, 2009]. Available from 13. Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans WJ. High-intensity strength training in nonagenarians. JAMA.1990; 263:3029–34. 14. Muller E. Influence of training and of inactivity on muscle strength. Arch Phys Med Rehabil.1970;51(8):449-62. References 15. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988 Dec 29;319(26):1701-7. 16. Whipple RH, Wolfson LI, Amerman PM. The relationship of knee and ankle weakness to falls in nursing home residents: an isokinetic study. J Am Geriatr Soc. 1987 Jan;35(1):13-20. 17. Ferrucci L, Guralnik JM, Simonsick E, Salive ME, Corti C, Langlois J. Progressive versus catastrophic disability: a longitudinal view of the disablement process. J Geron.1996;51A(3):M123-M130. 18. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro Scale for rating quality of Randomized Controlled Trials. Phys Ther. 2003;83(8):713-21. 19. Reid D. Preparing a proposal, levels of evidence, study designs, appraising studies, Level of Evidence. RSPT 532 Rehabilitation Research II, Day 3 Week 1 July 9 2008. 20. Review Manager (RevMan) [Computer program]. Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008. 21. Donald IP, Pitt K, Armstrong E, Shuttleworth H. Preventing falls on an elderly care rehabilitation ward. Clin Rehab. 2000;14(2):178-185. 22. Haines TP, Bennell KL, Osborne RH, Hill KD. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. BMJ. 2004;328(20):676-679. 23. Haines TP, Hill KD, Bennell KL, Osborne RH. Additional exercise for older subacute hospital inpatients to prevent falls: benefits and barriers to implementation and evaluation. Clin Rehab. 2007;21(8):742-753. 24. Jones CT, Lowe AJ, MacGregor L, Brand CA. A randomised controlled trial of an exercise intervention to reduce functional decline and health service utilisation in the hospitalized elderly. Australasian Journal on Ageing. 2006;25(3):126-133. 25. Stenvall M, Olofsson B, Lundstrom M, Englund U, Borssen B, Svensson O, Nyberg L, Gustafson Y. A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture. Osteoporos Int. 2007;18(2):167-175. 26. Portney & Watkins (1999). Foundations of clinical research: applications to practice.; 2nd Edition. Prentice Halll; Boston, MA. How Haines & Stenvall identified their target populations  Haines 2007 had 3 sub-criteria  High risk for falls  Impaired strength, mobility & balance  Able to participate in exercise  Stenvall 2007  Aware that many fall again soon after fracture  ↓ strength post-op  High risk & likely to benefit from exercise Why we proceeded to do a meta-analysis with an I2 = 84%  I2 is in general of limited use when assessing clinically relevant heterogeneity Rucker et al.1 concluded that the yardstick should be clinical relevance of any heterogeneity present rather than I2 1. Rucker G, Schwarzer G, Carpenter JR, Schumacher M. Undue reliance on I2 in assessing heterogeneity may mislead. BMC Med Res Methodol. 2008;8(79). Why we excluded neurological populations  Haines (2004)1 reported falls in up to 47% of patients on a stroke rehabilitation ward2 Therefore we didn’t want to skew our results with including this population 2. Rapport LJ, Webster JS, Flemming KL, Lingberg JW, Godlewski MC, Brees JE et al. Predictors of falls among right- hemisphere stroke patients in the rehabilitation setting. Arch Phys Med Rehabil 1993;74:621-6. Why we used a risk ratio  Most common measure of relative effect1 Interpretable & consistent with the way people think  Odds ratio Tendency to overstate differences between groups  Risk difference Based on assumption of a causal relationship 1. Portney & Watkins (1999). Foundations of clinical research: applications to practice.; 2nd Edition. Prentice Halll; Boston, MA. Why we used Mantel-Haenszel Statistic  Usual method for pooling risk ratios  Provides weighted summary value  Can be used to report relative risk associated with specific exposure adjusting for confounding variables  Peto statistic  Can cause bias especially when substantial heterogeneity exists1  Inverse variance  Can be used with fixed effects but Mantel-Haenszel generally more robust1 1. SDSS: statsdirect statistical software. C2009. Available from Why we used a random effects analysis model  Statistical heterogeneity was likely  Accounts for heterogeneity beyond variation associated with fixed effects Allows inclusion of covariates1  Fixed vs. random Fixed assumes that exactly the same value underlies all studies2 Random allows for possibility that population parameters vary2 1. Berkey CS (1995). A random effects regression model for meta-analysis. 2. Hunter JE, Schmidt FL. (2004). Methods of meta-analysis: correcting error and bias in research findings. Search Databases  CINAHL ~ Cumulative Index to Nursing and Allied Health Literature (from 1982)  Owned and operated by EBSCO Publishing  CIRRIE ~ Centre for International Rehabilitation Research Information & Exchange  From 1990  Clinical Trials Registry  Federally & privately supported clinical trials (US & International)  Cochrane Database of Systematic Reviews  Gold standard in evidence based healthcare  Cochrane Library contains high-quality, independent evidence to inform healthcare decision-making (SR, clinical trials)  EBM ~ Evidence-Based Medicine  International medical journals applying strict criteria for quality & validity  Published bi-monthly; wide array of clinical disciplines  EMBASE ~ Biomedical database produced by Elsevier (from 1980)  Citations, abstracts & indexing from biomedical articles (peer reviewed)  Updated daily on most platforms covering 5,000 active journals; 2,000 are unique compared to MEDLINE Search Databases  MEDLINE ~ from 1950  World's most comprehensive source of life sciences & biomedical info  ~11 million records from over 7,300 different publications  Compiled by U.S. National Library of Medicine (NLM) & published on Web by Community of Science  NARIC ~ National Agency Rehabilitation Information Centre  REHABDATA  ~ index spans research from 1956 to present  Over 69,000 abstracts of books, articles, reports (disability &  rehabilitation research)  PEDro ~ Physiotherapy Evidence Databases  Initiative of the Centre for Evidence-Based Physiotherapy (CEBP)  RCTs, systematic reviews & evidence-based clinical practice guidelines in physiotherapy.  Web of Science  World’s leading citation database (multidisciplinary coverage)  Over 10,000 high-impact journals & over 120,000 international proceedings Search Databases Grey Literature  Grey Matters ~ a practical search tool for evidence based medicine  Canadian Agency for Drugs & Technologies in Health (CADTH)  Provides federal, provincial & territorial health care decisions with crediable, impartial advice for evidence based info  Grey Literature = all government, academia, business & industry in electronic or print format not controlled by commercial publishing  PROQUEST ~ ProQuest Dissertations and Theses  (from 1861)  World's most comprehensive collection of dissertations & theses.  Includes 2.4 million dissertation & theses citations worldwide Fall Prevention Programs  Otago Fall Prevention Program1  Well-designed & tested specifically to prevent falls  Targets strength and balance deficits  Can lead to a reduction in falls by about one-third  Home based individually tailored leg strength, walking & balance retraining programme (30min, 3x/wk)  Taught by PT or RN (supervised by PT)  Supporting Research  Evaluated on1016 people aged 65 to 97 living at home  Exercise programme was effective in reducing by 35% both # of falls and # number of injuries resulting from falls  It was equally effective in men and women  Greatest effect in high-risk groups:  Over 80 years of age & those with previous fall 1. Otago exercise programme. Available at .  Fall Prevention Programs  Tai Chi  Slow, gentle movement to promote strength, balance and overall function  2x/wk 1-hour classes were held in local senior centers x12wks  Participants showed significant improvements in health-related outcome measures:  Balance, reduction in falls, and increased functional independence1  JointWorks®2& WaterWorks®3  Recreational programs for people with arthritis  Certified health professionals trained by arthritis society  Improves strength and flexibility  Osteofit4  Safe exercise, education for osteoporosis, osteopenia and/or those at risk for falling  Focus on strength, balance and coordination  Developed with BC Women’s & Health Centre, by physiotherapists 1. Li F, Harmer P, Fisher KJ, McAuley E, Chaumeton N, Eckstrom E, Wilson NL (2005). Tai Chi and fall reductions in older adults: A randomized controlled trial. Journal of Gerontology.2005;60A, 66-74. 2. JointWorks. Available from 3. WaterWorks. Available from 4. Osteofit . Available from Study Table Cumming et al. (2006) & Donald et al. (2007) Study Table Haines et al. (2004) & Haines et al. (2007) Study Table Jones et al. (2006) & Stenvall et al. (2007)


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