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The Effectiveness of Multifactorial Interventions Incorporating Exercise to Reduce Falls in Older Adults.. Huck, Kerri; Fell, Alex; Curle, Meghan; Waddington, Karen; Neufeld, Amy; Ashe, Maureen 2009

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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-AnalysisMeghan CurleAlex FellKerri HuckAmy NeufeldKaren WaddingtonDr. Maureen Ashe, SupervisorOutlineBackgroundObjectiveMethodsResultsDiscussion ConclusionsImplications & Dissemination PlansBackgroundFallsThe prevalence of falling:Rises progressively after middle age Highest among individuals > 80 years old50% of women and 33% of men 85+ fall annuallySerious activity-limiting injuries  2/3 due to falls, ½ = fractures1Nationally:Falls are the 3rd leading cause of chronic disability2Falls account for 86% of injurious admissions in 65+3Fall-related injuries in older adults will increase almost threefold in the next 50 years4Fall 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)6Illness & injuries leading to hospitalization accounted for 50% to 80% of disabilities post discharge7Direct costs do not include long term consequences!Fall Consequences on Health CareFalls Prevention TodayWhat we know:Effective interventions to prevent falls are available in the community8Otago program, Tai Chi, Osteofit, WaterWorks®, JointWorks®↑ balance = ↓ falls8Minimal research done in acute & sub-acute settings9Operational DefinitionsFall10 	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 healthOperational Definitions Multifactorial Interventions12 Interventions of two or more sub-domains Linked to individual’s risk profileUnlike multiple interventions, not all participants in a program receive the same combination of sub-domains.Acute & Sub-acute and/or Rehabilitation12Acute, post-acute, rehabilitative, or preventive medical care Periodic or temporary in nature Administered in a hospital for the treatment ofInjury, Illness, or During recovery from surgery 	Acute and Sub-acute SettingsUsual CareMay include:Physiotherapy Occupational therapyAvailable for consultationDietician Dependent on ward/hospitalTeamwork between health professionalsDependent on hospital/ward Individual care planning Does not include:Routine analysis of fall risk Specific education regarding falls for patients or staffFall Prevention: The Role of Exercise Muscle weakness develops with acute illness Can be recoverable with exercise13Loss of muscle strength5% per day with bed rest in younger adults14Proportionally greater in the lower limbs14Due to effects of aging muscle loss will likely be ↑ in the older adult Deficiency in muscle strength is a key factor associated with falls15,16Preservation of strength           key to prevent functional decline & maintain independenceFalls In Hospital SettingsRehabilitation Setbacks Injury sustained & resulting fear-avoidance behavioursHigh risk for falls in institution ↑ potential of	catastrophic disability17Fall related injuries result in:Increased dependence on health care staff Potential increased LOSIncreased cost of patient careObjectiveAssess the effectiveness of multifactorialinterventions incorporating exercise inpreventing falls in older adults while in acuteand sub-acute hospital settings.Rationale for ReviewLimited research to address in-patient fallsThorough analysis of all research investigating this topicSummary of current interventionsFacilitates dissemination to enhance standards of careMethodsInclusion/Exclusion CriteriaParticipants  65+ years old, male or female With or without history of fallsAcute or sub-acute care facilityInterventionProgram vs. Standard CareAim to reduce fall frequency or risk of fallsExercise OutcomeFalls and/or # of fallersStudy TypeRCT including low levels of concealmentStudies were excluded if:Specific to neurological populationsIntervention following a neurological treatment model to reduce fallsSearch StrategyElectronic Databases 	up to 19 April 2009CINAHL (from 1982)CIRRIE (from 1990)Clinical Trials RegistryCochrane DSREBMEMBASE (from 1980)MEDLINE (from 1950)NARIC Rehab DataPEDro Web of ScienceNon-peer reviewed Grey MattersPROQUEST Broad search of Randomized Control Trials (RCTs)Updates received via email from EMBASE and MEDLINENew publications from ongoing trials via Clinical Trials RegistryPrimary search terms (Key words & MeSH)“hospital”; “acute care”; “subacute care”; “rehabilitation”; “exercise”; “physical activity”; “fall prevention”; “accidental fall”; and “accident prevention”Study IdentificationIdentified by title, abstract, & full-text reviewAll studies independently screened by 2 reviewers ConsensusFull text screenAbstractsTitles Search ResultsAgreement via consensus or through third party	adjudication at all levelsCitation screen Literature accepted at full-text levelSystematic reviews that incorporated fall-based interventionsMethodological Quality AssessmentStudies were scored by 2 independent reviewers PEDro scale (Score: 0 < 10) Designed for RCTs assessing PT interventions18Rates the quality of studies by fulfillment of 11 specific criteriaSackett’s Level of Evidence (Level: I > V)Enables assignment of study outcome strength19Agreement reached via consensus or third party specific to each criterionAll inclusive reviewData ExtractionData extracted via standardized formStudy characteristicsParticipantsInterventionsOutcome measuresStudy analysisStudy resultsPilotRaterRaterRaterRaterRaterRaterRaterData ExtractionDiscussionCompiled ResultsRaterRaterPiloted x5 to ensure interrater reliabilityData extracted by 2 reviewersResults compared via discussionResults compiled to identify study trendsData AnalysisQualitative analysis Performed via tabulationMeta-analysis Falls per days at riskSensitivity analysisInfluence of effective sample size of cluster RCT Meta-analysisRandom effects meta-analysis (falls/bed days)Revman 5.0 software20Mantel-Haenszel testCompared risk ratios from 4 studies2 studies excludedMissing dataStudy authors contactedNot all information retrievedResultsArticle SelectionSubjects Study Characteristics Individual Study Overview Methodological Quality Qualitative Results Quantitative ResultsArticle SelectionStudies Retrieved for Data Abstraction N = 6Excluded by Full-text N = 71Total Studies Retrieved N = 2535Excluded by Title / Abstract N = 2458 Studies Retrieved for Full-text Analysis N = 77Studies Retrieved from Citations N = 1381 Studies Retrieved from Databases N = 1153Studies Included for Review N = 6Subjects5038 total participants1958 Male 3080 FemaleAdmission diagnosisOrthopedicGeriatric managementElective joint replacementStroke/NeurologicalOther disabling impairmentCo-morbidities: ArthritisDementiaDepressionDiabetesHeart diseaseHip fractureStrokeStudy CharacteristicsLocationsAustralia (4)Sweden (1)England (1)Hospital settingsAcute and rehabilitation elderly care wardsGeneral medicine wardsPost-op geriatric wards & geriatric unitsOrthopedic wardsMean LOS (SD) 8.2 (2.7) to 38 (40.6) days7 months36 monthsStudy DurationIndividual Study OverviewCumming et al. (2008)9  Cluster RCTInterventions50 hrs/wk per ward	3 year study periodOutcome MeasuresTotal falls # of Injurious falls (including fractures)Clinically Relevant ResultsIntervention showed no effect on outcomesExercise – Balance & Functional Education – Patient & Family Staffing – RN & PT 25hrs/wkUsual CareVS.Donald et al. (2000)21       		     Interventions 2x/day  7 month study periodOutcome MeasuresIncidence of fallsFall riskStrength (Hip flexor, Ankle DF)  Clinically Relevant ResultsLower incidence of falls in intervention groupCarpet flooring had higher incidence of falls vs. vinylExercise – Strength 3x10 repsEnviro – Carpet / Vinyl flooringUsual Care 1-2x/dayMobility – T/F, Walking, BalanceVS.Haines et al. (2004)22	           	            Interventions Additional 105 min, 5x/week9 month study period	Outcome MeasuresIncidence of fallsFall related injuriesNumber of patient falls  Clinically Relevant ResultsFall incidence ↓ 30% with interventionInjurious falls ↓ by 28% in intervention groupExercise – Functional & Tai ChiEducation – 30 min, 2x/wk (≤ 4)Usual Care 2hrs/dayMobility & Balance – PT & OTVS.Haines et al. (2007)23      		     Interventions Additional 105 min, 5x/week 9 month study period	Outcome MeasuresRate of falls (/1000 patient days)Balance, strength & mobilityClinically Relevant Results↓ fall rate in intervention vs. usual care (10:21)No difference in strength, step balance or mobilityImproved Functional Reach Test in intervention groupExercise – Functional & Tai ChiEducation – 30 min, 2x/wk (≤ 4)Usual Care 2hrs/dayMobility & Balance – PT & OTVS.Jones et al. (2006)24       		     InterventionsAdditional 160 min over LOS10 month study period 	Outcome MeasuresAdverse events (including falls)LOSClinically Relevant ResultsAdverse events ↓ 5.6% intervention vs. 2.6% control ↓ LOS in intervention group PT – 100min + 160min group ex Strength & FunctionUsual CareIncludes PT  ~90 min over LOSVS.Stenvall et al. (2007)25	           	    Interventions2x/wk  31 month study period	Outcome MeasuresIncidence of falls# of falls / injurious fallsLOSClinically 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 focusedTeam Collaboration – Care PlanUsual CareMobility & Exercise – by PTVS.Methodological Quality of StudiesPrimary AuthorTitlePEDro ScoreSackett’sLevel of EvidenceCumming (2008)Cluster randomized trial of a targeted multifactorial Intervention to prevent falls among older people in the hospital6IDonald (2000)Preventing falls on an elderly care rehabilitation ward6IIHaines (2004)Effectiveness of targeted falls prevention programme in sub-acute hospital setting: RCT6IIHaines (2007)Additional exercise for older sub-acute hospital inpatients to prevent falls: benefits and barriers to implementation and evaluation5IIJones (2006)An RCT of an exercise intervention to reduce functional decline and health service utilization in the hospitalized elderly6IIStenvall (2006)A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture9IIMethodological QualityMean quality score 6.3/10 (range 5-9)Agreement between raters (ICC)0.796 (95%CI -0.466 to 0.972)“Good reliability”26CriteriaRandom allocation (6 studies)Allocation concealment (4 studies)Partial blinding (1 study)Staff unaware of study natureBlinding of assessors (2 studies)Intention to treat (5 studies)PEDro Score (/10)Qualitative ResultsFall OutcomesFalls and / or FallersSelf reportedHealthcare verbal communicationHealthcare documentationTargeted interventionsPopulation homogeneity23,25LOSExtended LOS = Better intervention outcomes25Quantitative ResultsHeterogeneity (I2 =84%)Risk ratio 0.59 (95%CI 0.32 to 1.07)40% reduction in fall rateStatisticallyMeta-analysis not exclusive of no effectLimited to 4 studiesExcluded StudiesJones24 unable to report total days at riskHaines22 (2007 was population of interest)Sensitivity analysisCluster RCT9 effective sample size = no changeClinically Effectiveness of 2 studies warrants attentionDiscussionLength of StayExercise AppropriatenessProgram Delivery MethodsSocializationFollow-UpStudy WeightLimitationsDiscussionLOSEffective interventions reduced LOS24,25Homogeneity and ↑ LOS with high risk populations allowed results of intervention to be seen25↓ intervention timeframes or ↑ medical acuity may limit the effectiveness of interventions9,21-23Exercise appropriateness Screening is necessary Potential fallersThose that may benefit from exerciseOptimizing allocation of resourcesDiscussionProgram delivery methods Tailor interventions to specific individual risk factorsEnhances proper exercise execution & program compliance vs. group exercise8Socialization Exercise intervention hours = ↑ socializationNo comparison to rule out socialization / therapist contact timeDiscussionFollow-UpPatients not followed post-dischargeImportanceEnables assessment of fall rates 2° to inpatient intervention Long term program evaluation = long term effect on falling Patient re-admission dataStudy weightLarge sample size (Cumming9 = 32%)Conclusions based on a potentially skewed resultLimitations6 studies = small body of research to draw conclusionsPotential for publication biasSmall RCTs with no effect may not be publishedIdentified positive results potentially misrepresentativeLack 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 interventionDiversity may have led to variation in outcomes English & French literature only This review of multifactorial interventions including exerciseto 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 settingsConsider:Disparity in the literature Clinically relevant reduction in fall rates identified How this knowledge can benefit the growing high-risk older adult population ConclusionClinical RecommendationsFuture ResearchImplicationsClinical RecommendationsFall prevention programs need to be:TargetedPatient specificMultifactorialCollaborative team effort Due to variation in scope of practice / procedures between hospitals, health authority & countryAppropriate time frames to optimize resultsImplications for ResearchFollow up post-discharge Evaluate long term effects of multifactorial inpatient falls interventionsFuture studiesLarge RCTs neededDevelopment of optimal screening tool for fallsOptimum exercise intervention not yet identifiedPublish in Journal of Clinical RehabilitationWidely available to health care practitionersPromote awareness Audio-cast availablePABC WebsiteMultidisciplinary In-servicesPeer-Reviewed JournalPABC Website & PodcastIn-servicesSystematic Review Symposium          2009Dissemination PlansAcknowledgementsWe would like to thank:Dr. Maureen Ashe - SupervisorDr. Penny Brasher - Biostatistician AdvisorCharlotte Beck - UBC Reference LibrarianDr. Darlene Reid - UBC PT FacultyDr. Elizabeth Dean - UBC PT FacultyThank-youReferences1. 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 http://www.statcan.gc.ca/pub/82-003-s/2005000/pdf/9088-eng.pdf. 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 http://www.cihi.ca. 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 http://www.health.gov.bc.ca/library/publications/year/2004/falls.pdf .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 http://www.profane.eu.org.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.References15. 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 populationsHaines 2007 had 3 sub-criteriaHigh risk for fallsImpaired strength, mobility & balanceAble to participate in exerciseStenvall 2007Aware that many fall again soon after fracture↓ strength post-opHigh risk & likely to benefit from exerciseWhy we proceeded to do a meta-analysis with an I2 = 84%I2 is in general of limited use when assessing clinically relevant heterogeneityRucker et al.1 concluded that the yardstick should be clinical relevance of any heterogeneity present rather than I21. 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 populationsHaines (2004)1 reported falls in up to 47% of patients on a stroke rehabilitation ward2Therefore we didn’t want to skew our results with including this population2. 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 ratioMost common measure of relative effect1Interpretable & consistent with the way people thinkOdds ratioTendency to overstate differences between groupsRisk differenceBased on assumption of a causal relationship1. Portney & Watkins (1999). Foundations of clinical research: applications to practice.; 2nd Edition. Prentice Halll; Boston, MA.Why we used Mantel-Haenszel StatisticUsual method for pooling risk ratiosProvides weighted summary valueCan be used to report relative risk associated with specific exposure adjusting for confounding variablesPeto statisticCan cause bias especially when substantial heterogeneity exists1 Inverse varianceCan be used with fixed effects but Mantel-Haenszel generally more robust1 1. SDSS: statsdirect statistical software. C2009. Available from http://www.statsdirect.com.Why we used a random effects analysis modelStatistical heterogeneity was likelyAccounts for heterogeneity beyond variation associated with fixed effectsAllows inclusion of covariates1 Fixed vs. randomFixed assumes that exactly the same value underlies all studies2Random allows for possibility that population parameters vary21. 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 DatabasesCINAHL ~ Cumulative Index to Nursing and Allied Health Literature (from 1982)Owned and operated by EBSCO PublishingCIRRIE ~ Centre for International Rehabilitation Research Information & ExchangeFrom 1990Clinical Trials RegistryFederally & privately supported clinical trials (US & International)Cochrane Database of Systematic ReviewsGold standard in evidence based healthcareCochrane 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 & validityPublished 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 MEDLINESearch DatabasesMEDLINE ~ from 1950World's most comprehensive source of life sciences & biomedical info~11 million records from over 7,300 different publicationsCompiled by U.S. National Library of Medicine (NLM) & published on Web by Community of ScienceNARIC ~ 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 ScienceWorld’s leading citation database (multidisciplinary coverage) Over 10,000 high-impact journals & over 120,000 international proceedingsSearch DatabasesGrey LiteratureGrey Matters ~ a practical search tool for evidence based medicineCanadian Agency for Drugs & Technologies in Health (CADTH) Provides federal, provincial & territorial health care decisions with crediable, impartial advice for evidence based infoGrey Literature = all government, academia, business & industry in electronic or print format not controlled by commercial publishingPROQUEST ~ ProQuest Dissertations and Theses  (from 1861)World's most comprehensive collection of dissertations & theses. Includes 2.4 million dissertation & theses citations worldwideFall Prevention ProgramsOtago Fall Prevention Program1Well-designed & tested specifically to prevent fallsTargets strength and balance deficitsCan lead to a reduction in falls by about one-thirdHome based individually tailored leg strength, walking & balance retraining programme (30min, 3x/wk)Taught by PT or RN (supervised by PT)Supporting ResearchEvaluated on1016 people aged 65 to 97 living at homeExercise programme was effective in reducing by 35% both # of falls and # number of injuries resulting from fallsIt was equally effective in men and womenGreatest effect in high-risk groups: Over 80 years of age & those with previous fall1. Otago exercise programme. Available at http://www.acc.co.nz/preventing-injuries/at-home/older-people/information-for-older-people/otago-exercise-programme/index.htm. Fall Prevention ProgramsTai ChiSlow, gentle movement to promote strength, balance and overall function2x/wk 1-hour classes were held in local senior centers x12wksParticipants showed significant improvements in health-related outcome measures:Balance, reduction in falls, and increased functional independence1JointWorks®2& WaterWorks®3Recreational programs for people with arthritisCertified health professionals trained by arthritis societyImproves strength and flexibilityOsteofit4Safe exercise, education for osteoporosis, osteopenia and/or those at risk for fallingFocus on strength, balance and coordinationDeveloped with BC Women’s & Health Centre, by physiotherapists1. 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 http://www.argbc.ca/lifestyle/exercise/jointworks.3. WaterWorks. Available from http://www.argbc.ca/lifestyle/exercise/waterworks. 4. Osteofit . Available from http://www.osteofit.org/.Study TableCumming et al. (2006) & Donald et al. (2007)Study TableHaines et al. (2004) & Haines et al. (2007)Study TableJones et al. (2006) & Stenvall et al. (2007) Start with umbrella statement of s soceital and personal setbacksTherefore…………………our objective was to………The methods applied for this review were as follows:Inclusion / Exclusion criteriaStudies were included if:Participants were: A minimum 65 years of age, male or female With or without a history of fallsAnd in an Acute or sub-acute care facilityInterventions were required to:Be a program vs. Standard (or Usual) CareBe aimed at reducing falls (for example frequency or risk of falls)And include a component of exercise Outcomes were to report:Falls and/or # of fallersAnd study types included only:RCTs including those with low levels of concealmentStudies were excluded if:They were specific to neurological populations or The intervention followed a neurological treatment model to reduce falls*The search strategy for this review Included a broad search of both peer-reviewed and non-peer reviewed databases for RCTsRegular electronic updates from EMBASE and MEDLINE databases were received throughout the review periodand new publications from recent trials were monitored through the Clinical Trials RegistryIn total, 10 electronic peer-reviewed databases were searched up until April 19, 2009Also, 2 non-peer reviewed databases were included in our search Primary search terms included:Hospital, rehabilitation, exercise, and fall preventionStudies were identified first by title, then by abstract. Those appropriate for further review were then reviewed by full-textAll studies were screened independently by 2 reviewers at all levels of the review processAgreement was reached by consensus or a third partyA citation screen was also performed and included:	Literature that was accepted at the full-text level, and also 	Systematic reviews that incorporated fall-based interventionsThe method-o-logical quality assessment was performed by 2 independent reviewers andUtilized both the PEDro scale and Sackett’s Level of Evidence.The PEDro scale was chosen as it is designed for RCTs and has shown to be both reliable and valid when assessing Physical Therapy interventions (by Maher and colleagues).The PEDro scale rates the quality of a study based on its fulfillment of 11 criteria, 10 of which are used to determine the score. Scores therefore range from 0 to 10 with 10 representing the highest quality.Sackett’s level of evidence was used to associate strength to the study outcomes. This scale ranges from 1 to 5 with 1 representing the highest level of evidence.During the quality assessment, agreement was reached by consensus or third party adjudication as needed.This review was an all inclusive review therefore no articles were to be excluded based on their quality score.*Data Extraction was performed using a standardized form developed specifically for this review.The form gathered information on:Study characteristicsParticipantsInterventionsOutcome measuresStudy analysisStudy resultsThe Data Extraction form was piloted 5 times in order to ensure its reliability between raters.Data was then extracted by 2 reviewers and results were compared through discussion.Results were then compiled to identify any trends within the data.3 different methods of Data Analysis were performedFirst, a qualitative analysis was performed through tabulation of the retrieved dataSecondly, a meta-analysis was performed for falls per bed days at riskLastly, a sensitivity analysis was performed to determine the influence of effective sample size of the included cluster RCT *Meta-analysisA random effects meta-analysis was performed using falls / bed days at risk	A random effects analysis was chosen as study hetero-geneity was likely.	A Mantel-Haenszel statistical test was used to compare Risk ratios from 4 studies as2 studies were excluded from this analysisAs well, missing data was identified and Authors were contacted, however, not all information was able to be retrievedThis concludes the explanation of the methods undertaken in this review.___________________________________________________________Note:Missing Data: For studies which did not report the total LOS, this was calculated using the mean LOS and number of participants in each study group. For studies which did not report total falls in the control and intervention group separately this number was calculated by dividing the unaccounted falls up equally between the two groups (Cummings!)*30 mins 2X/day for group exerciseADVERSE EVENTS HAD MINIMAL CLINICAL RELEVANCEPopulation Homogeneity = Stenvall and Haines 2007Heterogeneity definition: This means that the differences between studies was vast as 84% of the differences were not attributable to chanceDespite these differences, it was possible to compare data from 4 studies as falls and total days at risk were reported.Define risk ratioThe calculated risk ratio for falls/days at risk was 0.59 with a CI of 0.32 to 1.07This indicates a reduction in fall rate of 40%However, statistically cant exclude no effect as CI is inclusive of a RR of 1These results need to be interpreted carefully as limited to 4 studies2 excluded because….Despite the limitations of this meta-analysis, the clinical effectiveness of 2 of the included studies and a 40% reduction in fall rates warrants attentionPublication biasLimited study pool  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%    Serious activity-limiting injuries  2/3    of women and 33% of men 85+ fall annually  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 Consequences on Health Care 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!  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   Dependent on hospital/ward   Individual    between health professionals  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    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)  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    “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  Consensus Full text screen Abstracts    All studies independently screened by 2 reviewers  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  Piloted x5 to ensure interrater reliability    Data extracted by 2 reviewers    Results compared via discussion    Results compiled to identify study trends  Rater  Rater  Rater  Data Extraction Rater  Rater  Discussion Rater  Rater  Compiled Results  Rater  Data Analysis   Qualitative analysis     Meta-analysis     Performed via tabulation  Falls per days at risk  Sensitivity analysis   Influence of effective sample size of cluster RCT  Meta-analysis   Random effects meta-analysis (falls/bed days)     Mantel-Haenszel test      Revman 5.0 software20  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 from Databases N = 1153  Studies Retrieved from Citations N = 1381  Total Studies Retrieved N = 2535  Excluded by Title / Abstract N = 2458  Studies Retrieved for Full-text Analysis N = 77  Excluded by Full-text N = 71  Studies Retrieved for Data Abstraction N = 6  Studies Included for Review N = 6  Subjects   5038 total participants    1958 Male 3080 Female  Male  Female    Co-morbidities:       Admission diagnosis       Orthopedic Geriatric management Elective joint replacement Stroke/Neurological Other disabling impairment       Arthritis Dementia Depression Diabetes Heart disease Hip fracture Stroke  Study Characteristics   Locations         Australia (4) Sweden (1) England (1)  Mean LOS (SD)   8.2 (2.7) to 38 (40.6) days  Hospital settings      Acute and rehabilitation elderly care wards General medicine wards Post-op geriatric wards & geriatric units Orthopedic wards  7 months  S tudy Duration  36 months  Individual Study Overview  Cumming et al. (2008)  9    Cluster RCT  Interventions  50  hrs/wk per ward  3 year study period Exercise – Balance & Functional VS.  Usual Care  Education – Patient & Family Staffing – RN & PT 25hrs/wk    Outcome Measures  Total  falls  # of Injurious falls (including fractures)   Clinically Relevant Results  Intervention  showed no effect on outcomes  Donald et al. (2000)  21    Interventions  2x/day 7  month study period Exercise – Strength 3x10 reps  Usual Care 1-2x/day Mobility – T/F, Walking, Balance    Enviro – Carpet / Vinyl flooring  Outcome Measures  Incidence  Fall  of falls  risk   Strength    VS.  (Hip flexor, Ankle DF)  Clinically Relevant Results  Lower  incidence of falls in intervention group  Carpet flooring had higher incidence of falls vs. vinyl  Haines et al. (2004)  22    Interventions  Additional  105 min, 5x/week  9 month study period Usual Care 2hrs/day Mobility & Balance – PT & OT    VS.  Exercise – Functional & Tai Chi Education – 30 min, 2x/wk (≤ 4)  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  Haines et al. (2007)  23    Interventions  Additional  105 min, 5x/week  9 month study period Usual Care 2hrs/day Mobility & Balance – PT & OT    VS.  Exercise – Functional & Tai Chi Education – 30 min, 2x/wk (≤ 4)  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  Jones et al. (2006)  24    Interventions  Additional  160 min over LOS  10 month study period Usual Care  VS.  PT – 100min + 160min group ex  Includes PT ~90 min over LOS    Strength & Function  Outcome Measures  Adverse  events (including falls)   LOS    Clinically Relevant Results  Adverse  events ↓ 5.6% intervention vs. 2.6% control  ↓ LOS in intervention group  Stenvall et al. (2007)   25  Interventions  2x/wk  31  month study period  Usual Care Mobility & Exercise – by PT    VS.  Exercise – ADL & Fall focused Team Collaboration – Care Plan  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)  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    4  (range 5-9)  Agreement between raters (ICC) (95%CI -0.466 to 0.972)  “Good reliability”26  3  Number of Studies   0.796    2  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)  1  0  5 6 7 8 9 10 P E D ro 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)     Statistically        40% reduction in fall rate  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 LOS  1.     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  Exercise appropriateness  1.   Screening is necessary      Potential fallers Those that may benefit from exercise  Optimizing allocation of resources  Discussion Program delivery methods  1.   Tailor interventions to specific individual risk factors  Enhances proper exercise execution & program compliance vs. group exercise8  Socialization  1.   Exercise intervention hours = ↑ socialization  No comparison to rule out socialization / therapist contact time  Discussion Follow-Up  1.    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  Study weight  1.   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  Conclusion 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  Implications Clinical Recommendations Future Research  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  Dissemination Plans   Publish in Journal of Clinical Rehabilitation      Audio-cast available     Widely available to health care practitioners Promote awareness  Peer-Reviewed Journal  PABC Website & Podcast  Systematic Review Symposium 2009  PABC Website  Multidisciplinary In-services  In-services  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 http://www.statcan.gc.ca/pub/82-003-s/2005000/pdf/9088-eng.pdf. 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 http://www.cihi.ca. 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 http://www.health.gov.bc.ca/library/publications/year/2004/falls.pdf . 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 http://www.profane.eu.org. 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 righthemisphere 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 http://www.statsdirect.com.  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)     CIRRIE ~ Centre for International Rehabilitation Research Information & Exchange       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      Federally & privately supported clinical trials (US & International)  Cochrane Database of Systematic Reviews     From 1990  Clinical Trials Registry     Owned and operated by EBSCO Publishing  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     PEDro ~ Physiotherapy Evidence Databases      Over 69,000 abstracts of books, articles, reports (disability & rehabilitation research)  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 http://www.acc.co.nz/preventing-injuries/at-home/older-people/information-for-older-people/otago-exercise-programme/inde .  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 http://www.argbc.ca/lifestyle/exercise/jointworks. 3. WaterWorks. Available from http://www.argbc.ca/lifestyle/exercise/waterworks. 4. Osteofit . Available from http://www.osteofit.org/.  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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