Anita Bundy

Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial

Objectives To determine whether a lifestyle integrated approach to balance and strength training is effective in reducing the rate of falls in older, high risk people living at home. Design Three arm, randomised parallel trial; assessments at baseline and after six and 12 months. Randomisation done by computer generated random blocks, stratified by sex and fall history and concealed by an independent secure website. Setting Residents in metropolitan Sydney, Australia. Participants Participants aged 70 years or older who had two or more falls or one injurious fall in past 12 months, recruited from Veteran’s Affairs databases and general practice databases. Exclusion criteria were moderate to severe cognitive problems, inability to ambulate independently, neurological conditions that severely influenced gait and mobility, resident in a nursing home or hostel, or any unstable or terminal illness that would affect ability to do exercises. Interventions Three home based interventions: Lifestyle integrated Functional Exercise (LiFE) approach (n=107; taught principles of balance and strength training and integrated selected activities into everyday routines), structured programme (n=105; exercises for balance and lower limb strength, done three times a week), sham control programme (n=105; gentle exercise). LiFE and structured groups received five sessions with two booster visits and two phone calls; controls received three home visits and six phone calls. Assessments made at baseline and after six and 12 months. Main outcome measures Primary measure: rate of falls over 12 months, collected by self report. Secondary measures: static and dynamic balance; ankle, knee and hip strength; balance self efficacy; daily living activities; participation; habitual physical activity; quality of life; energy expenditure; body mass index; and fat free mass. Results After 12 months’ follow-up, we recorded 172, 193, and 224 falls in the LiFE, structured exercise, and control groups, respectively. The overall incidence of falls in the LiFE programme was 1.66 per person years, compared with 1.90 in the structured programme and 2.28 in the control group. We saw a significant reduction of 31% in the rate of falls for the LiFE programme compared with controls (incidence rate ratio 0.69 (95% confidence interval 0.48 to 0.99)); the corresponding difference between the structured group and controls was non-significant (0.81 (0.56 to 1.17)). Static balance on an eight level hierarchy scale, ankle strength, function, and participation were significantly better in the LiFE group than in controls. LiFE and structured groups had a significant and moderate improvement in dynamic balance, compared with controls. Conclusions The LiFE programme provides an alternative to traditional exercise to consider for fall prevention. Functional based exercise should be a focus for interventions to protect older, high risk people from falling and to improve and maintain functional capacity. Trial registration Australia and New Zealand Clinical Trials Registry 12606000025538.

The risk is that there is ‘no risk’: a simple, innovative intervention to increase children’s activity levels

School playgrounds offer everyday opportunities for physically active and social play that combats obesity, develops skills, and promotes well‐being. However, teachers’ fear of the legal consequences of injury can elicit over‐zealous risk reduction with the result that playgrounds lack challenge, and the potential benefits of play become limited. In this research, we trialled a simple, cost‐effective strategy to encourage children to be more active and social on a school playground. Over 11 weeks, we made available materials with no fixed purpose (e.g. car tires, boxes) to a playground of children aged five to seven. Accelerometers showed children became significantly more active. Interviews with teachers suggested children also became more social, creative, and resilient. However, despite no incidence of injuries, teachers perceived an increased risk and encountered dilemmas regarding duty of care. We conclude that future interventions should address issues of ‘surplus safety’ at individual, school, system, and policy levels.

Validity and Reliability of a Test of Playfulness

Since play wears many faces, occupational therapists (OTs) are concerned with the ways it may be expressed. Because adaptability is an important by-product of approaching activity in a playful manner, playfulness is a valuable outcome of occupational therapy. The Test of Play fulness (ToP) is an observational assessment requiring no special equipment. It represents a conceptualization of playfulness drawn from the literature. The purpose of this paper was to trace the development of the ToP and examine its preliminary construct and concurrent validity and inter-rater reliability. Validity and reliability were examined using the many-faceted Rasch analysis. Concurrent validity was examined by comparing childrens ToP scores with their scores on the Childrens Playfulness Scale. Results suggested that the ToP is both valid and reliable when applied to children, with or without disabilities, between 15 months and 10 years.

LiFE Pilot Study: A randomised trial of balance and strength training embedded in daily life activity to reduce falls in older adults

BACKGROUND Exercise as a falls prevention strategy is more complex with people at risk than with the general population. The Lifestyle approach to reducing Falls through Exercise (LiFE) involves embedding balance and lower limb strength training in habitual daily routines. METHODS A total of 34 community-residing people aged ≥70 years were randomised either into the LiFE programme or into a no-intervention control group and followed up for six months. Inclusion criteria were two or more falls or an injurious fall in the past year. RESULTS There were 12 falls in the intervention group and 35 in the control group. Therelative risk (RR) analysis demonstrated a significant reduction in falls (RR = 0.23; 0.07-0.83). There were indications that dynamic balance (P = 0.04 at three months) and efficacy beliefs (P = 0.04 at six months) improved for the LiFE programme participants. In general, secondary physical and health status outcomes, which were hypothesised as potential mediators of fall risk, improved minimally and inconsistently. CONCLUSIONS LiFE was effective in reducing recurrent falls in this at-risk sample. However, there were minimal changes in secondary measures. The study was feasible in terms of recruitment, randomisation, blinding and data collection. A larger randomised trial is needed to investigate long-term efficacy, mechanisms of benefit and clinical significance of this new intervention.

Increasing physical activity in young primary school children - it's child's play: a cluster randomised controlled trial.

OBJECTIVE To explore the effects of an innovative school-based intervention for increasing physical activity. METHODS 226 children (5-7 years old) randomly selected from 12 Australian primary schools were recruited to a cluster randomised trial with schools randomly allocated to intervention or control conditions. The 13-week intervention comprised: (1) altering the school playground by introducing loose materials and (2) a teacher-parent intervention exploring perceptions of risk associated with childrens free play. The primary outcomes were total accelerometer counts and moderate-vigorous physical activity during break times. Testing took place in Sydney, 2009-2010. RESULTS 221 participants were tested at baseline. Mixed-effect multilevel regression revealed a small but significant increase from the intervention on total counts (9400 counts, 95% CI 3.5-15.2, p=0.002) and minutes of MVPA (1.8 min, 95% CI 0.5-3.1, p=0.006); and a decrease in sedentary activity (2.1 min, 95% CI 0.5-3.8, p=0.01) during break times. We retested children in one intervention school after 2 years; they maintained the gains. CONCLUSIONS Capturing childrens intrinsic motivations to play while simultaneously helping adults reconsider views of free play as risky provided increases in physical activity during break times. Using accelerometry as the sole measure of physical activity may underestimate the effect. TRIAL REGISTRATION ACTRN12611000089932.

The sydney playground project: popping the bubblewrap - unleashing the power of play: a cluster randomized controlled trial of a primary school playground-based intervention aiming to increase children's physical activity and social skills

BackgroundIn the Westernised world, numerous children are overweight and have problems with bullying and mental health. One of the underlying causes for all three is postulated to be a decrease in outdoor free play. The aim of the Sydney Playground Project is to demonstrate the effectiveness of two simple interventions aimed to increase childrens physical activity and social skills.Methods/DesignThis study protocol describes the design of a 3-year cluster randomised controlled trial (CRCT), in which schools are the clusters. The study consists of a 13-week intervention and 1 week each of pre-and post-testing. We are recruiting 12 schools (6 control; 6 intervention), with 18 randomly chosen participants aged 5 to 7 years in each school. The two intervention strategies are: (1) Child-based intervention: Unstructured materials with no obvious play value introduced to the playground; and (2) Adult-based intervention: Risk reframing sessions held with parents and teachers with the aim of exploring the benefits of allowing children to engage in activities with uncertain outcomes. The primary outcome of the study, physical activity as measured by accelerometer counts, is assessed at baseline and post-intervention. Additional assessments include social skills and interactions, self-concept, after school time use and anthropometric data. Qualitative data (i.e., transcriptions of audio recordings from the risk reframing sessions and of interviews with selected teacher and parent volunteers) are analysed to understand their perceptions of risk in play. The control schools have recess as usual. In addition to outcome evaluation, regular process evaluation sessions are held to monitor fidelity to the treatment.DiscussionThese simple interventions, which could be adopted in every primary school, have the potential of initiating a self-sustaining cycle of prevention for childhood obesity, bullying and mental ill health.Trial registrationAustralian and New Zealand Clinical Trials Registration Number ACTRN12611000089932.

Intrinsic and extrinsic motivation for stereotypic and repetitive behavior.

This study provides evidence for intrinsic and extrinsic motivators for stereotypical and repetitive behavior in children with autism and intellectual disability and children with intellectual disability alone. We modified the Motivation Assessment Scale (MAS) (1988b); dividing it into intrinsic and extrinsic measures and adding items to assess anxiety as an intrinsic motivator. Rasch analysis of data from 279 MASs (74 children) revealed that the items formed two unidimensional scales. Anxiety was a more likely intrinsic motivator than sensory seeking for children with dual diagnoses; the reverse was true for children with intellectual disability only. Escape and gaining a tangible object were the most common extrinsic motivators for those with dual diagnoses and attention and escape for children with intellectual disability.

Psychometric properties of the Pediatric Motor Activity Log used for children with cerebral palsy.

The Pediatric Motor Activity Log (PMAL) is a parent‐report measure of the use, by children with hemiplegic cerebral palsy (CP), of their affected upper limb in everyday activities. The aim of this study was to examine the psychometric properties of both scales of the PMAL (‘How Often’ and ‘How Well’ scales) using Rasch measurement modelling. Sixty‐one parents of children with hemiplegic CP completed the PMAL and 31 completed it again 3 weeks later. The mean age of children was 4 years 6 months (SD 1y 9mo); 35 males, 26 females. Children were at Gross Motor Function Classification System (GMFCS) levels I (83%) and II (17%), and Manual Ability Classification System levels I (35%), II (52%), and III (14%). The original scales were found to have disordered rating scale structure. Further Rasch modelling with collapsed rating scale structures resulted in both scales conforming to the expectations of the Rasch model, yielding strong evidence for construct validity and reliability. One item from the How Often scale failed to conform to Rasch expectations and was deleted in subsequent analyses. Test–retest reliability of both scales was high (the intraclass correlation coefficient for the How Often scale was 0.94, and for the How Well scale 0.93). The revised scales possess good psychometric properties, specifically a logical item hierarchy, evidence of unidimensionality, adequate rating scale structure, and good test–retest reliability. We conclude that the revised PMAL has the capacity to yield valid and reliable scores except for children at the extremes of upper limb ability.

Predicting Fitness to Drive in People With Cognitive Impairments by Using DriveSafe and DriveAware

OBJECTIVES To examine the psychometric properties of DriveSafe and DriveAware and their predictive validity. DESIGN Prospective study compared screening tests with criterion standard. SETTING Two driving rehabilitation centers affiliated with a university and a geriatric rehabilitation facility. PARTICIPANTS Consecutive sample of drivers with functional impairments (n=115) and subgroup of drivers with cognitive impairments (n=96) referred for a driving assessment. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Driving performance was measured by a standardized assessment in real traffic. RESULTS Rasch analysis provided evidence for construct validity and internal reliability of both tests. Tests trichotomized drivers into unsafe, safe, and further testing categories. The optimal lower cutoff identified unsafe drivers with a specificity of 97% (95% confidence interval [CI], 83-100) in the test sample and 96% (95% CI, 80-100) in the validation sample. The optimal upper cutoff identified safe drivers with a sensitivity of 93% (95% CI, 77-99) and 95% (95% CI, 76-100), respectively. CONCLUSIONS By using DriveSafe and DriveAware, drivers with cognitive impairments referred for a driving assessment can be categorized as unsafe, safe, or requiring further testing, with only 50% needing an on-road assessment. Before clinical practice is changed, these findings should be replicated.

Validity and reliability of the on-road driving assessment with senior drivers.

The on-road driving assessment is widely regarded as the criterion measure for driving performance despite a paucity of evidence concerning its psychometric properties. The purpose of this study was 2-fold. First, we examined the psychometric properties of an on-road driving assessment with 100 senior drivers between 60 and 86 years (80 healthy volunteers and 20 with specific vision deficits) using Rasch modeling. Second, we compared the outcome of the gestalt decision made by trained professionals with that based on weighted error scores from the standardized assessment. Rasch analysis provided good evidence for construct validity and inter-rater reliability of the on-road assessment and some evidence for internal reliability. Goodness of fit statistics for all items were within an acceptable range and the item hierarchy was logical. The test had a moderate reliability index (0.67). The best cut off score yielded sensitivity of 81% and specificity of 95% compared with the gestalt decision. Further research is required with less competent drivers to more fully examine reliability. Healthy senior drivers failed to check blind spots when changing lanes and made errors when asked to report road markings and traffic signs as they drove. In addition unsafe drivers had difficulty negotiating intersections and lane changes.