Catherine Sherrington

Home exercise to improve strength and walking velocity after hip fracture: a randomized controlled trial.

OBJECTIVEnTo determine the effect of a home exercise program on strength, postural control, and mobility following hip fracture.nnnDESIGNnRandomized controlled trial of 1 months duration.nnnSETTINGnDaily exercise carried out within the subjects home environments.nnnPARTICIPANTSnForty-two people 64 to 94 years of age, 35 of whom were living independently in the community and 7 of whom were residing in institutional care. Subjects were recruited on average 7 months after a fall-related hip fracture and randomly allocated to either the intervention or the control group (n = 21 each). The groups were well matched in terms of medical conditions, medication use, disability, and activity levels.nnnINTERVENTIONnA home-based program of weight-bearing exercise established at a visit by a physiotherapist.nnnMAIN OUTCOME MEASURESnQuadriceps strength, postural sway, functional reach, weight-bearing ability, walking velocity, and self-rated fall risk. The subjects undertook these assessments at the beginning and end of the trial.nnnRESULTSnAt pretest, exercisers and controls performed similarly in all tests. At the end of the trial, the intervention group showed significantly greater quadriceps strength in the affected (hip-fractured) leg and increased walking velocity. The intervention subjects also improved their weight-bearing ability and reported reduced subjective falls risk. In contrast, there were no significant improvements in any of the test measures in the controls. Within the intervention group, improvements in quadriceps strength were significantly associated with improved performances in the weight-bearing test measures and with increased walking velocity.nnnCONCLUSIONSnThis exercise program improved strength and mobility following hip fracture. Further research is needed to ascertain whether the extent of this improvement in these fall risk factors is sufficient to prevent falls.

Increased Prevalence of Fall Risk Factors in Older People following Hip Fracture

Background: Many people who suffer a hip fracture do not achieve full functional recovery. Simple tests of physical function such as quadriceps strength and postural sway may provide insight into why this population is at increased risk of experiencing further falls and fractures and assist in developing rehabilitation strategies for preventing falls. Objective: To determine whether impairments in a range of physiological measures and specific medical conditions are more prevalent in people who have suffered a fall-related hip fracture than in a matched sample of community-dwelling people without a history of falls. Methods: This case-control study involved 88 older people. The hip fracture group comprised 44 persons aged 64–94 years, assessed on average 7 months following a fall-related hip fracture. An age- and sex-matched control group (older persons who had not fallen in a 12-month period before recruitment) was drawn randomly from community samples. Results: Compared with the control group, the hip fracture group had markedly reduced quadriceps strength and increased body sway when tested on firm and compliant (foam rubber) surfaces. Patients in the hip fracture group also had higher prevalence rates of poor vision, arthritis and stroke, were taking more medications, were less physically active and perceived themselves to be at greater risk of falling than the control group. No significant differences were apparent for cardiovascular conditions, subjective health status and psychoactive medication use between the groups. Multivariate analyses identified quadriceps strength and body sway on the compliant surface as the most important variables for distinguishing between the hip fracture and no hip fracture groups. These two variables correctly classified 92% of the cases, with equal sensitivity and specificity. Conclusion: The findings identify an increased prevalence of certain physical fall risk factors among older persons who have suffered a hip fracture. Decreased quadriceps strength and increased postural sway are potentially modifiable. Intervention programs designed to improve performance on these variables among this population require investigation.

Falls in Older People: Epidemiology of falls and fall-related injuries

In this chapter, we examine the epidemiology of falls in older people. We review the major studies that have described the incidence of falls, the locations where falls occur and falls sequelae. We also examine the costs and services required to treat and manage falls and fall-related injuries. Before addressing these issues, however, it is helpful to briefly discuss four important methodological considerations that are pertinent to all research studies of falls in older people: how falls are defined, how falls are counted, how injurious falls are defined and what constitutes an older person. The definition of a fall In 1987, the Kellogg International Working Group on the Prevention of Falls in the Elderly defined a fall as ‘unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure’. Since then, many researchers have used this or very similar definitions of a fall. The Kellogg definition is appropriate for studies aimed at identifying factors that impair sensorimotor function and balance control, whereas broader definitions that include dizziness and loss of consciousness are appropriate for studies that also address cardiovascular and neurological causes of falls such as syncope, postural hypotension and transient ischaemic attacks.

Falls in Older People: Postural stability and falls

Postural stability can be defined as the ability of an individual to maintain the position of the body, or more specifically, its centre of mass, within specific boundaries of space, referred to as stability limits . Stability limits are boundaries in which the body can maintain its position without changing the base of support. This definition of postural stability is useful as it highlights the need to discuss stability in the context of a particular task or activity. For example, the stability limit of normal relaxed standing is the area bounded by the two feet on the ground, whereas the stability limit of unipedal stance is reduced to the area covered by the single foot in contact with the ground. Due to this reduction in the size of the stability limit, unipedal stance is an inherently more challenging task requiring greater postural control. Regardless of the task being performed, maintaining postural stability requires the complex integration of sensory information regarding the position of the body relative to the surroundings and the ability to generate forces to control body movement. Thus, postural stability requires the interaction of musculo-skeletal and sensory systems. The musculo-skeletal component of postural stability encompasses the biomechanical properties of body segments, muscles and joints. The sensory components include vision, vestibular function and somatosensation, which act to inform the brain of the position and movement of the body in three-dimensional space.

Falls in Older People: Modifying the environment to prevent falls

This chapter outlines commonly suggested environmental modification strategies, and reviews the literature evaluating falls prevention programmes that have involved environmental modification as an individual intervention or as part of multi-faceted programmes. It discusses potential barriers to home modification, issues related to hazard removal and design strategies for minimizing older peoples risk of falling in public places. Approaches for addressing environmental risk factors within institutions are discussed in Chapter 15. Environmental modification strategies Table 8.1 in Chapter 8 presents a list of environmental falls risk factors that have been suggested in the literature. These posited risk factors are replicated in Table14.1 along with potential solutions. Environmental modification as an individual intervention Environmental modification is seen by many as an attractive falls prevention strategy. The homes of most older people have many environmental hazards and the majority of these are amenable to modification. Correction and/or removal of potential hazards is a one-off intervention that can be carried out relatively cheaply. Indeed, cost-effectiveness modelling has predicted that spending AUD

Falls in Older People: Exercise interventions to prevent falls

244 per person on a programme involving home assessment by an occupational therapist and subsequent modifications, would save

PEDro. A database of randomized trials and systematic reviews in physiotherapy.

92 per person and

The Extent and Quality of Evidence in Neurological Physiotherapy: An Analysis of the Physiotherapy Evidence Database (PEDro)

916 per fall prevented, over a ten year period. However, this study assumes that such a programme could prevent 25% of falls. Reductions of this magnitude have yet to be demonstrated in controlled studies. Early investigations indicated that home modification might be an effective falls prevention strategy for the general population of older people.

Falls in Older People: Environmental risk factors for falls

Exercise has a major role to play in preventing falls among older people and is recommended in recent evidence-based guidelines for falls prevention. As acknowledged in these guidelines, there are many different types of exercise, some of which are likely to result in greater reductions in falls than others. It is therefore incumbent upon health professionals to do better than merely suggest that older people should exercise. As Hadley has stated ‘telling an older person that ‘exercise’ can prevent falls is not much better than telling them that ‘antibiotics’ can cure an infection: although true, the advice would be much more useful if it were more specific’. This chapter aims to assist the health professional to prescribe exercise for falls prevention. The first section reviews the findings of randomized controlled trials into exercise interventions for falls prevention. From this, a synthesis of the findings is undertaken in an effort to delineate the important components for successful exercise interventions. Analysis of randomized controlled trials (RCTs) investigating exercise and falls In revising and updating this chapter, a detailed analysis of the specific components of exercise was undertaken. A total of 44 RCTs of exercise interventions for falls prevention written in English were identified via searches of electronic databases (MEDLINE, CINAHL, EMBASE, PEDro), and reference lists of systematic reviews and clinical practice guidelines.