Claire Ballinger

A randomised controlled trial of a home based exercise programme to reduce the risk of falling among people with Parkinson’s disease

Objective: To evaluate the effectiveness of a personalised home programme of exercises and strategies for repeat fallers with Parkinson’s disease (PD). Method: Patients with a confirmed diagnosis of idiopathic PD, independently mobile, living at home in the community, experiencing more than one fall in the previous 12 months and with intact gross cognitive function were invited to participate in this randomised controlled trial. Usual care was compared with a personalised 6 week, home based exercise and strategy programme. The primary outcomes were rates of falling at 8 weeks and 6 months. Whether participants had repeat fallen, nearly fallen or experienced injurious falls were also examined. Functional Reach, the Berg Balance Test, PD Self-assessment Scale and the Euro Quol were rated by a blinded assessor. Results: Participants were randomised to the exercise (n = 70) and control (n = 72) groups. There was a consistent trend towards lower fall rates in the exercise group at both 8 weeks and 6 months and lower rates of injurious falls needing medical attention at 6 months. Lower rates of repeat near falling were evident for the exercise group at 8 weeks (p = 0.004) and 6 months (p = 0.007). There was a positive effect of exercises at 6 months on Functional Reach (p = 0.009) and quality of life (p = 0.033). No significant differences were found on other secondary outcomes measures. Conclusion: There was a trend towards a reduction in fall events and injurious falls with a positive effect of exercises on near falls and quality of life.

Environmental Interventions to Prevent Falls in Community-Dwelling Older People A Meta-Analysis of Randomized Trials

Objective: This study seeks to determine the efficacy of environmental interventions in reducing falls in community-dwelling older people. Method: A systematic review and meta-analysis of randomized trials was performed. Results: Pooled analysis of six trials (N = 3,298) demonstrated a 21% reduction in falls risk (relative risk [RR] = 0.79; 0.65 to 0.97). Heterogeneity was attributable to the large treatment effect of one trial. Analysis of a subgroup of studies with participants at high risk of falls (four trials, n = 570) demonstrated a clinically significant 39% reduction of falls (RR = 0.61; 0.47 to 0.79), an absolute risk difference of 26% for a number needed to treat four people. Discussion: Home assessment interventions that are comprehensive, are well focused, and incorporate an environmental-fit perspective with adequate follow-up can be successful in reducing falls with significant effects. The highest effects are associated with interventions that are conducted with high-risk groups.

The circumstances of falls among people with Parkinson's disease and the use of Falls Diaries to facilitate reporting

Purpose. Falls are common in Parkinsons disease (PD). Falls Diaries are one way of recording fall frequency and the surrounding circumstances; completing them encourages recall, and their content focuses intervention. We reviewed the diaries completed by people with PD during a randomized controlled trial (RCT) of fall prevention to ascertain the key circumstances surrounding falls. Method. We asked independently mobile, cognitively intact people with a diagnosis of PD to maintain a Falls Diary throughout a six-month RCT. We sent monthly diary sheets on which to answer questions about the ‘Location’, ‘Fall-related activity’, ‘Perceived cause’, ‘Landing’ and ‘Consequences’ of every fall. We coded responses and counted frequencies. Results. Of the 142 RCT participants (mean age 72 years; mean years since diagnosis 8), 135 completed the trial and their diary. We excluded 11 (8%) for missing data and/or unintelligible writing. The 124 remaining diaries recorded 639 falls: 80% happened at home, commonly in bedrooms, living areas, kitchens and gardens. Fallers had been ambulant in 45% of events, standing in 32% and transferring in 21%. Six ‘activity-cause combinations’ accounted for 55% of falls (tripping 13%; freezing, festination and retropulsion 11%; and postural instability when bending or reaching 9%, transferring 8%, walking 7% and washing or dressing 7%). Misjudgement and distraction played a part in 12% of falls described. Conclusions. Of over 600 falls surveyed, most happened at home, provoked by postural instability, tripping and freezing. Environmental adaptation and cognitive training should be trialled in falls prevention in PD, plus or minus traditional movement rehabilitation. Most participants completed Falls Diaries successfully. We advocate diary use, with follow-up interviews, in research and clinically. People with handwriting difficulty may require a typed diary, proxy diarist or interview.

Recommendations for promoting the engagement of older people in activities to prevent falls

Objective: To develop recommendations for promoting uptake of and adherence to falls-prevention interventions among older people. Design: The recommendations were initially developed from literature review, clinical experience of the core group members, and substantial qualitative and quantitative studies of older people’s views. They were refined through a consultation process with members of the falls-prevention community, drawing on Delphi survey and nominal group techniques. Transparency was enhanced by recording and reporting aspects of the iterative consultation process such as the degree of consensus and critical comments on drafts of the recommendations. Setting: The recommendations were developed and refined at three meetings of the core group, and through internet-based consultation and two meetings involving members of the wider falls-prevention community. Participants: The authors developed the recommendations incorporating the feedback from the researchers and practitioners responding to a broad-based internet consultation and consulted in the meetings. Results: A high degree of consensus was achieved. Recommendations addressed the need for public education, ensuring that interventions were compatible with a positive identity, tailoring interventions to the specific situation and values of the individual, and using validated methods to maintain longer-term adherence. Conclusion: These recommendations represent a consensus based on current knowledge and evidence, but the evidence base from which these recommendations were developed was limited, and not always specific to prevention of falls. To increase the effectiveness of falls-prevention interventions, further research is needed to identify the features of falls-prevention programmes that will encourage older people’s engagement in them.

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

Qualitative research is a mode of inquiry with which many occupational therapists engage and which some claim is particularly suited to researching the complexity and richness of occupational therapy practice. This paper, written as part of a research series in this journal, has a dual purpose: first, to encourage qualitative researchers to identify their own ontology and use recognised strategies for ensuring high quality work which are consistent with their own world-view of research and, secondly, to consider how best to represent those strategies within their written accounts of their research. Three researcher positions ranged along a continuum are proposed – realist, subtle realist and relativist – and alternative criteria for each of these positions are suggested. Occupational therapy and health examples are used to illuminate each of these traditions. It is hoped that the paper will assist qualitative researchers both to clarify their own position along the research continuum and remain coherent within it and to identify the key features relating to quality and rigour that they should consider including in papers submitted for publication.

Characteristics of outdoor falls among older people: A qualitative study

BackgroundFalls are a major threat to older people’s health and wellbeing. Approximately half of falls occur in outdoor environments but little is known about the circumstances in which they occur. We conducted a qualitative study to explore older people’s experiences of outdoor falls to develop understanding of how they may be prevented.MethodsWe conducted nine focus groups across the UK (England, Wales, and Scotland). Our sample was from urban and rural settings and different environmental landscapes. Participants were aged 65+ and had at least one outdoor fall in the past year. We analysed the data using framework and content analyses.ResultsForty-four adults aged 65 – 92 took part and reported their experience of 88 outdoor falls. Outdoor falls occurred in a variety of contexts, though reports suggested the following scenarios may have been more frequent: when crossing a road, in a familiar area, when bystanders were around, and with an unreported or unknown attribution. Most frequently, falls resulted in either minor or moderate injury, feeling embarrassed at the time of the fall, and anxiety about falling again. Ten falls resulted in fracture, but no strong pattern emerged in regard to the contexts of these falls. Anxiety about falling again appeared more prevalent among those that fell in urban settings and who made more visits into their neighbourhood in a typical week.ConclusionsThis exploratory study has highlighted several aspects of the outdoor environment that may represent risk factors for outdoor falls and associated fear of falling. Health professionals are recommended to consider outdoor environments as well as the home setting when working to prevent falls and increase mobility among older people.

College of Occupational Therapists: Research and Development Strategy

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

Self reported adherence to a home-based exercise programme among people with Parkinson's disease.

BACKGROUND There is an extensive literature addressing compliance with medication, techniques to measure, and ways to improve it. In comparison the literature concerning adherence to exercise programmes agreed with a physiotherapist is limited. OBJECTIVE We estimate the percentage of exercise repetitions completed of those agreed with a physiotherapist in the context of a six week personalized exercise programme to reduce falling in people with Parkinsons disease, and examine patient characteristics that predict adherence. METHODS Secondary analysis of data collected during a randomized controlled trial. Participants allocated to receive the exercise programme self-reported the number of repetitions of prescribed strengthening, range of movement and balance exercises they had completed in daily dairies. Indoor or outdoor walking was also prescribed but in terms of target distances or lengths of time, and was not included in our analysis. RESULTS On average the 70 participants allocated to the exercise programme reported completing 79% (95% confidence interval 73%-86%) of the prescribed number of repetitions of their exercises. The percentage of exercises completed varied depending on the specific exercise prescribed, and on participant characteristics: those who were older, in poorer health and with anxiety, depression, or mental heath problems reported lower adherence to exercise. CONCLUSION Several of the factors we found to reduce adherence to exercise have been shown by others to reduce compliance with antiparkinsonian medication, but we found adherence decreased with age in contrast to the pattern of better compliance with medication amongst older people with Parkinsons disease reported previously.

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

Although targets have been set for the establishment of falls prevention services, little is known about the views of older people in respect of such initiatives. The purpose of this study was to investigate the perspectives of the older participants in a community group falls prevention programme in Australia and to explore their views about the most and least useful aspects of the programme, using methods deriving from a grounded theory approach. Semi-structured interviews were carried out with nine women and two men who had attended a falls prevention programme. The multifaceted intervention comprised seven weekly meetings of 2 hours each. The key principle underpinning the programme was enhancement of self-efficacy. Four themes were identified through qualitative analysis: identity (focusing on participants as active elders); the salience of interventions (or the meaning attributed to different programme components); the social experience (the views about group interaction); and the consequences of participation. The participants were very positive about their experience of the programme and described a range of psychological and physical outcomes. A decrease in the likelihood of a fall did not feature prominently in these interviews. It may be more meaningful to older people to embed falls prevention within a wider context of wellbeing and independence.

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

Objectives: The aim of this paper is to report a pilot study in which participants who had recently received a diagnosis of dementia were randomised to either a 10-week group intervention or a waiting-list control. Method: Memory clinic staff with limited previous experience of group therapy were trained to lead a 10-week group therapy intervention called ‘Living Well with Dementia’. Fifty-eight participants, all of whom had received a diagnosis of Alzheimers disease, vascular or Lewy body dementia within the previous 18 months, were randomised to receive either the intervention or treatment as usual (waiting-list control). Data collection occurred at baseline, within two weeks after the intervention finished and at 10-week follow-up. Results: The study met its recruitment targets, with a relatively low attrition rate for the intervention arm. The acceptability of the intervention and research methods was examined qualitatively and will be reported on elsewhere. For the primary outcome, measure of quality of life in Alzheimers disease (QoL-AD), and secondary outcome, self-esteem, there was some evidence of improvement in the intervention group compared to the control group. There was, also, evidence of a reduction in cognitive functioning in the treatment group compared to the control. Such reported differences should be treated with caution because they are obtained from a pilot and not a definitive study. Conclusion: This pilot study succeeded in collecting data to inform a future definitive cost effectiveness clinical trial of Living Well with Dementia group therapy.