Serene S. Paul

Exercise to prevent falls in older adults: an updated systematic review and meta-analysis

Objective Previous meta-analyses have found that exercise prevents falls in older people. This study aimed to test whether this effect is still present when new trials are added, and it explores whether characteristics of the trial design, sample or intervention are associated with greater fall prevention effects. Design Update of a systematic review with random effects meta-analysis and meta-regression. Data sources Cochrane Library, CINAHL, MEDLINE, EMBASE, PubMed, PEDro and SafetyLit were searched from January 2010 to January 2016. Study eligibility criteria We included randomised controlled trials that compared fall rates in older people randomised to receive exercise as a single intervention with fall rates in those randomised to a control group. Results 99 comparisons from 88 trials with 19 478 participants were available for meta-analysis. Overall, exercise reduced the rate of falls in community-dwelling older people by 21% (pooled rate ratio 0.79, 95% CI 0.73 to 0.85, p<0.001, I2 47%, 69 comparisons) with greater effects seen from exercise programmes that challenged balance and involved more than 3 hours/week of exercise. These variables explained 76% of the between-trial heterogeneity and in combination led to a 39% reduction in falls (incident rate ratio 0.61, 95% CI 0.53 to 0.72, p<0.001). Exercise also had a fall prevention effect in community-dwelling people with Parkinsons disease (pooled rate ratio 0.47, 95% CI 0.30 to 0.73, p=0.001, I2 65%, 6 comparisons) or cognitive impairment (pooled rate ratio 0.55, 95% CI 0.37 to 0.83, p=0.004, I2 21%, 3 comparisons). There was no evidence of a fall prevention effect of exercise in residential care settings or among stroke survivors or people recently discharged from hospital. Summary/conclusions Exercise as a single intervention can prevent falls in community-dwelling older people. Exercise programmes that challenge balance and are of a higher dose have larger effects. The impact of exercise as a single intervention in clinical groups and aged care facility residents requires further investigation, but promising results are evident for people with Parkinsons disease and cognitive impairment.

Exercise for falls prevention in Parkinson disease: A randomized controlled trial

Objective: To determine whether falls can be prevented with minimally supervised exercise targeting potentially remediable fall risk factors, i.e., poor balance, reduced leg muscle strength, and freezing of gait, in people with Parkinson disease. Methods: Two hundred thirty-one people with Parkinson disease were randomized into exercise or usual-care control groups. Exercises were practiced for 40 to 60 minutes, 3 times weekly for 6 months. Primary outcomes were fall rates and proportion of fallers during the intervention period. Secondary outcomes were physical (balance, mobility, freezing of gait, habitual physical activity), psychological (fear of falling, affect), and quality-of-life measures. Results: There was no significant difference between groups in the rate of falls (incidence rate ratio [IRR] = 0.73, 95% confidence interval [CI] 0.45–1.17, p = 0.18) or proportion of fallers (p = 0.45). Preplanned subgroup analysis revealed a significant interaction for disease severity (p < 0.001). In the lower disease severity subgroup, there were fewer falls in the exercise group compared with controls (IRR = 0.31, 95% CI 0.15–0.62, p < 0.001), while in the higher disease severity subgroup, there was a trend toward more falls in the exercise group (IRR = 1.61, 95% CI 0.86–3.03, p = 0.13). Postintervention, the exercise group scored significantly (p < 0.05) better than controls on the Short Physical Performance Battery, sit-to-stand, fear of falling, affect, and quality of life, after adjusting for baseline performance. Conclusions: An exercise program targeting balance, leg strength, and freezing of gait did not reduce falls but improved physical and psychological health. Falls were reduced in people with milder disease but not in those with more severe Parkinson disease. Classification of evidence: This study provides Class III evidence that for patients with Parkinson disease, a minimally supervised exercise program does not reduce fall risk. This study lacked the precision to exclude a moderate reduction or modest increase in fall risk from exercise. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).

Three Simple Clinical Tests to Accurately Predict Falls in People With Parkinson's Disease

Falls are a major cause of morbidity in Parkinsons disease (PD). The objective of this study was to identify predictors of falls in PD and develop a simple prediction tool that would be useful in routine patient care. Potential predictor variables (falls history, disease severity, cognition, leg muscle strength, balance, mobility, freezing of gait [FOG], and fear of falling) were collected for 205 community‐dwelling people with PD. Falls were monitored prospectively for 6 months using monthly falls diaries. In total, 125 participants (59%) fell during follow‐up. A model that included a history of falls, FOG, impaired postural sway, gait speed, sit‐to‐stand, standing balance with narrow base of support, and coordinated stability had high discrimination in identifying fallers (area under the receiver‐operating characteristic curve [AUC], 0.83; 95% confidence interval [CI], 0.77–0.88). A clinical tool that incorporated 3 predictors easily determined in a clinical setting (falling in the previous year: odds ratio [OR], 5.80; 95% CI, 3.00–11.22; FOG in the past month: OR, 2.39; 95% CI, 1.19–4.80; and self‐selected gait speed < 1.1 meters per second: OR, 1.86; 95% CI, 0.96–3.58) had similar discrimination (AUC, 0.80; 95% CI, 0.73–0.86) to the more complex model (P = 0.14 for comparison of AUCs). The absolute probability of falling in the next 6 months for people with low, medium, and high risk using the simple, 3‐test tool was 17%, 51%, and 85%, respectively. In people who have PD without significant cognitive impairment, falls can be predicted with a high degree of accuracy using a simple, 3‐test clinical tool. This tool enables individualized quantification of the risk of falling.

Prevention of falls in Parkinson's disease: a review of fall risk factors and the role of physical interventions

Falls in people with Parkinsons disease (PD) are frequent and recurrent events with devastating and widespread consequences. Despite this, understanding of the predictive and explanatory value of fall risk factors, as well as the development and testing of interventions aimed at reducing falls, are in their infancy. This review focuses on fall prediction and risk factors that are potentially remediable with physical interventions. We show that falls can be predicted with high accuracy using a simple three-step clinical tool. Evidence from recently published randomized controlled trials supports the implementation of balance-challenging exercises in reducing falls. Larger scale trials utilizing technologically advanced monitoring methods will further elucidate those interventions most likely to be cost effective according to individual risk factor profiles.

Exercise and Motor Training in People with Parkinson's Disease: A Systematic Review of Participant Characteristics, Intervention Delivery, Retention Rates, Adherence, and Adverse Events in Clinical Trials

There is research evidence that exercise and motor training are beneficial for people with Parkinsons disease (PD), and clinicians seek to implement optimal programs. This paper summarizes important factors about the nature and reporting of randomized controlled trials of exercise and/or motor training for people with PD which are likely to influence the translation of research into clinical practice. Searches identified 53 relevant trials with 90 interventions conducted for an average duration of 8.3 (SD 4.2) weeks. Most interventions were fully supervised (74%) and conducted at a facility (79%). Retention rates were high with 69% of interventions retaining ≥85% of their participants; however adherence was infrequently reported, and 72% of trials did not report adverse events. Overall, the labor-intensive nature of most interventions tested in these trials and the sparse reporting of adherence and adverse events are likely to pose difficulties for therapists attempting to balance benefits and costs when selecting protocols that translate to sustainable clinical practice for people with PD.

Is automaticity of walking regained after stroke

Purpose. The aim of this study was to determine whether people who have completed rehabilitation after stroke have regained a level of automaticity of walking comparable to healthy people of similar age. Method. Twenty stroke subjects, 20 healthy elderly controls and 20 healthy young controls were tested. To quantify the automaticity of walking, subjects were required to walk simultaneously while performing an additional task(s). Subjects walked under four counterbalanced conditions: a single walking task, a dual-cognitive task, a dual-manual task and a triple-task. Walking velocity, cadence, stride length and step length were analysed. Results. Stroke subjects walked slower ( p = 0.001), took shorter strides ( p = 0.002) and fewer steps/min ( p = 0.04) than elderly controls. Velocity declined significantly across conditions from the single to the dual-cognitive to the dual-manual and finally to the triple-task ( p < 0.001). Both stroke and elderly groups showed similar deterioration in walking velocity across conditions ( p = 0.99), while the deterioration in the young subjects was significantly less than for healthy elderly subjects ( p = 0.04) and the stroke subjects ( p = 0.02). Conclusion. Community dwelling stroke subjects display the same level of automaticity of walking as elderly controls, but both elderly controls and stroke subjects are less automated than young controls.

The Relative Contribution of Physical and Cognitive Fall Risk Factors in People With Parkinson’s Disease A Large Prospective Cohort Study

Background. In order to develop multifaceted fall prevention strategies for people with Parkinson’s disease (PD), greater understanding of the impact of physical and cognitive performance on falls is required. Objective. We aimed to identify the relative contribution of a comprehensive range of physical and cognitive risk factors to prospectively-measured falls in a large sample of people with PD and develop an explanatory multivariate fall risk model in this group. Methods. Measures of PD signs and symptoms, freezing of gait, balance, mobility, proprioception, leg muscle strength, and cognition were collected on 205 community-dwelling people with PD. Falls were monitored prospectively for 6 months using falls diaries. Results. A total of 120 participants (59%) fell during follow-up. Freezing of gait (P < .001), dyskinesia (P = .02), impaired anticipatory and reactive balance (P < .001), impaired cognition (P = .002), reduced leg muscle strength (P = .006), and reduced proprioception (P = .04) were significantly associated with future falls in univariate analyses. Freezing of gait (risk ratio [RR] = 1.03, 95% confidence interval [CI] = 1.00-1.05, P = .02), impaired anticipatory (RR = 1.01, 95% CI = 1.00-1.02, P = .03) and reactive (RR = 1.26, 95% CI = 1.01-1.58, P = .04) balance, and impaired orientation (RR = 1.28, 95% CI = 1.01-1.62, P = .04) maintained significant associations with falls in multivariate analysis. Conclusion. The study findings elucidate important physical and cognitive determinants of falls in people with PD and may assist in developing efficacious fall prevention strategies for this high-risk group.

Validity of the Fitbit activity tracker for measuring steps in community-dwelling older adults

Background Commercially available activity monitors, such as the Fitbit, may encourage physical activity. However, the accuracy of the Fitbit in older adults remains unknown. This study aimed to determine (1) the criterion validity of Fitbit step counts compared to visual count and ActiGraph accelerometer step counts and (2) the accuracy of ActiGraph step counts compared to visual count in community-dwelling older people. Methods Thirty-two community-dwelling adults aged over 60 wore Fitbit and ActiGraph devices simultaneously during a 2 min walk test (2MWT) and then during waking hours over a 7-day period. A physiotherapist counted the steps taken during the 2MWT. Results There was excellent agreement between Fitbit and visually counted steps (intraclass correlation coefficient (ICC2,1)=0.88, 95% CI 0.76 to 0.94) from the 2MWT, and good agreement between Fitbit and ActiGraph (ICC2,1=0.66, 95% CI 0.41 to 0.82), and between ActiGraph and visually counted steps (ICC2,1=0.60, 95% CI 0.33 to 0.79). There was excellent agreement between the Fitbit and ActiGraph in average steps/day over 7 days (ICC2,1=0.94, 95% CI 0.88 to 0.97). Percentage agreement was closest for Fitbit steps compared to visual count (mean 0%, SD 4%) and least for Fitbit average steps/day compared to the ActiGraph (mean 13%, SD 25%). Conclusions The Fitbit accurately tracked steps during the 2MWT, but the ActiGraph appeared to underestimate steps. There was strong agreement between Fitbit and ActiGraph counted steps. The Fitbit tracker is sufficiently accurate to be used among community-dwelling older adults to monitor and give feedback on step counts.

Leg muscle power is enhanced by training in people with Parkinson’s disease: a randomized controlled trial:

Objective: To determine the effects of leg muscle power training in people with Parkinson’s disease. Design: Randomized controlled trial. Setting: University laboratory (outcome measures and experimental intervention), community (control intervention). Subjects: Community-dwelling people with Parkinson’s disease. Interventions: Leg muscle power training using pneumatic variable resistance equipment (experimental) was compared with low intensity sham exercise (control). Both groups exercised twice weekly for 12 weeks. Main measures: Primary outcomes were peak power of four leg muscle groups. Secondary outcomes were measures of muscle strength, mobility, balance and falls. Results: Exercise adherence was high in both groups. Leg muscle power was significantly better in the experimental group than the control group in all four primary outcome measures at 12 weeks after adjusting for baseline values: leg extensors (57.9 watts, 95% confidence interval (CI) 22.0–93.7, p = 0.002); knee flexors (29.6 watts, 95% CI 7.4–51.8, p = 0.01); hip flexors (68.1 watts, 95% CI 19.6–116.5, p = 0.007); and hip abductors (37.4 watts, 95% CI 19.9–54.9, p < 0.001). The experimental group performed significantly better on tests of leg muscle strength (p < 0.001 to 0.07) and showed trends toward better performance in the Timed Up and Go (p = 0.13) and choice stepping reaction time (p = 0.11). There was a non-significant reduction in the rate of falls in the experimental group compared with the control group (incidence rate ratio 0.84, p = 0.76). Conclusions: This programme significantly improved muscle power in all trained muscle groups.

AUTOMATICITY OF WALKING - IMPLICATIONS FOR PHYSIOTHERAPY PRACTICE

Abstract Automaticity is the term used to indicate that a skill is performed with little demand on attentional resources. One of the features of everyday tasks performed by healthy people is their automaticity. For example, walking is normally automated so that it is possible to perform additional tasks, such as talking and/or buttoning a jacket, concurrently. This review examines models of attention underlying automaticity, methods to improve automaticity, measurement of automaticity and implications of this information for physiotherapy practice. A measure of automaticity, an automaticity index, is proposed which enables studies to be compared, patients to be assessed and interventions to be evaluated. Strategies for assessment and training of automaticity in clinical practice are outlined using the everyday task of walking as an example.