Stephen N. Robinovitch

Falls and Parkinson's Disease: Evidence from Video Recordings of Actual Fall Events

To compare the fall characteristics of individuals with and without Parkinsons disease (PD) through the analysis of real‐life falls captured on video.

Study protocol for the Flooring for Injury Prevention (FLIP) Study: a randomised controlled trial in long-term care

Background A promising strategy for reducing the incidence and severity of fall-related injuries in long-term care (LTC) is to decrease the ground surface stiffness, and the subsequent forces applied to the body parts at impact, through installation of compliant flooring that does not substantially affect balance or mobility. Definitive evidence of the effects of compliant flooring on fall-related injuries in LTC is lacking. The Flooring for Injury Prevention (FLIP) Study is designed to address this gap. Methods The FLIP Study is a 4-year, parallel-group, 2-arm, randomised controlled superiority trial of flooring in 150 resident rooms at a LTC site. The primary objective is to determine whether compliant flooring reduces serious fall-related injuries relative to control flooring. Intervention (2.54 cm SmartCells compliant; 74 rooms) and control (2.54 cm plywood; 76 rooms) floorings were installed over the top of existing concrete floors and covered with identical 2.00 mm vinyl. The primary outcome is serious fall-related injury, defined as any impact-related injury due to a fall in a study room that results in Emergency Department visit or hospital admission. Secondary outcomes include minor fall-related injury, any fall-related injury, falls, number of fallers, fractures, and healthcare utilisation and costs for serious fall-related injuries. Randomisation of study rooms, and residents in rooms, was stratified by residential unit, and flooring assignments were concealed. Outcome ascertainment began September 2013. Discussion Results from the FLIP Study will provide evidence about the effects of compliant flooring on fall-related injuries in LTC and will guide development of safer environments for vulnerable older adults. Trial registration number NCT01618786.

Perceptions about Compliant Flooring from Senior Managers in Long-Term Care

ABSTRACT This study explored barriers and facilitators to adoption of compliant flooring as a fall injury prevention strategy within long-term care from the perspective of 18 long-term care senior managers. In-depth interviews were recorded, transcribed, and analyzed using the Framework Method. The most important organizational facilitators to adoption were potential for injury prevention and long-term care staffs openness to change. The most important organizational barriers to adoption were negative effects to long-term care staff and financial considerations (i.e., cost and lack of funding). The most important general organizational considerations were uncertainties about clinical effectiveness, effects on long-term care staff, and flooring performance. Overall, compliant flooring was viewed positively for long-term care. The findings also suggest an opportunity for knowledge translation to inform long-term care senior managers about the existing evidence on compliant flooring.

Hand forces exerted by long-term care staff when pushing wheelchairs on compliant and non-compliant flooring

Purpose-designed compliant flooring and carpeting have been promoted as a means for reducing fall-related injuries in high-risk environments, such as long-term care. However, it is not known whether these surfaces influence the forces that long-term care staff exert when pushing residents in wheelchairs. We studied 14 direct-care staff who pushed a loaded wheelchair instrumented with a triaxial load cell to test the effects on hand force of flooring overlay (vinyl versus carpet) and flooring subfloor (concrete versus compliant rubber [brand: SmartCells]). During straight-line pushing, carpet overlay increased initial and sustained hand forces compared to vinyl overlay by 22-49% over a concrete subfloor and by 8-20% over a compliant subfloor. Compliant subflooring increased initial and sustained hand forces compared to concrete subflooring by 18-31% when under a vinyl overlay. In contrast, compliant flooring caused no change in initial or sustained hand forces compared to concrete subflooring when under a carpet overlay.

Effects of Compliant Flooring Systems and Resident Weight on Hand Forces When Pushing Floor-Based Lifts and Wheelchairs among Long-Term Care Staff

Preliminary clinical findings suggest that compliant flooring may reduce the incidence and severity of fall- related injuries in long-term care (Knoefel et al., 2013) and acute-care settings (Drahota et al., 2013). However, there is concern that manoeuvring wheeled equipment on compliant flooring could expose care staff to potentially harmful pushing forces (Drahota et al., 2013; Wynn et al., 2011). We measured the external resultant hand forces (initial and sustained) required for female direct care staff to push two floor - based lifts (conventional manual and motor-driven) (n=14) or a wheelchair (n=14), loaded with passengers of average (67 kg) and ninetieth percentile (90 kg) resident weights, over four flooring systems: concrete + vinyl, compliant (1” SmartCells) + vinyl, concrete + carpet, and compliant + carpet. We observed an interaction between lift type and floor system for initial (p < 0.001) and sustained (p < 0.001) forces. Independent of resident weight, mean forces were lower for the motor-driven lift than the conventional lift on all flooring conditions (by 34.8 – 74.4 N for initial forces and by 14.1 – 64.5 N for sustained forces). With the vinyl overlay, initial forces were higher on compliant than concrete subflooring when using the conventional lift (mean difference = 44.7 N, 47.7% increase, p < 0.001) and motor-driven lift (29.8 N, 45.8% increase, p < 0.001). Similarly, with the vinyl overlay, sustained resultant forces were higher on compliant subflooring than concrete subflooring when using the conventional lift (39.0 N, 88.2% increase, p < 0.001) and motor-driven lift (9.7 N, 29.0% increase, p < 0.001). With the carpet overlay, the differences between compliant and concrete subfloors were less pronounced than with the vinyl overlay for the conventional lift (Finitial: 23.0 N higher, 14.9% increase, p < 0.001; Fsustained: 15.6 N higher, 18.7% increase, p < 0.001) and absent when using the motor-driven lift (Finitial: p = 0.975; Fsustained: p = 0.999). We also observed an interaction between resident weight and lift type for initial (p = 0.004) and sustained forces (p < 0.001). Independent of flooring system, Finitial was 18.6 N higher (13.5% increase, p < 0.001) and Fsustained was 11.7 N higher (14.3% increase, p < 0.001) for the ninetieth percentile weight than the average weight for the conventional lift. In contrast, there were no differences in Finitial (p = 0.200) and Fsustained (p = 0.100) between the average and ninetieth percentile weight conditions for the motor-driven lift. Similar trends were observed when participants pushed the wheelchair. In summary, this study found that compliant subflooring increased the external hand forces required for female direct care staff to push floor -based lifts and wheelchairs compared to concrete subflooring, and these increases in force were greater when pushing over vinyl than carpet overlay. This study also demonstrated that a motor-driven lift substantially reduced push forces compared to a conventional manual lift. Thus, motor-driven lifts may help to prevent work- related musculoskeletal injuries in long-term care facilities, especially in facilities with compliant flooring.

Push Forces on Vinyl and Carpet for Conventional Wheeled and Motor-Driven Floor-Based Lifts among Direct Care Staff in Long-Term Care

In response to high rates of work-related musculoskeletal injury (MSI) in long-term care (LTC), decision makers have implemented minimal-lift policies to reduce strain arising from resident transferring, often advocating the use of lifting devices. Floor-based lifts, in particular, are widely used in LTC, even though users are known to experience potentially injurious forces when pushing overweight or obese residents on carpet (Marras, Knapik & Ferguson, 2009). Motivated by this, a European manufacturer has developed a motor-driven, floor-based lift to assist users with resident transferring (esense Rise, Active4Care, Enschede, NL). Despite the motor-driven lift’s promise as a strategy for improved workplace safety, no research has been published examining its ability to reduce external hand forces, or perceptions of ease among users, during pushing. Therefore, we compared external hand forces and subjective ratings of perceived ease when straight-line pushing a motor-driven versus conventional (manual wheeled) floor-based lift, under conditions of low (vinyl) and high (carpet) rolling resistance, and while transporting passengers of average (67 kg) and ninetieth percentile (90 kg) resident weight. We recruited fourteen female direct care staff from a partner LTC site in British Columbia, Canada. We collected external hand force data using a piezoelectric, triaxial load cell (model 9074C, Kistler, Winterthur, Switzerland), custom mounted between existing lift handholds and a cylindrical handlebar. We also collected information on exposure (frequency, distance) to pushing in LTC by questionnaire, and calculated participant-specific tolerance limits for initial and sustained forces using Snook and Ciriello’s (1991) Hazard Analysis Tool. We observed a significant interaction between lift type and floor surface on initial (p < 0.001) and sustained (p < 0.001) forces. On vinyl, the motor-driven lift required, on average, 35 N (34%) less initial force (p < 0.001) and 14 N (27%) less sustained force (p < 0.001) than the conventional lift, regardless of resident weight. On carpet, we observed larger differences in forces between lifts, with the motor-driven lift requiring, on average, 64 N (36%) less initial force (p < 0.001) and 51 N (52%) less sustained force (p < 0.001) than the conventional lift, regardless of resident weight. Furthermore, there was an interaction between lift type and floor surface on subjective ratings of perceived ease of pushing (p < 0.001). On vinyl, subjective ratings did not differ between lifts (p = 0.32), with the majority of participants rating their ease of pushing as ‘very easy’ when pushing 90 kg passengers in both the conventional lift (n = 8, 57.1%) and the motor- driven lift (n = 12, 85.7%). On carpet, however, ratings were, on average, 1.8-points lower with the motor- driven lift (mean = 1.7; ‘somewhat easy’) than the conventional lift (mean = 3.5; ‘somewhat difficult’), independent of resident weight (p < 0.001). No conditions involving the motor-driven lift imposed forces above tolerable limits, while three of fourteen (21.4%) direct care staff exerted forces above tolerable limits when using the conventional lift on carpet only. Our results did not demonstrate a clear need for a motor-driven lift to mitigate the biomechanical demands of linear pushing on vinyl, as no participants’ force values approached tolerable limits for either lift on vinyl. Subjective ratings were also no different between lifts on vinyl. We did, however, demonstrate that motor-driven lifts reduce the biomechanical demands associated with pushing floor-based lifts on carpet. This insight can be used to inform evidence-based practices to improve worker safety during resident transferring, which could lead to reductions in both the incidence and severity of work-related MSI in LTC.