A Randomized Trial of a Multifactorial Strategy to Prevent Serious Fall Injuries.

BACKGROUND: Injuries from falls are major contributors to complications and death in older adults. Despite evidence from efficacy trials that many falls can be prevented, rates of falls resulting in injury have not declined. METHODS: We conducted a pragmatic, cluster-randomized trial to evaluate the effectiveness of a multifactorial intervention that included risk assessment and individualized plans, administered by specially trained nurses, to prevent fall injuries. A total of 86 primary care practices across 10 health care systems were randomly assigned to the intervention or to enhanced usual care (the control) (43 practices each). The participants were community-dwelling adults, 70 years of age or older, who were at increased risk for fall injuries. The primary outcome, assessed in a time-to-event analysis, was the first serious fall injury, adjudicated with the use of participant report, electronic health records, and claims data. We hypothesized that the event rate would be lower by 20% in the intervention group than in the control group. RESULTS: The demographic and baseline characteristics of the participants were similar in the intervention group (2802 participants) and the control group (2649 participants); the mean age was 80 years, and 62.0% of the participants were women. The rate of a first adjudicated serious fall injury did not differ significantly between the groups, as assessed in a time-to-first-event analysis (events per 100 person-years of follow-up, 4.9 in the intervention group and 5.3 in the control group; hazard ratio, 0.92; 95% confidence interval [CI], 0.80 to 1.06; P = 0.25). The rate of a first participant-reported fall injury was 25.6 events per 100 person-years of follow-up in the intervention group and 28.6 events per 100 person-years of follow-up in the control group (hazard ratio, 0.90; 95% CI, 0.83 to 0.99; P = 0.004). The rates of hospitalization or death were similar in the two groups. CONCLUSIONS: A multifactorial intervention, administered by nurses, did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care. (Funded by the Patient-Centered Outcomes Research Institute and others; STRIDE ClinicalTrials.gov number, NCT02475850.).

Mobile and Web-Based Partnered Intervention to Improve Remote Access to Pain and Posttraumatic Stress Disorder Symptom Management: Recruitment and Attrition in a Randomized Controlled Trial.

BACKGROUND: Increasing access to nonpharmacological interventions to manage pain and posttraumatic stress disorder (PTSD) is essential for veterans. Complementary and integrative health (CIH) interventions can help individuals manage symptom burden with enhanced accessibility via remotely delivered health care. Mission Reconnect (MR) is a partnered, self-directed intervention that remotely teaches CIH skills. OBJECTIVE: The purpose of this paper is to describe the recruitment, onboarding phase, and attrition of a fully remote randomized controlled trial (RCT) assessing the efficacy of a self-directed mobile and web-based intervention for veterans with comorbid chronic pain and PTSD and their partners. METHODS: A total of 364 veteran-partner dyads were recruited to participate in a mixed methods multisite waitlist control RCT. Qualitative attrition interviews were conducted with 10 veterans with chronic pain and PTSD, and their self-elected partners (eg, spouse) who consented but did not begin the program. RESULTS: At the point of completing onboarding and being randomized to the 2 treatment arms, of the 364 recruited dyads, 97 (26.6%) failed to complete onboarding activities. Reported reasons for failure to complete onboarding include loss of self-elected partner buy-in (n=8, 8%), difficulties with using remote data collection methods and interventions (n=30, 31%), and adverse health experiences unrelated to study activities (n=23, 24%). Enrolled veterans presented at baseline with significant PTSD symptom burden and moderate-to-severe pain severity, and represented a geographically and demographically diverse population. Attrition interviews (n=10) indicated that misunderstanding MR including the intent of the intervention or mistaking the surveys as the actual intervention was a reason for not completing the MR registration process. Another barrier to MR registration was that interviewees described the mailed study information and registration packets as too confusing and excessive. Competing personal circumstances including health concerns that required attention interfered with MR registration. Common reasons for attrition following successful MR registration included partner withdrawal, adverse health issues, and technological challenges relating to the MR and electronic data collection platform (Qualtrics). Participant recommendations for reducing attrition included switching to digital forms to reduce participant burden and increasing human interaction throughout the registration and baseline data collection processes. CONCLUSIONS: Challenges, solutions, and lessons learned for study recruitment and intervention delivery inform best practices of delivering remote self-directed CIH interventions when addressing the unique needs of this medically complex population. Successful recruitment and enrollment of veterans with chronic pain and PTSD, and their partners, to remote CIH programs and research studies requires future examination of demographic and symptom-associated access barriers. Accommodating the unique needs of this medically complex population is essential for improving the effectiveness of CIH programs. Disseminating lessons learned and improving access to remotely delivered research studies and CIH programs is paramount in the post-COVID-19 climate. TRIAL REGISTRATION: ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772.

Ecological and environmental factors affecting the risk of tick-borne encephalitis in Europe, 2017 to 2021.

BackgroundTick-borne encephalitis (TBE) is a disease which can lead to severe neurological symptoms, caused by the TBE virus (TBEV). The natural transmission cycle occurs in foci and involves ticks as vectors and several key hosts that act as reservoirs and amplifiers of the infection spread. Recently, the incidence of TBE in Europe has been rising in both endemic and new regions.AimIn this study we want to provide comprehensive understanding of the main ecological and environmental factors that affect TBE spread across Europe.MethodsWe searched available literature on covariates linked with the circulation of TBEV in Europe. We then assessed the best predictors for TBE incidence in 11 European countries by means of statistical regression, using data on human infections provided by the European Surveillance System (TESSy), averaged between 2017 and 2021.ResultsWe retrieved data from 62 full-text articles and identified 31 different covariates associated with TBE occurrence. Finally, we selected eight variables from the best model, including factors linked to vegetation cover, climate, and the presence of tick hosts.DiscussionThe existing literature is heterogeneous, both in study design and covariate types. Here, we summarised and statistically validated the covariates affecting the variability of TBEV across Europe. The analysis of the factors enhancing disease emergence is a fundamental step towards the identification of potential hotspots of viral circulation. Hence, our results can support modelling efforts to estimate the risk of TBEV infections and help decision-makers implement surveillance and prevention campaigns.

VectorNet: collaborative mapping of arthropod disease vectors in Europe and surrounding areas since 2010.

BackgroundArthropod vectors such as ticks, mosquitoes, sandflies and biting midges are of public and veterinary health significance because of the pathogens they can transmit. Understanding their distributions is a key means of assessing risk. VectorNet maps their distribution in the EU and surrounding areas.AimWe aim to describe the methodology underlying VectorNet maps, encourage standardisation and evaluate output.Methods: Vector distribution and surveillance activity data have been collected since 2010 from a combination of literature searches, field-survey data by entomologist volunteers via a network facilitated for each participating country and expert validation. Data were collated by VectorNet members and extensively validated during data entry and mapping processes.ResultsAs of 2021, the VectorNet archive consisted of ca 475,000 records relating to > 330 species. Maps for 42 species are routinely produced online at subnational administrative unit resolution. On VectorNet maps, there are relatively few areas where surveillance has been recorded but there are no distribution data. Comparison with other continental databases, namely the Global Biodiversity Information Facility and VectorBase show that VectorNet has 5-10 times as many records overall, although three species are better represented in the other databases. In addition, VectorNet maps show where species are absent. VectorNet's impact as assessed by citations (ca 60 per year) and web statistics (58,000 views) is substantial and its maps are widely used as reference material by professionals and the public.ConclusionVectorNet maps are the pre-eminent source of rigorously validated arthropod vector maps for Europe and its surrounding areas.

World guidelines for falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present. OBJECTIVES: to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries. METHODS: a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting. RECOMMENDATIONS: all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations. CONCLUSIONS: the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

Prescription characteristics associated with fall-related injury risk among older adults prescribed benzodiazepines: a cohort study.

BACKGROUND: Benzodiazepines (BZD) are widely prescribed to older adults despite their association with increased fall injury. Our aim is to better characterize risk-elevating factors among those prescribed BZD. METHODS: A retrospective cohort study using a 20% sample of Medicare beneficiaries with Part D prescription drug coverage. Patients with a BZD prescription ("index") between 1 April 2016 and 31 December 2017 contributed to incident (n=379,273) and continuing (n=509,634) cohorts based on prescriptions during a 6-month pre-index baseline. Exposures were index BZD average daily dose and days prescribed; baseline BZD medication possession ratio (MPR) (for the continuing cohort); and co-prescribed central nervous system-active medications. Outcome was a treated fall-related injury within 30 days post-index BZD, examined using Cox proportional hazards adjusting for demographic and clinical covariates and the dose prescribed. RESULTS: Among incident and continuing cohorts, 0.9% and 0.7% experienced fall injury within 30 days of index. In both cohorts, injury risk was elevated immediately post-index among those prescribed the lowest quantity: e.g., for <14-day fill (ref: 14-30 days) in the incident cohort, risk was 37% higher the 10 days post-fill (adjusted hazard ratio [HR] 1.37 [95% confidence interval [CI] 1.19-1.59]). Risk was elevated immediately post-index for continuing users with low baseline BZD exposure (e.g., for MPR <0.5 [ref: MPR 0.5-1], HR during days 1-10 was 1.23 [CI 1.08-1.39]). Concurrent antipsychotics and opioids were associated with elevated injury risk in both cohorts (e.g., incident HRs 1.21 [CI 1.03-1.40] and 1.22 [CI 1.07-1.40], respectively; continuing HRs 1.23 [1.10-1.37] and 1.21 [1.11-1.33]). CONCLUSIONS: Low baseline BZD exposure and a small index prescription were associated with higher fall injury risk immediately after a BZD fill. Concurrent exposure to antipsychotics and opioids were associated with elevated short-term risk for both incident and continuing cohorts.

New horizons in falls prevention and management for older adults: a global initiative.

BACKGROUND: falls and fall-related injuries are common in older adults, have negative effects both on quality of life and functional independence and are associated with increased morbidity, mortality and health care costs. Current clinical approaches and advice from falls guidelines vary substantially between countries and settings, warranting a standardised approach. At the first World Congress on Falls and Postural Instability in Kuala Lumpur, Malaysia, in December 2019, a worldwide task force of experts in falls in older adults, committed to achieving a global consensus on updating clinical practice guidelines for falls prevention and management by incorporating current and emerging evidence in falls research. Moreover, the importance of taking a person-centred approach and including perspectives from patients, caregivers and other stakeholders was recognised as important components of this endeavour. Finally, the need to specifically include recent developments in e-health was acknowledged, as well as the importance of addressing differences between settings and including developing countries. METHODS: a steering committee was assembled and 10 working Groups were created to provide preliminary evidence-based recommendations. A cross-cutting theme on patient's perspective was also created. In addition, a worldwide multidisciplinary group of experts and stakeholders, to review the proposed recommendations and to participate in a Delphi process to achieve consensus for the final recommendations, was brought together. CONCLUSION: in this New Horizons article, the global challenges in falls prevention are depicted, the goals of the worldwide task force are summarised and the conceptual framework for development of a global falls prevention and management guideline is presented.

Team VA Video Connect (VVC) to optimize mobility and physical activity in post-hospital discharge older veterans: baseline assessment.

BACKGROUND: Telehealth is increasingly used for rehabilitation and exercise but few studies include older adult participants with comorbidities and impairment, particularly cognitive. Using Veterans Administration Video Connect (VVC), the aim of the present study is to present the screening, recruitment, baseline assessment, and initial telehealth utilization of post-hospital discharge Veterans in a VVC home-telehealth based program to enhance mobility and physical activity. METHODS: Older adult Veterans (n = 45, mean age 73), recently discharged from the hospital with physical therapy goals, were VVC-assessed in self-report and performance-based measures, using test adaptations as necessary, by a clinical pharmacy specialist and social worker team. RESULTS: Basic and instrumental ADL disabilities were common as were low mobility (Short Portable Performance Battery) and physical activity levels (measured by actigraphy). Half had Montreal Cognitive Assessment (MoCA) scores in the mild cognitive impairment range (< 24). Over 2/3 of the participants used VA-supplied tablets. While half of the Veterans were fully successful in VVC, 1/3 of these and an additional group with at least one failed connection requested in-person visits for assistance. One-quarter had no VVC success and sought help for tablet troubleshooting, and half of these eventually "gave up" trying to connect; difficulty with using the computer and physical impairment (particularly dexterity) were described prominently in this group. On the other hand, Veterans with at least mild cognitive impairment (based on MoCA scores) were present in all connectivity groups and most of these used caregiver support to facilitate VVC. CONCLUSIONS: Disabled older post-hospital discharged Veterans with physical therapy goals can be VVC-assessed and enrolled into a mobility/physical activity intervention. A substantial proportion required technical support, including in-person support for many. Yet, VVC seems feasible in those with mild cognitive impairment, assuming the presence of an able caregiver. Modifications of assessment tools were needed for the VVC interface, and while appearing feasible, will require further study. TRIAL REGISTRATION: ClinicalTrials.gov NCT04045054 05/08/2019.

Cognitive status as a robust predictor of repeat falls in older Veterans in post-acute care.

BACKGROUND: While repeat falls are common in post-acute care (PAC), risk factors have not been fully elucidated. AIMS: The objective of thids study is to evaluate the contribution of cognitive function to repeat falls in older PAC Veterans. METHODS: Data were collected from medical records for 91 single and 30 repeat fallers over 5 consecutive years (2011-2016). RESULTS: After controlling for demographic and medical factors, lower Mini-Mental State Exam (MMSE) score was associated with increased odds of repeat falls. MMSE scores below 20 (with age held constant at the mean) were associated with a greater than 50% chance of a repeat fall (compared to 24.7% base rate). Admission for a neurologic reason further increased risk. DISCUSSION: PAC Veterans who experience a fall have an increased risk of repeat falls with concomitant cognitive dysfunction and/or admission for neurologic reasons. CONCLUSIONS: Results support tailoring multi-component interventions for those with cognitive dysfunction utilizing standardized mental status screening upon admission.

Automated Loss-of-Balance Event Identification in Older Adults at Risk of Falls during Real-World Walking Using Wearable Inertial Measurement Units.

Loss-of-balance (LOB) events, such as trips and slips, are frequent among community-dwelling older adults and are an indicator of increased fall risk. In a preliminary study, eight community-dwelling older adults with a history of falls were asked to perform everyday tasks in the real world while donning a set of three inertial measurement sensors (IMUs) and report LOB events via a voice-recording device. Over 290 h of real-world kinematic data were collected and used to build and evaluate classification models to detect the occurrence of LOB events. Spatiotemporal gait metrics were calculated, and time stamps for when LOB events occurred were identified. Using these data and machine learning approaches, we built classifiers to detect LOB events. Through a leave-one-participant-out validation scheme, performance was assessed in terms of the area under the receiver operating characteristic curve (AUROC) and the area under the precision recall curve (AUPR). The best model achieved an AUROC ≥0.87 for every held-out participant and an AUPR 4-20 times the incidence rate of LOB events. Such models could be used to filter large datasets prior to manual classification by a trained healthcare provider. In this context, the models filtered out at least 65.7% of the data, while detecting ≥87.0% of events on average. Based on the demonstrated discriminative ability to separate LOBs and normal walking segments, such models could be applied retrospectively to track the occurrence of LOBs over an extended period of time.

The kinematics and strategies of recovery steps during lateral losses of balance in standing at different perturbation magnitudes in older adults with varying history of falls.

BACKGROUND: Step-recovery responses are critical in preventing falls when balance is lost unexpectedly. We investigated the kinematics and strategies of balance recovery in older adults with a varying history of falls. METHODS: In a laboratory study, 51 non-fallers (NFs), 20 one-time fallers (OFs), and 12 recurrent-fallers (RFs) were exposed to random right/left unannounced underfoot perturbations in standing of increasing magnitude. The stepping strategies and kinematics across an increasing magnitude of perturbations and the single- and multiple-step threshold trials, i.e., the lowest perturbation magnitude to evoke single step and multiple steps, respectively, were analyzed. Fall efficacy (FES) and self-reported lower-extremity function were also assessed. RESULTS: OFs had significantly lower single- and multiple-step threshold levels than NFs; the recovery-step kinematics were similar. Surprisingly, RFs did not differ from NFs in either threshold. The kinematics in the single-step threshold trial in RFs, however, showed a significant delay in step initiation duration, longer step duration, and larger center of mass (CoM) displacement compared with NFs and OFs. In the multiple-step threshold trial, the RFs exhibited larger CoM displacements and longer time to fully recover from balance loss. Interestingly, in the single-stepping trials, 45% of the step-recovery strategies used by RFs were the loaded-leg strategy, about two times more than OFs and NFs (22.5 and 24.2%, respectively). During the multiple-stepping trials, 27.3% of the first-step recovery strategies used by RFs were the loaded-leg strategy about two times more than OFs and NFs (11.9 and 16.4%, respectively), the crossover stepping strategy was the dominated response in all 3 groups (about 50%). In addition, RFs reported a lower low-extremity function compared with NFs, and higher FES in the OFs. CONCLUSIONS: RFs had impaired kinematics during both single-step and multiple-step recovery responses which was associated with greater leg dysfunction. OFs and NFs had similar recovery-step kinematics, but OFs were more likely to step at lower perturbation magnitudes suggesting a more "responsive" over-reactive step response related from their higher fear of falling and not due to impaired balance abilities. These data provide insight into how a varying history of falls might affect balance recovery to a lateral postural perturbation. TRIAL REGISTRATION: This study was registered prospectively on November 9th, 2011 at clinicaltrials.gov ( NCT01439451 ).

Feasibility and behavioral effects of prolonged static and dynamic standing as compared to sitting in older adults with type 2 diabetes mellitus.

BACKGROUND: Physical inactivity is prevalent in older adults with type 2 diabetes mellitus (T2DM) and may exacerbate their clinical symptoms. The aim of this study was to examine the feasibility of 4-h regular versus more dynamic standing sessions while performing routine desktop activities as a non-exercise physical activity intervention in older adults with T2DM to increase non-exercise activity. METHODS: Twelve older adult patients with T2DM (3 female; age 71 ± 4 years; Body mass index 34 ± 5 kg/m2) completed three sessions (baseline sitting followed by "static" or "dynamic" desktop standing sessions). Participants stood behind a regular height-adjustable desk in the "static" standing session. An upright dynamic standing desk, which provides cues to make small weight-shifting movements, was used for the "dynamic" standing session. Oxygen consumption, cognitive performance, as well as net standing duration, total movement activity, and musculoskeletal discomfort were assessed during all three sessions. RESULTS: All participants were able to complete all sessions. Oxygen consumption and overall movements progressively increased from sitting to static and dynamic standing, respectively (p < 0.001). The duration of breaks during standing (p = 0.024) and rate of total musculoskeletal discomfort development (p = 0.043) were lower in the dynamic standing compared to static standing sessions. There was no evidence of executive cognitive worsening during either standing session compared to sitting. CONCLUSIONS: Prolonged 4-h standing as a simple non-exercise physical intervention is feasible in older adults with T2DM and may have metabolic (oxygen consumption) benefits. Increasing movement during desktop standing may offer incremental benefits compared to regular standing. Prolonged desktop standing might provide an effective intervention in T2DM older participants to target sedentariness. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04410055), retrospectively registered May 27, 2020.

Dual-tasking gait variability and cognition in late-life depression.

OBJECTIVES: Studies have demonstrated an association between major depressive disorder (MDD) symptoms and fall risk in older adults, which may be at least partially mediated by executive functioning skills. There have also been observations of increased gait variability associated with fall risk and disease. This preliminary study first sought to understand whether gait variability in the context of dual task cost differs among older adults with MDD, relative to those with no history of psychiatric illness, and second, to identify relationships between gait variability measures and cognitive functioning in the context of MDD. METHODS: We recruited 15 older adults with MDD and 17 non-depressed (ND) community-dwelling older adults. All participants had impaired balance based on unipedal stance time. Assessments included neuropsychological measures and measures of gait variability using an instrumented gait mat (GAITRite© ) in the context of dual task relative to single task performance (i.e., dual task cost). RESULTS: The groups did not differ on any gait variability parameters. The MDD group demonstrated poorer performance in the psychomotor speed domain, relative to the ND group, but cognitive functioning between the groups in other domains was equivalent. In MDD, increased variability in stride time, stride velocity, and swing time during dual-tasking were associated with poorer executive functioning and visual memory. In ND, no significant relationships between gait variables and cognitive performance were observed. CONCLUSIONS: Findings suggest that unique cognitive mechanisms underlie mobility problems associated with fall risk in late-life depression.

Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE: To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs). DATA SOURCES AND STUDY SETTING: Secondary data from Medicare were used. STUDY DESIGN: Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities). DATA COLLECTION: Not applicable. PRINCIPAL FINDINGS: We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001). CONCLUSIONS: HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Development of an exercise therapy referral clinical support tool for patients with osteoporosis at risk for falls.

BACKGROUND: The purpose of this study was to develop a clinical support tool for osteoporosis clinic providers to support risk assessment and referrals for evidence-based exercise therapy programs. METHODS: A sequential Delphi method was used with a multidisciplinary group of national falls experts, to provide consensus on referral to exercise therapy for patients at risk for falls. The Delphi study included a primary research team, expert panel, and clinical partners to answer the questions: (1) "What patient characteristics are needed to develop a clinical support tool?"; (2) "What are the recommended exercise referrals for patients with osteoporosis at risk for falls?" The consensus process consisted of two rounds with 8 weeks between meetings. Two qualitative researchers analyzed the data using a modified version of a matrix analysis approach. RESULTS: The following were the most important variables to include when determining exercise therapy referrals for patients with osteoporosis: Patient history and demographics, falls history over the last year, current physical function and balance, caregiver and transportation status, socioeconomic and insurance status, and patient preference. Potential exercise therapy referrals included one-on-one physical therapy, group physical therapy, home health, community-based exercise programs, and not acceptable for exercise therapy. CONCLUSIONS: Patient characteristics including patient history, physical function and balance performance, socioeconomic and insurance status, and patient preference for exercise therapy are important to inform both the medical provider and patient with osteoporosis to choose the most appropriate exercise therapy referral. Adoption of the algorithmic suggestions may have a significant impact on uptake and adherence to exercise therapy, ultimately improving patient physical function and reducing falls risk.

High habitat richness reduces the risk of tick-borne encephalitis in Europe: A multi-scale study.

Background: The natural transmission cycle of tick-borne encephalitis (TBE) virus is enhanced by complex interactions between ticks and key hosts strongly connected to habitat characteristics. The diversity of wildlife host species and their relative abundance is known to affect transmission of tick-borne diseases. Therefore, in the current context of global biodiversity loss, we explored the relationship between habitat richness and the pattern of human TBE cases in Europe to assess biodiversity's role in disease risk mitigation. Methods: We assessed human TBE case distribution across 879 European regions using official epidemiological data reported to The European Surveillance System (TESSy) between 2017 and 2021 from 15 countries. We explored the relationship between TBE presence and the habitat richness index (HRI1) by means of binomial regression. We validated our findings at local scale using data collected between 2017 and 2021 in 227 municipalities located in Trento and Belluno provinces, two known TBE foci in northern Italy. Findings: Our results showed a significant parabolic effect of HRI on the probability of presence of human TBE cases in the European regions included in our dataset, and a significant, negative effect of HRI on the local presence of TBE in northern Italy. At both spatial scales, TBE risk decreases in areas with higher values of HRI. Interpretation: To our knowledge, no efforts have yet been made to explore the relationship between biodiversity and TBE risk, probably due to the scarcity of high-resolution, large-scale data about the abundance or density of critical host species. Hence, in this study we considered habitat richness as proxy for vertebrate host diversity. The results suggest that in highly diverse habitats TBE risk decreases. Hence, biodiversity loss could enhance TBE risk for both humans and wildlife. This association is relevant to support the hypothesis that the maintenance of highly diverse ecosystems mitigates disease risk.

Effects of integrated motor imagery practice on gait of individuals with chronic stroke: a half-crossover randomized study.

OBJECTIVES: To test the effects of a new motor imagery practice approach, in which motor and motivational contents were integrated in order to improve gait in subjects with chronic poststroke hemiparesis. DESIGN: A half-crossover study composed of 2 phases. In phase 1, subjects were randomly assigned to receive either the experimental or the control treatment. In phase 2, the subjects who had initially received the control treatment "crossed over" to receive the experimental intervention. SETTING: The experimental and the control intervention were delivered in the subjects' homes; assessments were performed in a hospital laboratory. PARTICIPANTS: Community-dwelling individuals (N=23) with chronic poststroke hemiparesis whose gait was impaired. INTERVENTIONS: The experimental intervention, called integrated motor imagery practice, consisted of imagery scripts aimed at improving home and community walking as well as fall-related self-efficacy. The control treatment consisted of executed exercises to improve the function of the involved upper extremity. MAIN OUTCOME MEASURES: In-home walking, indoor and outdoor community ambulation, and fall-related self-efficacy. These were assessed before and after the intervention as well as at a 2-week follow-up. RESULTS: In-home walking was significantly improved after application of the experimental intervention (P≤.003), but not after the control treatment (P≤.68). Community ambulation did not improve. Fall-related self-efficacy was slightly improved by the integrated motor imagery intervention; however, the findings were not unequivocal. CONCLUSIONS: Home delivery of integrated motor imagery practice was feasible and exerted a positive effect on walking in the home. However, it was ineffective for improving gait in public domains. We speculate that the addition of physical practice to imagery practice may be essential for achieving that end.

Minimally supervised multimodal exercise to reduce falls risk in economically and educationally disadvantaged older adults.

Few studies have evaluated the benefit of providing exercise to underprivileged older adults at risk for falls. Economically and educationally disadvantaged older adults with previous falls (mean age 79.06, SD = 4.55) were randomized to 4 mo of multimodal exercise provided as fully supervised center-based (FS, n = 45), minimally supervised home-based (MS, n = 42), or to nonexercise controls (C, n = 32). Comparing groups on the mean change in fall-relevant mobility task performance between baseline and 4 mo and compared with the change in C, both FS and MS had significantly greater reduction in timed up-and-go, F(2,73) = 5.82, p = .004, η2 p = .14, and increase in tandem-walk speed, F(2,73) = 7.71, p < .001 η2 p = .17. Change in performance did not statistically differ between FS and MS. In community-dwelling economically and educationally disadvantaged older adults with a history of falls, minimally supervised home-based and fully supervised center-based exercise programs may be equally effective in improving fall-relevant functional mobility.

Evaluating a moving target: Using Practical Participatory Evaluation (P-PE) in hospital settings.

This article describes lessons learned about implementing evaluations in hospital settings. In order to overcome the methodological dilemmas inherent in this environment, we used a practical participatory evaluation strategy to engage as many stakeholders as possible in the process of evaluating a clinical demonstration project. Demonstration projects, in this context, push the envelope about what is known about effectiveness in novel settings, and turnover of staff and patient populations can present challenges to gathering optimal data. By using P-PE, we built capacity in the environment while expanding possibilities for data collection. Suggestions are made based on our experience.

Minimizing fall-related injuries in at-risk older adults: The falling safely training (FAST) study protocol.

Background: Falls are the leading cause of accidental injury among the elderly. Fall prevention is currently the main strategy to minimize fall-related injuries in at-risk older adults. However, the success of fall prevention programs in preventing accidental injury in elderly populations is inconsistent. An alternative novel approach to directly target fall-related injuries is teaching older adults movement patterns which reduce injury risk. The purpose of the current study will be to explore the feasibility and preliminary efficacy of teaching at-risk older adults safe-falling strategies to minimize the risk of injury. Methods/design: The Falling Safely Training (FAST) study will be a prospective, single-blinded randomized controlled trial. A total of 28 participants will be randomly assigned to four weeks of FAST or to an active control group with a 1:1 allocation. People aged ≥65 years, at-risk of injurious falls, and with normal hip bone density will be eligible. The FAST program will consist of a standardized progressive training of safe-falling movement strategies. The control group will consist of evidence-based balance training (modified Otago exercise program). Participants will undergo a series of experimentally induced falls in a laboratory setting at baseline, after the 4-week intervention, and three months after the intervention. Data on head and hip movement during the falls will be collected through motion capture. Discussion: The current study will provide data on the feasibility and preliminary efficacy of safe-falling training as a strategy to reduce fall impact and head motion, and potentially to reduce hip and head injuries in at-risk populations. Registration: The FAST study is registered at http://Clinicaltrials.gov (NCT05260034).