Lower-limb inter-joint coordination during balance recovery after trips.

BACKGROUND: Trips are one of the most common external perturbations that can lead to accidental falls. Knowledge about postural control attributes of balance recovery after trips could help reveal the biomechanical causes for trip-induced falls and provide implications for fall prevention interventions. RESEARCH QUESTION: The objective of the present study was to examine coordinated lower-limb movements during balance recovery after trips. METHODS: One hundred and twenty-three volunteers participated in an experimental study. They were tripped unexpectedly by a metal pole when walking on a linear walkway at their self-selected speed. Lower-limb inter-joint coordination quantified by continuous relative phase measures, including the mean of the absolute relative phases (MARP) and the deviation phase (DP), was analyzed during the execution of the first recovery step after unexpected trips. RESULTS: Compared to unsuccessful balance recovery, smaller MARPknee-ankle and DPknee-ankle of successful recovery were observed with distal inter-joint coordination on the swing side. Inter-joint coordination of the stance limb did not significantly differ between successful and unsuccessful recovery conditions. These findings indicate that the control of the swing limb's distal joints is crucial for regaining balance after trips. SIGNIFICANCE: An implication derived from this study is that greater in-phase coordination and smaller coordination variability in distal joints of the swing limb could be considered as potential targets for interventions aimed at preventing trip-induced accidental.

[Analysis of the Effectiveness of a Fall Prevention Program Incorporating an Interprofessional Team Collaboration Model on Reducing Fall Risk in Elderly Living in Long-term Care Facilities].

BACKGROUND: Concurrent with population ageing, falls have become a significantly more challenging public health issue among older adults. Three years of data collected recently from a nursing home in northern Taiwan reveals an increasing trend in fall density that is primarily associated with aging, physiological decline, chronic diseases, polypharmacy, osteoporosis, and lack of exercise. The percentage of nursing home residents at high risk of falls is currently at 12.6%, and the fall rate has been reported as reaching as high as 30% annually. PURPOSE: A fall prevention program was implemented to reduce the fall incidence rate to 18%, with secondary goals of improving fall prevention awareness, behavior, self-efficacy, lower limb muscle strength, balance, and gait by 10% on average, respectively, between pre-test and post-test. RESOLUTION: From September 30, 2023 to February 29, 2024, a health promotion activity and fall prevention exercise course were implemented using an interdisciplinary team collaboration model over a six-week period, providing individualized exercise for the participants. RESULTS: The study included 20 older adults with an average age of 88 years. Most (90%; n = 18) had chronic diseases, 25% (n = 5) were on more than nine medications, 70% (n = 14) had reduced bone mass, and 40% (n = 8) were at high risk of falls, with a fall incidence rate of 30% during the immediately preceding year. Post-intervention, the fall incidence rate dropped to 5%, fall prevention awareness, behavior, and self-efficacy increased by 18.3%, and lower limb muscle strength, balance, and gait improved by 11.7%. The post-test results in fall prevention awareness, behavioral changes, self-efficacy, and lower limb strength, balance, and gait were all significantly better than pre-test results, with all results achieving statistical significance. CONCLUSIONS: The project results support the positive effects of the developed intervention effectively on elderly physical fitness and fall risk, providing valuable insights for the implementation of fall prevention strategies in nursing homes.

Ability of Heart Rate Recovery and Gait Kinetics in a Single Wearable to Predict Frailty: Quasiexperimental Pilot Study.

BACKGROUND: Aging is a risk factor for falls, frailty, and disability. The utility of wearables to screen for physical performance and frailty at the population level is an emerging research area. To date, there is a limited number of devices that can measure frailty and physical performance simultaneously. OBJECTIVE: The aim of this study is to evaluate the accuracy and validity of a continuous digital monitoring wearable device incorporating gait mechanics and heart rate recovery measurements for detecting frailty, poor physical performance, and falls risk in older adults at risk of falls. METHODS: This is a substudy of 156 community-dwelling older adults ≥60 years old with falls or near falls in the past 12 months who were recruited for a fall prevention intervention study. Of the original participants, 22 participants agreed to wear wearables on their ankles. An interview questionnaire involving demographics, cognition, frailty (FRAIL), and physical function questions as well as the Falls Risk for Older People in the Community (FROP-Com) was administered. Physical performance comprised gait speed, timed up and go (TUG), and the Short Physical Performance Battery (SPPB) test. A gait analyzer was used to measure gait mechanics and steps (FRAIL-functional: fatigue, resistance, and aerobic), and a heart rate analyzer was used to measure heart rate recovery (FRAIL-nonfunctional: weight loss and chronic illness). RESULTS: The participants' mean age was 74.6 years. Of the 22 participants, 9 (41%) were robust, 10 (46%) were prefrail, and 3 (14%) were frail. In addition, 8 of 22 (36%) had at least one fall in the past year. Participants had a mean gait speed of 0.8 m/s, a mean SPPB score of 8.9, and mean TUG time of 13.8 seconds. The sensitivity, specificity, and area under the curve (AUC) for the gait analyzer against the functional domains were 1.00, 0.84, and 0.92, respectively, for SPPB (balance and gait); 0.38, 0.89, and 0.64, respectively, for FRAIL-functional; 0.45, 0.91, and 0.68, respectively, for FROP-Com; 0.60, 1.00, and 0.80, respectively, for gait speed; and 1.00, 0.94, and 0.97, respectively, for TUG. The heart rate analyzer demonstrated superior validity for the nonfunctional components of frailty, with a sensitivity of 1.00, specificity of 0.73, and AUC of 0.83. CONCLUSIONS: Agreement between the gait and heart rate analyzers and the functional components of the FRAIL scale, gait speed, and FROP-Com was significant. In addition, there was significant agreement between the heart rate analyzer and the nonfunctional components of the FRAIL scale. The gait and heart rate analyzers could be used in a screening test for frailty and falls in community-dwelling older adults but require further improvement and validation at the population level.

Enhancing Patient Safety Through an Integrated Internet of Things Patient Care System: Large Quasi-Experimental Study on Fall Prevention.

BACKGROUND: The challenge of preventing in-patient falls remains one of the most critical concerns in health care. OBJECTIVE: This study aims to investigate the effect of an integrated Internet of Things (IoT) smart patient care system on fall prevention. METHODS: A quasi-experimental study design is used. The smart patient care system is an integrated IoT system combining a motion-sensing mattress for bed-exit detection, specifying different types of patient calls, integrating a health care staff scheduling system, and allowing health care staff to receive and respond to alarms via mobile devices. Unadjusted and adjusted logistic regression models were used to investigate the relationship between the use of the IoT system and bedside falls compared with a traditional patient care system. RESULTS: In total, 1300 patients were recruited from a medical center in Taiwan. The IoT patient care system detected an average of 13.5 potential falls per day without any false alarms, whereas the traditional system issued about 11 bed-exit alarms daily, with approximately 4 being false, effectively identifying 7 potential falls. The bedside fall incidence during hospitalization was 1.2% (n=8) in the traditional patient care system ward and 0.1% (n=1) in the smart ward. We found that the likelihood of bedside falls in wards with the IoT system was reduced by 88% (odds ratio 0.12, 95% CI 0.01-0.97; P=.047). CONCLUSIONS: The integrated IoT smart patient care system might prevent falls by assisting health care staff with efficient and resilient responses to bed-exit detection. Future product development and research are recommended to introduce IoT into patient care systems combining bed-exit alerts to prevent inpatient falls and address challenges in patient safety.

Administrative Analysis of the Home-Based Older Persons Upstreaming Prevention Physical Therapy Program: A Pilot Observational Study.

Introduction Traditionally, physical therapist (PT) services do not commence until an injury, fall, or health issue has already occurred although there is increasing evidence that preventative programs administered by PTs may decrease the fall risk among elderly individuals. The purpose of this study was to examine billing, reimbursement, and administrative outcomes of the previously established and investigated prevention-based screening and intervention HOP-UP-PT (Home-based Older Persons Upstreaming Prevention-Physical Therapy) program delivered by a physical therapist in the home of older adults after being referred by a community partner. A randomized controlled trial of the HOP-UP-PT program demonstrated an 8-fold reduction in falls for participants at moderate and high fall risk compared to those who did not participate in the program. Methods A prospective observational study was performed to examine administrative and payment outcomes of HOP-UP-PT participation. Participants were referred into the HOP-UP-PT program via a local community center. Physician authorization for physical therapy participation was obtained for each participant as required for payment under United States' Center for Medicare and Medicaid Services (CMS) guidelines. The HOP-UP-PT program is preventative physical therapy delivered in the person's home with five in person visits (approximately one per month) followed by a monthly telehealth visit and a final in-person visit. Interventions included a balance program, home safety recommendations, health coaching, and addressing individual risks of falling or becoming homebound. A retrospective analysis was performed on the administrative and insurance payment data from this study which was then analyzed descriptively. Results Six participants with four different insurances completed the 7-month program (mean age=77 years) in 2021. The physical therapy visits were submitted to the participants' Medicare Part B plan. One participant's physical therapy visits were not submitted for payment as the health system did not have an active agreement with that health insurer. Due to the unclear status of telehealth visits in 2021, these services were not submitted to the insurance company for payment. All other PT visits were paid by the insurance companies. The mean amount paid for the initial evaluation code was $102.83 and the mean payment for the ~15 minute treatment codes was $25.90 per unit. Initial pilot data demonstrated a potential for a 4.2% positive operating margin when considering salary costs and travel. The mean delay from the initial referral into the HOP-UP-PT program until the physician provided written authorization for physical therapy was 69.7 days. Conclusion This study demonstrated initial evidence that payment for prevention-focused outpatient physical therapist services delivered in the home was feasible, however delays and costs in procuring physician authorization was a substantial barrier to prevention-focused physical therapy. A 4.2% operating margin demonstrated that, when efficiently operated, similar programs are likely to be viable. Furthermore, if telehealth services would have been paid, the operating margin was estimated to increase to 32%. Physical therapists are highly qualified to deliver efficient, effective preventative services which has the potential to reduce falls and institutionalization and subsequent healthcare cost savings.

Unveiling human biomechanics: insights into lower limb responses to disturbances that can trigger a fall.

Introduction: Slip-related falls are a significant concern, particularly for vulnerable populations such as the elderly and individuals with gait disorders, necessitating effective preventive measures. This manuscript presents a biomechanical study of how the lower limbs react to perturbations that can trigger a slip-like fall, with the ultimate goal of identifying target specifications for developing a wearable robotic system for slip-like fall prevention. Methods: Our analysis provides a comprehensive understanding of the natural human biomechanical response to slip perturbations in both slipping and trailing legs, by innovatively collecting parameters from both the sagittal and frontal plane since both play pivotal roles in maintaining stability and preventing falls and thus provide new insights to fall prevention. We investigated various external factors, including gait speed, surface inclination, slipping foot, and perturbation intensity, while collecting diverse data sets encompassing kinematic, spatiotemporal parameters, electromyographic data, as well as torque, range of motion, rotations per minute, detection, and actuation times. Results: The biomechanical response to slip-like perturbations by the hips, knees, and ankles of the slipping leg was characterized by extension, flexion, and plantarflexion moments, respectively. In the trailing leg, responses included hip flexion, knee extension, and ankle plantarflexion. Additionally, these responses were influenced by gait speed, surface inclination, and perturbation intensity. Our study identified target range of motion parameters of 85.19°, 106.34°, and 95.23° for the hips, knees, and ankles, respectively. Furthermore, rotations per minute values ranged from 17.85 to 51.10 for the hip, 21.73 to 63.80 for the knee, and 17.52 to 57.14 for the ankle joints. Finally, flexion/extension torque values were estimated as -3.05 to 3.22 Nm/kg for the hip, -1.70 to 2.34 Nm/kg for the knee, and -2.21 to 0.90 Nm/kg for the ankle joints. Discussion: This study contributes valuable insights into the biomechanical aspects of slip-like fall prevention and informs the development of wearable robotic systems to enhance safety in vulnerable populations.

A Temporospatial Analysis of Activity Patterns for Fall Risk Assessment in Older Adults with Comorbid Type 2 Diabetes.

This study explores how daily activities, including duration and location within the home, affect fall risk in older adults with type 2 diabetes. Body-worn cameras on 26 participants provided data on activity (e.g. exercise), time and location (kitchen, living room). Demographics and health factors were considered to understand their influence. By visualising activity patterns, this study aimed to identify behaviours linked to falls to inform personalised fall prevention strategies and digital technologies for independent living.

Effectiveness of evidence-based fall prevention programs to reduce loneliness in the United States.

Introduction: Falls are associated with activity limitations and injuries among older adults. An estimated 25% of older adults fall each year, and over 40% of older adults report they are lonely. Small group, evidence-based fall prevention programs are widely available in the United States and may be a strategy to improve social connectedness within our aging population. The purpose of this study was to identify the effectiveness of evidence-based fall prevention programs to reduce loneliness among older adults. Administration for Community Living (ACL) grantee data were collected in a national repository. Methods: Data were analyzed from 12,944 participants across 12 fall prevention programs (e.g., A Matter of Balance, Stepping On, Tai Ji Quan, Otago Exercise Program, Bingocize) between January 2021 and July 2023. To assess loneliness, participants were asked, "how often do you feel lonely or isolated?" The response choices for this single 5-point item ranged from "never" to "always." A linear mixed-effects multivariable regression, with program type included as a random effect, was fitted to assess changes in loneliness before and after fall prevention workshops. The model controlled for program type and delivery site type as well as participants' age, sex, ethnicity, race, education, living alone, number of chronic conditions, number of falls in the three months preceding baseline, and workshop delivery site type and attendance. Results: Significant reductions in loneliness scores were observed from baseline to post-workshop (p < 0.001), which were more pronounced among participants with more frequent baseline loneliness (p < 0.001). Participants who attended more workshop sessions reported reduced loneliness at post-workshop (p = 0.028). From baseline to post-workshop, loneliness increased among participants who lived alone (p < 0.001) and reported two or more falls in the three months preceding baseline (p =0.002). From baseline to post-workshop, compared to White participants, increased loneliness was observed among Black (p = 0.040), and Asian (p < 0.001) participants. Participants with more chronic conditions reported more loneliness from baseline to post-workshop (p = 0.004). Relative to participants who attended workshops at senior centers, increased loneliness was observed among participants who attended workshops at residential facilities (p = 0.034) and educational institutions (p = 0.035). Discussion: Findings expand our understanding about the benefits of small-group fall prevention workshops to reduce loneliness among older participants. Results suggest that disease profiles, living alone, fall history, and workshop location (and attendee dynamic) may impede social connection among some participants. Beyond small group activities, purposive strategies should be embedded within fall prevention programs to foster meaningful interactions and a sense of belonging between participants. Other social connection programs, services, and resources may complement fall prevention programming to reduce loneliness.

Effects of Stroboscopic Goggles on Standing Balance in the Spatiotemporal and Frequency Domains: An Exploratory Study.

Balance training paradigms have been shown to effectively reduce fall risk. Visual feedback is an important sensory mechanism for regulating postural control, promoting visual perturbations for balance training paradigms. Stroboscopic goggles, which oscillate from transparent to opaque, are a form of visual perturbation, but their effect on standing balance has not been assessed. In this study, 29 participants stood in bilateral and tandem stances as the center of pressure was recorded for 6 consecutive minutes wherein there were no stroboscopic perturbations in the first and last minutes. Spatial-temporal, frequency domain, and nonlinear standing balance parameters were calculated for each period. More differences in spatial-temporal parameters due to the strobe were found in the medial-lateral direction than the anterior-posterior direction. More differences in frequency domain parameters were observed in the anterior-posterior direction than the medial-lateral direction, but this did not occur for each variable. The nonlinear parameters were strongly affected by the strobe. Stroboscopic perturbations did not affect the bilateral and tandem stances equally. Spatial-temporal parameters for the tandem stance were greater in magnitude during the strobe period than the no strobe periods. This effect was not seen with the bilateral stance. This indicates that the efficacy of stroboscopic perturbations for challenging standing balance depends on task difficulty. Balance training paradigms that utilize stroboscopic perturbations will need to harmonize these perturbations with task difficulty.

Qualitative Comparative Analysis of exercise interventions for fall prevention in residential aged care facilities.

BACKGROUND: Exercise interventions are highly effective at preventing falls in older people living in the community. In residential aged care facilities (RACFs), however, the evidence for effectiveness is highly variable, warranting exploration of drivers of successful trials. This study aims to identify the conditions of randomised controlled trials (RCTs) that are associated with reducing falls in RACFs and test whether it can explain the variability. METHODS: RCTs testing exercise interventions in RACFs compared to usual care, reporting rate or risk of falls from the 2018 Cochrane Collaboration review and a search update to December 2022 were included. Two authors independently extracted and coded trial conditions and outcomes according to a theory developed from prior Intervention Component Analysis. Trial outcomes were coded as successful or unsuccessful based on point estimates for the rate or risk ratio for falls, or p value. Qualitative Comparative Analysis (QCA), utilising Boolean minimisation theory, was conducted to determine the key conditions driving trial success. A subgroup meta-analysis and the GRADE approach was applied to the final theory. RESULTS: Eighteen trials undertaken in 11 countries with 2,287 residents were included. Participants were predominately ambulant females aged 70 to 80 with cognitive impairment. Most interventions were fully supervised or supervised at the start of the intervention. QCA identified two configurations as drivers of successful exercise falls prevention programs: (i) group exercise that is moderate or low intensity, or (ii) for independent ambulatory residents, exercise for more than 1 h per week. The combination of configuration (i) and (ii) had consistency and total coverage scores of 1, indicating all trials were explained. This combination was associated with a reduction in falls (rate ratio 0.45, 95%CI 0.34 to 0.59; risk ratio 0.66, 95%CI 0.53 to 0.82; low certainty evidence). CONCLUSION: To successfully reduce falls in RACFs, exercise programs should provide continuous supervised moderate-intensity group exercise. For programs that mostly include independent ambulatory residents, exercise for at least 80 min per week should be provided. As many current residents are frail, tailored exercise is likely necessary and an individualised dose may be required. Future trials should test exercise interventions for less mobile residents.