Nature-based interventions for physical health conditions: A systematic review and meta-analysis.

Nature-based interventions (NBIs) are activities, strategies, or programs taking place in natural settings, such as exercising in greenspaces, to improve the health and well-being of people by integrating the benefits of nature exposure with healthy behaviours. Current reviews on NBIs do not report the effects on different groups of physical health conditions. The purpose of this systematic review and meta-analysis was to identify and synthesize the evidence of the effect of NBIs on physical health outcomes and biomarkers of physical health conditions. Overall, 20,201 studies were identified through searching MEDLINE, Embase, CINAHL, SPORTDiscus, and CENTRAL databases up to June 7, 2024. Inclusion criteria were: 1) randomized controlled intervention studies; 2) population with a physical health condition; 3) NBIs vs. different intervention or no intervention; and 4) measuring physical health outcomes and/or biomarkers. Twenty-six studies were included in the review, 15 of which contributed to the meta-analysis. Compared to control groups, NBIs groups showed significant improvements in: diastolic blood pressure (MD -3.73 mmHg [-7.46 to -0.00], I2 = 62%) and heart rate (MD -7.44 bpm [-14.81 to -0.06], I2 = 0%) for cardiovascular conditions, fatigue (SMD -0.50 [-0.82 to -0.18], I2 = 16%) for central nervous system conditions, and body fat percentage (MD -3.61% [-5.05 to -2.17], I2 = 0%) for endocrine conditions. High effect heterogeneity was found in several analyses and the included studies had moderate-to-high risk of bias (RoB). The non-significant outcomes showed a direction of effect in favour of NBI groups for cardiovascular, central nervous system, endocrine, musculoskeletal, and respiratory conditions. This review found some beneficial effects in favour of NBIs for health outcomes in at least three condition groups though RoB and inconsistent effects limited some interpretations. NBIs are promising therapies that healthcare professionals can consider integrating into clinical practice.

Prevalence of vision loss among hospital in-patients; a risk factor for falls?

PURPOSE: Despite poor vision being a risk factor for falls, current hospital policies and practices often do not include a vision assessment at patient admission or in the hospital's incident reporting system when a fall occurs. Our purpose was to document the prevalence of vision loss in hospital general medicine units to increase awareness of poor vision as a potential risk factor for falls that occur within the hospital, and inform future preventative practice. METHODS: This cross-sectional study took place in medicine units of an acute care hospital. Participants were adult in-patients. Visual acuity (VA), contrast sensitivity and stereoacuity were measured, and patients were screened for field loss, extinction and neglect. RESULTS: 115 participants took part (average age 67 ± 17, 48% female). Overall, 89% had a visual impairment defined as being outside the age-norms for one or more vision measure, 62% had low vision, and 36% had vision loss equivalent to legal blindness [VA equal to or poorer than 1.0 logMAR (6/60, 20/200) or ≥10x below age-norms]. There was a considerable discrepancy between the prevalence of low vision and the percentage of patients who reported an ocular diagnosis that would result in visual loss (30%). Ten patients fell during the study period, and of these 100% had visual impairment, 90% had low vision and 60% had vision loss equivalent to legal blindness, which compares to 58%, 22% and 9% for non-fallers. Similar high prevalences were found in those whose reason for admission to the hospital was a fall (92%, 63% and 33% respectively). CONCLUSIONS: Vision loss has a high prevalence among patients in hospital medicine units, and is higher still among those who fall. Since vision loss may be a contributing factor to falls that occur in hospitals, implementing an assessment of vision at hospital admission would be useful to alert staff to those patients who are at risk for falls due to poor vision, so that preventative measures can be applied.

"I Just Roll Over, Pick Myself Up, and Carry On!" Exploring the Fall-Risk Experience of Canadian Masters Athletes.

OBJECTIVES: The risk of falling increases in adults aged 65 years and older. A common barrier to take up physical activity in sedentary older adults is the fear of falls and injury. Experiences of master athletes can provide insights into management of the risk of falling. The purpose of this phenomenological study was to explore the fall-risk experience of masters athletes actively competing in sport. METHODS: Masters athletes aged 55 years and older (N = 22) described their experiences in semistructured interviews. Data were analyzed through an interpretive-constructivist paradigm using inductive content analysis. RESULTS: Five dominant themes emerged: acceptance, learning, awareness, resilience, and self-fulfillment. Participants of this study reported an acceptance of the risk they take in sport for falls and injuries in their pursuits for self-fulfillment. DISCUSSION: Findings indicate that master athletes accept the risk for falls and injuries in sport, find ways to adapt, and continue to compete because it is self-fulfilling. Sharing their experiences might inspire other older adults to get active as a rewarding means of remaining independent.

Improving safety culture in hospitals: Facilitators and barriers to implementation of Systemic Falls Investigative Method (SFIM).

OBJECTIVE: The purpose of this study was to assess the facilitators and barriers to implementation of the Systemic Falls Investigative Method (SFIM) on selected hospital units. DESIGN: A cross-sectional explanatory mixed methods design was used to converge results from a standardized safety culture survey with themes that emerged from interviews and focus groups. Findings were organized by six elements of the Ottawa Model of Research Use framework. SETTING: A geriatric rehabilitation unit of an acute care hospital and a neurological unit of a rehabilitation hospital were selected purposefully due to the high frequency of falls. PARTICIPANTS: Hospital staff who took part in: surveys (n = 39), interviews (n = 10) and focus groups (n = 12), and 38 people who were interviewed during falls investigations: fallers, family, unit staff and hospital management. INTERVENTION: Implementation of the SFIM to investigate fall occurrences. MAIN OUTCOME MEASURE(S): Percent of positive responses on the Modified Stanford Patient Safety Culture Survey Instrument converged with qualitative themes on facilitators and barriers for intervention implementation. RESULTS: Both hospital units had an overall poor safety culture which hindered intervention implementation. Facilitators were hospital accreditation, strong emphasis on patient safety, infrastructure and dedicated champions. Barriers included heavy workloads, lack of time, lack of resources and poor communication. CONCLUSIONS: Successful implementation of SFIM requires regulatory and organizational support, committed frontline staff and allocation of resources to identify active causes and latent contributing factors to falls. System-wide adjustments show promise for promotion of safety culture in hospitals where falls happen regularly.

Medication Prescribed Within One Year Preceding Fall-Related Injuries in Ontario Older Adults.

Background: Serious injuries secondary to falls are becoming more prevalent due to the worldwide ageing of societies. Several medication classes have been associated with falls and fall-related injuries. The purpose of this study was to describe medication classes and the number of medication classes prescribed to older adults prior to the fall-related injury. Methods: This population-based descriptive study used secondary administrative health-care data in Ontario, Canada for 2010-2014. Descriptive statistics were reported for Anatomic Therapeutic Chemical 4th level medication classes. Frequency of medications prescribed to older adults was calculated on different sex, age groups, types of medications, and injures. Results: Over five years (2010-2014), 288,251 older adults (63.2% females) were admitted to an emergency department for a fall-related injury (40.0% fractures, 12.1% brain injury). In the year before the injury, 48.5% were prescribed statins, 27.2% antidepressants, 25.0% opioids, and 16.6% anxiolytics. Females were prescribed more diuretics, antidepressants, and anxiolytics than males; and people aged 85 years and older had a higher percentage of diuretics, antidepressants, and antipsychotics. There were 36.4% of older adults prescribed 5-9 different medication classes and 41.2% were prescribed 10 or more medication classes. Discussion: Older adults experiencing fall-related injuries were prescribed more opioids, benzodiazepines, and antidepressants than previously reported for the general population of older adults in Ontario. Higher percentage of females and more 85+ older adults were prescribed with psychotropic drugs, and they were also found to be at higher risk of fall-related injuries. Further associations between medications and fall-related injuries need to be explored in well-defined cohort studies.

Medication Review in Preventing Older Adults' Fall-Related Injury: a Systematic Review & Meta-Analysis.

BACKGROUND: Medication review is essential in managing adverse drug reactions and improving drug safety in older adults. This systematic review evaluated medication review's role as a single intervention or combined with other interventions in preventing fall-related injuries in older adults. METHODS: Electronic databases search was conducted in PubMed, EMBASE, Scopus, and CINAHL. Two reviewers screened titles and abstracts, reviewed full texts, and performed data extraction and risk of bias assessment. Meta-analyses were conducted on studies with similar participants, interventions, outcomes or settings. RESULTS: Fourteen randomized, controlled studies were included. The pooled results indicated that medication review as a stand-alone intervention was effective in preventing fall-related injuries in community-dwelling older adults (Risk Difference [RD] = -0.06, 95% CI: [-0.11, -0.00], I2 = 61%, p = .04). Medication review also had a positive impact on decreasing the risk of fall-related fractures (RD = -0.02, 95% CI: [-0.04, -0.01], I2 = 0%, p = .01). DISCUSSION: This systematic review and meta-analysis has demonstrated that medication review is effective in preventing fall-related injuries in general, and fractures specifically, in community-dwelling older adults. Future investigations focusing on the process of performing medication review will further inform fall-related injury prevention for older adults.

A Sustainability Oriented and Mentored Approach to Implementing a Fall Prevention Guideline in Acute Care Over 2 Years.

The purpose of this study was to assess the impact of a mentored guideline implementation (Registered Nurses' Association of Ontario Prevention of Falls and Falls Injuries in the Older Adult Best Practice Guideline) focused on enhancing sustainability in reducing fall rates and number of serious falls and the experience of staff in three acute care hospitals. The National Health Service (NHS) Sustainability Model was used to guide the study. Interviews and focus groups were held with 82 point-of-care professional staff, support staff, volunteers, project leaders, clinical leaders, and senior leaders. Study results supported the importance of the factors in the NHS model for sustainability of the guideline in these practice settings. There were no statistically significant decreases in the overall fall rate and number of serious falls. The results supported strategies of participating hospitals to become senior friendly organizations and provided opportunities to enhance staff collaboration with patients and families.

Seniors Falls Investigative Methodology (SFIM): a systems approach to the study of falls in seniors.

An in-depth understanding of human factors and human error is lacking in current research on seniors' falls. Additional knowledge is needed to understand why seniors are falling. The purpose of this article is to describe the adapting of the Integrated Safety Investigation Methodology (ISIM) (used for investigating transportation and industrial accidents) to studying seniors' falls. An adapted version-the Seniors Falls Investigative Methodology (SFIM)-uses a systems approach to take an investigation beyond the immediate cause of an incident and reveal unsafe acts and deeply imbedded unsafe conditions that contribute to adverse outcomes. An example case study is used to describe six phases of the investigative process in detail. The SFIM has the potential to identify safety deficiencies; utilize existing knowledge about falls; establish a standardized reporting system; shift focus from the faller to the system; and guide targeted prevention.

Defining a fall and reasons for falling: comparisons among the views of seniors, health care providers, and the research literature.

PURPOSE: The purpose of this study was (a) to obtain information about the perceptions held by seniors and health care providers concerning what constitutes a fall and potential reasons for falling, and (b) to compare these perceptions to the research literature. DESIGN AND METHODS: As part of a larger telephone survey, interviewers asked 477 community-dwelling seniors to define a fall and to provide reasons for falling. In addition, we interviewed 31 health care providers from the community on the same topics. In order to capture patterns in conceptualized thinking, we used content analysis to develop codes and categories for a fall definition and reasons for falling. We reviewed selected articles in order to obtain a comprehensive overview of fall definitions currently used in the research and prevention literature. RESULTS: A fall had different meanings for different groups. Seniors and health care providers focused mainly on antecedents and consequences of falling, whereas researchers described the fall event itself. There were substantial differences between the reasons for falling as reported by seniors and the risk factors as identified in the research literature. IMPLICATIONS: If not provided with an appropriate definition, seniors can interpret the meaning of a fall in many different ways. This has the potential to reduce the validity in studies comparing fallers to nonfallers. Research reports and prevention programs should always provide an operational definition of a fall. In communication between health care providers and seniors, an appropriate definition increases the possibility for early detection of seniors in greater need of care and services.

"People are Getting Lost a Little Bit": Systemic Factors that Contribute to Falls in Community-Dwelling Octogenarians.

Octogenarians living in the community are the fastest-growing demographic in Canada. Simultaneously, they have the highest prevalence of falls and nine times greater risk of injury due to a fall. To understand how to improve the safety of octogenarians' aging-in-place, a systems approach is essential. Understanding how societal factors interact and affect the older adult can help care custodians identify and remove safety deficiencies that bring about falls. The purpose of this study was to identify system-wide factors contributing to falls in community-dwelling octogenarians. Eight falls were investigated using the systemic falls investigative method. Participants ranged in age from 83-90 years. Across-case analyses identified 247 contributing factors, grouped within four distinct themes: (a) everyday living has become risky; (b) supervision limitations; (c) health care system disconnects; and (d) poor fall risk identification and follow-up. This qualitative study provides systemic insights into how and why falls occur in community-dwelling octogenarians.

Mobility and Cognition in Seniors. Report from the 2008 Institute of Aging (CIHR) Mobility and Cognition Workshop.

BACKGROUND: The annual Scientific Meeting of the Canadian Association on Gerontology was held on October 24 and 25, 2008 in London, Ontario. Prior to the annual meeting, mobility and cognition experts met on October 23, 2008 to engage in a pre-conference workshop. METHODS: Discussions during the workshop addressed novel areas of research and knowledge and research gaps pertaining to the interaction between mobility and cognition in seniors. RESULTS: Workshop presenters moved from the neuromuscular, biomechanics, and neurology of gait impairments, and falls through the role of cognition and mood on mobility regulation to the whole person in the environment. Research gaps were identified. CONCLUSIONS: Despite a consensus that mobility and cognition are increasingly correlated as people age, several gaps in our understanding of mechanisms and how to assess the interaction were recognized. The gaps originally identified in 2008 are still pertinent today. Common and standardized assessments for "mobility and cognition" are still not in place in current practice. Interventions that target mobility and cognitive decline as a single entity are still lacking.

Managing agitation using nonpharmacological interventions for seniors with dementia.

Approximately 36 million people have Alzheimer's disease worldwide, and many experience behavioral issues such as agitation. The purpose of this study was to investigate the perceptions of long-term care (LTC) staff regarding the current use of nonpharmacological interventions (NPIs) for reducing agitation in seniors with dementia and to identify facilitators and barriers that guide NPI implementation. Qualitative methods were used to gather data from interviews and focus groups. A total of 44 staff from 5 LTC facilities participated. Findings showed that both medications and NPIs are used for the management of agitation. The use of NPIs was facilitated by consistency in staffing, and the ability of all the staff members to implement them. Common barriers to NPI use included the perceived lack of time, low staff-to-resident ratios, and the unpredictable and short-lasting effectiveness of NPIs. This study offers insight into perceived factors that influence implementation of NPIs and the perceived effectiveness of NPIs.

Toe-out, lateral trunk lean, and pelvic obliquity during prolonged walking in patients with medial compartment knee osteoarthritis and healthy controls.

OBJECTIVE: To compare the time-varying behavior of maximum toe-out angle, lateral trunk lean (over the stance leg), and pelvic obliquity (rise and drop on the swing leg) during prolonged walking in participants with and without medial compartment knee osteoarthritis (OA), and to explore correlations between these gait characteristics and pain. METHODS: Twenty patients with knee OA and 20 healthy controls completed 30 minutes of treadmill walking. Toe-out, trunk lean, pelvic obliquity, and pain were measured at 5-minute intervals. RESULTS: The mean ± SD toe-out angle was significantly smaller (P = 0.04) in patients with knee OA (6.7 ± 2.5 degrees) than in controls (10.3 ± 2.2 degrees). Toe-out changed significantly over time (P = 0.002), but not in a systematic way, and there was no interaction between group and time. The mean ± SD trunk lean was higher (P = 0.03) in patients with knee OA (2.0 ± 1.0 degrees) than in controls (0.7 ± 0.5 degrees). Trunk lean did not change over time and there was no interaction between group and time. There were no differences for pelvic drop. The mean ± SD pelvic rise was higher (P = 0.01) in patients with knee OA (2.8 ± 0.9 degrees) than in controls (1.2 ± 0.8 degrees), but did not change over time and there was no interaction. Patients experienced a small increase in pain (P < 0.001). Trunk lean and pelvic drop were correlated with pain (r = 0.49, P = 0.03 and r = 0.47, P = 0.04, respectively). CONCLUSION: Toe-out and trunk lean are consistently different between individuals with and without medial compartment knee OA during prolonged walking, and patients with greater pain have greater trunk lean. However, over 30 minutes of walking, these gait characteristics remain quite stable, suggesting they are not acute compensatory mechanisms in response to repetitive loading with subtle increases in pain.

Estimating the cost of serious injurious falls in a Canadian acute care hospital.

Falls represent 40 per cent of hospital accidents, and consequences range from none to serious injuries. The purpose of this study was to estimate the average hospital cost and length of stay (LOS) associated with serious injurious falls in an acute care hospital. We used data from risk management and case costing databases to identify cost associated with a serious injury after an in-hospital fall. Thirty-seven injured patients were matched with 2,113 controls by the most responsible medical diagnosis, age, and gender. Cost and LOS were compared using t-tests and multivariate regression. Average costs for seriously injured fallers and non-faller controls were CAD$44,203 and CAD$13,507, while LOS was 45 and 11 days respectively. Hospital cost for a seriously injured faller was $30,696 (95% CI: $25,158 - $36,781) greater than the cost for a non-faller. Hospital managers have a leading role in creating system-wide falls prevention programs and reducing hospital costs.

Time-varying behaviour, test-retest reliability and concurrent validity of lateral trunk lean and toe-out angles during prolonged treadmill walking.

Lateral trunk lean over the stance limb and toeing-out are potential adaptive gait mechanisms that reduce knee joint loading. The purpose of the present study was to evaluate the time-varying behaviour, the test-retest reliability and the concurrent validity of lateral trunk lean angle and toe-out angle during prolonged walking in healthy adults. Twenty healthy volunteers (51±8 years, 12 females) completed two test sessions at least 24h apart but within the same week. For each participant, at each session, three-dimensional gait kinematics were assessed intermittently during 60min of treadmill walking. Additionally, over-ground three-dimensional gait analysis was performed immediately before and after the treadmill walking. Maximum lateral trunk lean angle and maximum toe-out angle did not change over time (p>0.05), were consistent from day to day (test-retest reliability: ICC=0.61-0.72 and 0.90-0.95, respectively) and were consistent with over-ground measures (concurrent validity: ICC=0.88 and 0.92, respectively). These findings suggest that lateral trunk lean angle and toe-out angle are consistent during prolonged walking and that these measures are reliable and valid for use in studying adaptive gait mechanisms.

Comparison of the original and reduced versions of the Berg Balance Scale and the Western Ontario and McMaster Universities Osteoarthritis Index in patients following hip or knee arthroplasty.

PURPOSE: To compare the original and reduced versions of the Berg Balance Scale (BBS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), as completed by patients following total hip arthroplasty (THA) or total knee arthroplasty (TKA), with respect to their potential utility in clinical and research settings. METHOD: Patients with THA (n=26) or TKA (n=28) were evaluated before and after 5 to 7 weeks' participation in a home-based exercise programme. They were assessed using the original versions of the BBS and the WOMAC; scores for the reduced versions of the BBS and the WOMAC were extracted from the original versions. RESULTS: Good to excellent correlations (r≥0.80) were observed between the original and the reduced versions of the BBS and the WOMAC. The index of responsiveness, evaluated using standardized response means (SRM), was similar for the original and the reduced versions of the BBS and the WOMAC function sub-scale. CONCLUSIONS: The reduced versions of the BBS and the WOMAC provided similar information to the original versions and were equally responsive. These reduced versions comprise fewer questions and may be completed in considerably less time, which suggests that they may be advantageous for clinical and research use.

Pragmatism in practice: mixed methods research for physiotherapy.

The purpose of this paper is to provide an argument for the place of mixed methods research across practice settings as an effective means of supporting evidence-based practice in physiotherapy. Physiotherapy practitioners use both qualitative and quantitative methods throughout the process of patient care-from history taking, assessment, and intervention to evaluation of outcomes. Research on practice paradigms demonstrates the importance of mixing qualitative and quantitative methods to achieve 'expert practice' that is concerned with optimizing outcomes and incorporating patient beliefs and values. Research paradigms that relate to this model of practice would integrate qualitative and quantitative types of knowledge and inquiry, while maintaining a prioritized focus on patient outcomes. Pragmatism is an emerging research paradigm where practical consequences and the effects of concepts and behaviors are vital components of meaning and truth. This research paradigm supports the simultaneous use of qualitative and quantitative methods of inquiry to generate evidence to support best practice. This paper demonstrates that mixed methods research with a pragmatist view provides evidence that embraces and addresses the multiple practice concerns of practitioners better than either qualitative or quantitative research approaches in isolation.

Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors.

PURPOSE: As a highly heterogeneous group, seniors live in complex environments influenced by multiple physical and social structures that affect their safety. Until now, the major approach to falls research has been person centered. However, in industrial settings, the individuals involved in an accident are seen as the inheritors of system defects. The objective of the present study was to investigate safety deficiencies that contributed to falls in community-dwelling seniors using a systems approach. DESIGN AND METHODS: The investigations were conducted using the Seniors Falls Investigation Methodology (SFIM), an adapted version of a method used to examine transportation accidents, such as airplane crashes. Fifteen seniors, who experienced a fall or near fall, participated in multiple case studies. A cross-case synthesis was used to summarize findings and identify common patterns of causes and safety deficiencies. RESULTS: Falls and near falls are a result of latent unsafe conditions, and unsafe acts and decisions combined in a diverse set of circumstances. If not identified and removed, these unsafe conditions can cause falls for other seniors. IMPLICATIONS: This study provided compelling evidence that causes of falling are systemic and develop over time. It demonstrated that the systems approach is needed to expand the focus from the individual to multilayered organizational and supervisory causes. The SFIM demonstrated capability to identify causes of falls that will allow better prevention and management programs, hence advancing seniors' safety. SFIM shows great potential for implementation in organized settings, such as hospitals and long-term care homes.