Literature Review

Literature Review: (Insert Title Here)– Due Term 1, Year 2 By: Kale Burbine – ID: B00494353, E-mail: kale.burbine@dal.ca, Phone: (902) 266-3358 Instructor: Carolyn A. King Advisor: Marie Earl- E-mail: marie.earl@dal.ca, Phone: (902) 494-2633, Fax: (902) 494-1941 Module 2 PHYT 5202: Dalhousie University School of Physiotherapy

Literature Review Explanatory Notes Using EBSCOhost and CINAHL headings I combined the keywords of falls prevention, seniors, and exercise to obtain 12 results from January 2000. I then determined falls prevention may not be a good choice for a keyword, so I changed my search to falls, AND intervention, AND exercise, AND seniors. Upon setting my results to only include studies from January 2000 to the present, I had access to six articles. Since this was not many results I decided to reduce the number of key words I was combining, and used many different combinations of the aforementioned keywords to much greater success. Initially, I was too narrow with my search. I also used another tactic which involved combining all of the falls assessment and reduction tools I could find as a main concept. Upon ―searching with AND‖ seniors, I obtained 66 helpful articles which were narrowed down via desired year. I also used the NCBI database with pubmed.gov and incorporated a similar strategy with this database as with EBSCOhost. Using the Sciencedirect database, as well as numerous other key words, did not yield desirable results.
I'm still mostly guessing at what terms you actually searched, but I would definitely suggest trying a headings search in CINAHL (look at the top of the page) and a MeSH search in Pubmed. Try "Accidental falls" as a heading, then "Exercise" OR "Exercise therapy", and combine the two sets with AND. Then use the limit function to limit to the age group you want. I'd definitely suggest you use the thesaurus search in any database you use: CINAHL headings, MeSH database in PubMed, or Emtree headings in EMBASE. That usually lets you search for "falls" or "accidental falls" as a concept, rather than looking for an occurrence of the word. Usually, that will also let you look for subheadings like "prevention and control," which usually do a good job of getting you to articles about interventions without having to think of a lot of different keywords that mean "that therapeutic thing we plan to do" (which can be rendered in a lot of different ways.

Literature Review Topic Overview and Background Unintentional injuries are the fifth leading cause of death in adults age 65 or older, with falls representing two-thirds of these aforementioned injuries.1 About 30% of individuals aged 65 years or older who live at home experience at least one fall per year.2 There is evidence, however, to support that up to 60% of community-dwelling elderly individuals experience at least one falling episode per year 3 but the former percentage is more frequently cited as the actual amount. In 2006, approximately 5.8 million (almost 16%) of Americans aged ≥65 years reported falling at least once during the preceding three months, and 1.8 million (31.3%) of those who fell sustained an injury that resulted in a doctor visit or restricted activity for at least one day.4 Although the numbers seem staggering, it is also worth noting that the risk of falling and sustaining an injury due to falling increases with age.3 With that being said, it is not surprising to find that in community-dwelling elderly over the age of 80, the frequency of falls exceeds 40% and may even reach 50%.5,6 For the residents who reside in a community setting, effective fall prevention is important. It has the ability to reduce the likelihood of injury caused by a fall, reduce the demand for nursing home placements, and reduce the number of hospital visits. Since most of these aspects place increased strain on the health-care system and contribute greatly to funds spent on the health-care budget, more effort should be implemented on developing programs and tools designed for fall prevention, although it has already been deemed as an important objective for the public health sector to improve in.7 The economic burden is staggering. Based on 1999 data, falls among seniors cost Nova Scotians $72 million per year and as the rate of falls increases, so will the associated economic

Literature Review costs.8 A 20% reduction in falls would translate to an estimated 7,500 fewer hospitalizations and 1,800 fewer permanently disabled seniors which could allow the overall national savings to reach $138 million annually.8 The incidence of Fall-related injuries has increased by over 130% over the past 30 years and is predicted to increase by an additional 100% by 2030.9 These statistics represent a major societal concern because individuals over the age of 60 years currently represent the fastest growing age population in the world as it is estimated that by 2050, there will be over two billion people worldwide of at least 60 years of age.9 Falls represent the most common cause of injuryrelated deaths in adults over 65 years of age.10 Emerging baby-boomer population trends predict that adults aged 65 years and older will represent the majority of the healthcare consumer population, thus driving the demand of quality healthcare services.10 With that being said, it is crucial for physiotherapists along with the entire health care professional team to addresses this current problem in order to reduce future injuries and fatalities resulting from falls that have the potential to be prevented. Supporting research provides evidence that significant decreases in physical functioning, commonly associated with aging, are not due to the aging process itself but caused mainly by inactivity and disuse.11 Intentional activity restriction caused by fear of falling often decreases the quality of life in older adults, conversely increasing the risk of future falls.12 Physical activity becomes increasingly important for the older adult population, especially in maintaining and prolonging functional independence.13 Visual and cognitive deficits, as well as physical limitations secondary to osteoporosis, rheumatoid arthritis, and other age-related diseases that cause bone and joint deterioration, are more prevalent in adults over the age of 65 and can

Literature Review increase the incidence of falls in this population.14 A decrease in lean body mass, neuromuscular changes such as increased reaction time, as well as decreased strength of muscles, tendons, and ligaments are some additional physiological changes that happen over time as the human body ages and directly affect balance.1 Fall Definition Though there is not a universally-accepted definition of a fall,15 various suitable definitions have been established. A fall is most commonly defined as "an event which results in a person's coming to rest inadvertently on the ground or other lower level" (adapted from the definition proposed by the Kellogg International Work Group in 1987)16 and this has been adopted by the WHO. (Include this in abbreviation page) All types of falls are included whether they result from psychological reasons or environmental reasons.17 Physical shortcomings of falling Approximately 20-30% of falls in older adults cause injury,9 thus it may as little surprise to note that fall-related injuries are the leading cause of death in adults over the age of 65,17 with one in five fatal falls occur in nursing home residents who are 85 years and older.18 Thirty-tofifty percent of individuals who live in a long-term care institution fall each year, with approximately 40% of these individuals experiencing recurrent falls.9 Approximately 75-85% of fall-related deaths occur in adults 65 years and older.18 An older adult dies every five hours as a result of fall-related injuries, and for every 100 falls in adults 65 and older, approximately two result in death19. The annual rate of injury-related hospitalizations for seniors aged 75–79 years was 58 per 1,000; this rate increased to 70 per 1,000 for seniors aged 80–84 years and increased again to 88 per 1,000 for seniors aged 85 years and older.20 By age 90 years, falls accounted for more than

Literature Review 70% of all injury-related deaths in Nova Scotia with an annual average of about 3,644 fallrelated hospital admissions and 84 fall-related deaths in the province.20 Psychological Ramifications of Falling: Fear of Falling Along with physical shortcomings that occur as the result of falling, there are also several psychological difficulties that occur. These can limit independence and result in a heightened risk of future falls. A common psychological problem developing from a fall is a fear of falling which can be defined as ―a lasting concern about falling that can lead an individual to avoid activities that he/she remains capable of performing.21‖ Many people who fall, even those who are not injured, develop a fear of falling.22 This fear may result in these individuals reducing their activities, leading to deficits in mobility and physical fitness, and increasing their actual risk of falling.22 Fear of falling has been identified in 55-to-60% of community-dwelling older adults23 and tends to be higher in women, frail individuals, and older adults who have previously fallen.
21

Approximately 31-to-48% of older adults who have experienced a fall develop a fear of

falling19, although an individual can develop a fear of falling even if he or she has never fallen.21 Fear of falling can cause an individual to use increased caution while participating in an activity. Fear of falling can also lead to activity restriction, which can result in a decrease in self-esteem, confidence, strength and balance, which increases the individual‗s risk of falling. 9,21 Individuals who have a fear of falling tend to be more anxious, depressed, and have less social support than those who do not have a fear of falling21; this may be caused because of activity restriction for a fear that a person may fall during a social activity.9 A fear of falling can cause a decrease in mobility or reduce a person‗s ability to control balance, which increases one‗s risk of falling9,23Individuals who have a fear of falling lack confidence in preventing or managing falls,

Literature Review which also increases the person‗s risk of falling.9 Risk factors contributing to developing a fear of falling include: social isolation and depression, knowing an individual who has fallen, an individual‗s fall history23 and an increase in age.21 Fear of falling can be significantly reduced for older adults who participate in educational programs, which include discussions about falling, identification of risk factors and resources with additional information about topics discussed in the seminar.23 If not addressed through therapy or education, fear of falling can become a long-lasting condition12, thus it is important to engage older adults in educational programs to reduce this fear of falling, thus improving their quality of life. Risk Factors for Falling It is important for health care providers to identify and address an individual‗s risk factors for falling to help prevent falls. There are several risk factors for falling and an individual‗s probability of falling increases with the number of risk factors. Sixty-five percent to 100% of individuals who had three or more risk factors fell during a one-year time frame, compared to 8to-12% fall rate for individuals who did not have any risk factors.24 An increase in age is related to the likelihood that an individual will fall.18 Approximately 75% of falls in the United States occur in adults 65 years and older,18 and an individual over the age of 80 is twice more likely to fall than younger individuals.18 Vision The visual system is important for stabilizing balance by providing the nervous system information about the body‘s position in relation to the environment.25 The visual, proprioceptive, and somatosensory systems integrate information to determine where the body is in relation to space to maintain balance. If one of these systems is impaired, the body has an

Literature Review increased dependence on the intact systems to maintain stability.25 If the visual system is impaired, body sway increases by three-fold, which places the individual at an increased risk for falling.18 Older adults who have reduced visual acuity (clearness of objects) or reduced contrast sensitivity (the ability to distinguish an object from its background) are at an increased risk for falling and need to use adaptive techniques to safely move around their environment, such as walking slower than individuals without visual difficulties.26 Impaired depth-perception (the ability to determine how far away an object is related to the environment) can also increase a person‘s risk for falling because he or she may have difficulties with accurately placing the foot while walking up or down stairs or maneuvering around obstacles in the environment.26 Impaired depth-perception is the strongest visual factor that can cause an individual to experience multiple falls.27 Individuals who wear multifocal glasses are 35-to-50% more likely to have a fall, when compared to individuals who do not wear multifocal glasses. 26,27 A visual field loss increases the risk of falling due to a decreased ability to detect potential hazards in the peripheral field of vision.26 Visual interventions have proven to be a very effective way can reduce falls, with literature suggesting a greater than 60% fall reduction.26 It is recommended that health professionals visually screen older adults to determine if their vision could contribute to falls and to provide interventions to help improve vision, thus reducing their risk of falling. Gender and ethnicity An individual‗s gender can also place a person at an increased risk for falling. Men are 46-49% more likely than women to have a fatal fall15,18 because men are more likely to have underlying health conditions, which may increase their risk of falling.9 Women who are widows,

Literature Review frail due to age, or are not active are at an increased risk for falling.15 Caucasians have been found to have an increased risk of falling and are two-to-four times more likely to be hospitalized from a fall than Hispanics and Asian/Pacific Islanders.9 It is important for health care professionals to consider their client‗s gender and ethnicity when assessing an individual for a risk of falling, as these factors may increase their risk of falling. Vitamin D deficiency Vitamin D deficiency is another fall-related risk factor. Individuals who have low levels of Vitamin D have an increase in body sway, weakness in the quadriceps, and abnormal motor patterns.28 Vitamin D and calcium can help reduce bone loss and fractures.29 Researchers found a significant reduction in the fall rate for older adults who received a Vitamin D supplement of 700-800 IU/d.28,29 Literature supports the notion that participants who received a high dose of Vitamin D supplementation of 700-800 IU/d, had a 26% reduction in fractures resulting from a fall, compared to no reduction in fall fractures for the individuals who received a smaller dose of Vitamin D supplementation of 400/IU/d.29 Health care professionals should ensure clients are receiving adequate amounts of Vitamin D, to help prevent a fracture from falling. Chronic pain There is consistent evidence that chronic pain is associated with an increased risk for falling for community-dwelling older adults.30 Pain can lead to muscle weakness or a slower protective response to a fall, chronic pain may be distracting for the individual which causes him or her disregard cognitive activities that may prevent a fall, and/or the individual may develop an inappropriate gait because of pain.30 Health care professionals should help clients manage their pain to help reduce their risk for falling. Polypharmacy

Literature Review Individuals who take four or more medications daily are twice as likely to fall, compared with those who do not take any medication.31 Also, individuals who take multiple medications are at an increased risk for sustaining a hip fracture from a fall, especially women who take five or more medications daily.31 Polypharmacy, or the use of four or more medications, increases an older adult‘s risk for falling.32 Approximately 72% of individuals were taking at least one drug and approximately 20% were taking four or more medications.32 An individual‘s risk of falling increased with the number of daily medications taken and individuals who took one medication were at a 25% risk of falling, whereas, those who took six or more medications were at a 60% risk of falling.32 Also, the use of four or more medications results in a nine-fold increased risk of cognitive impairment and individuals are more likely to have a fear of falling with an increase in medication use.15 Various types of medication can increase an individual‗s risk for falling. Various risk drugs have been identified, which placed an individual at an increased risk for falling, these included: antiarrhymics, psyhotropic medications, diuretics, calcium preparations, potassium sparing diuretics, central acting antiobesity products, anilides, oxicams, quinine and derivatives, anxiolytics-benzodiazepine derivatives, and hypnotics-benzodiazepine derivatives.32 Medications that act on the central nervous system increase an older adult‗s risk of falling by 54% and are associated with recurrent falls.33 Medications that affect the central nervous system include: sedatives, benzodiazepines, and tranquilizers.15 Sedative medications, such as benzodiazepines, increase an individual‗s risk of falling by 51% and short-acting, high doses of benzodiazepines increase an individual‗s risk of falling by 90%.33 Antipsychotic medications increase an individual‗s risk of falling by 59% and increase an individual‗s risk of sustaining a hip fracture or recurrent falls.33 Antidepressants increase an individual‗s risk of falling by 61%, and selective

Literature Review serotonin reuptake inhibitors increase a risk for falling by 72%.33 Cardiovascular medications can increase an older adult‗s risk of falling due to the effect of postural blood pressure and cardiac arrhythmias; however, this risk various according to the type of cardiovascular medication; antihypertensive medications and diuretics have a modest increase risk for falling, whereas beta-blockers do not cause an increased risk for falling.33 Medications can increase an individual‗s risk of falling due to the side effects of the medications or physiological changes that occur with continued use of the medication. Older adults are at an increased risk for having these side effects due to physiological changes that occur with aging; such as: decreased lean body mass, decline of kidney and liver function, increased body fat, rate of absorption, and metabolism and elimination of medications.15 Various medications can cause side effects that significantly increase an older adult‗s risk for falling; diuretics can cause dizziness and increased ambulation, benzodiazepine derivatives can affect the central nervous system,32 beta blockers can cause postural hypotension and sedation, cardiac glycosides can cause lethargy and confusion.15 The use of multiple medications increases the risk for side effects from medications, and increases drug interactions, electrolyte imbalance, decreased drug clearance rates and impaired balance.31 It is important for health care professionals to be aware of any medications clients are taking and to educate clients on their increased risk for falling if taking multiple medications. Neurological conditions Individuals with a neurological condition, such as Parkinson‗s disease (PD), stroke, or multiple sclerosis (MS) are at an increased risk for falling. Sixty-two percent of patients with PD experienced a fall, 48% of individuals with polyneuropathy fell, 33% of people individuals with a motor neuron disease fell annually, and one-in-three patients with MS reported a fall in the

Literature Review year.34 Neurological diseases can lead to a fall due to disturbances in gait and stance. Thirty-four percent of individuals with motor neuron diseases fall each year and 55% of falls were caused due to a postural or gait disturbance.34 Individuals with a neurological condition in an inpatient hospital are twice as likely to fall, compared to community-dwelling older adults.34 An average of 40% of individuals who have experienced a stroke experience falls while in the hospital and 73% of individuals who had a stroke in the past 6 months experience a fall at home.35 In a one year follow-up study, 55% of individuals who have had a stroke experienced one falls, 42% had multiple falls, and 54% experienced near-falls.36 Seven-percent of falls were caused due to a sudden stroke.34 Common impairments that increase a stroke-survivor‗s risk for falling include: leg weakness, foot problems, sensory loss, visual problems, balance problems and continence problems.35 Therapists should ensure individuals with neurological conditions receive proper intervention to reduce fall risk. The Environment The environment in which a person lives can also increase their risk for falling. Approximately 30-50% of all falls occur due to hazards in an individual‗s environment.18 Fiftyto-sixty percent of falls occur in an individual‗s home9 and older adults are more likely to fall inside of their homes because they feel more comfortable in this environment and exhibit less caution when moving around their house.18 Environment hazards can include: wet floors, poor bed height18 throw rugs, high or narrow steps, uneven surfaces, loose electrical wires, poorfitting handrails, slippery surfaces, or inadequate or excessive lighting.9 Fifty-to-seventy percent of falls occur because of tripping over something or slipping.19 It is important for health care professionals to identify and remove potential hazards in an individual‗s environment to reduce an individual‗s risk of falling in their home.

Literature Review Additional risk factors Additional risk factors include: muscle weakness, mental status alteration, musculoskeletal deficits, postural hypotension, impairments in one or more ADLs, incontinence, and a sensory impairment, such as a deficit in proprioception, vestibular, or tactile input.18 Also, an individual with a history of falling is three times more likely to have additional falls than an individual with no history of falling.18 Components of a Successful Fall Prevention Program Based on evidence-based research, there are five basic components to create a successful fall prevention program, these include: 1) education about falls, 2) medication review, 3) vision assessment, 4) home safety assessment, and 5) exercise.37 Also, the fall prevention program should address the benefits of participation, such as increasing independence, increasing confidence and having an active role in society.9 A successful fall prevention program should help raise public awareness about the risk for older adults falling and the benefits of interventions and programs that reduce fall risk.9 A fall prevention program is most successful if it promotes positive beliefs about taking preventative action to reduce the risk of falling. Research shows older adults believe falls are an inevitable aspect of aging; this misconception may decrease a person‗s motivation to participate in a fall prevention program.9 Raising awareness and educating older adults can help motivate individuals to participate in the program and change their belief that falls are inevitable with aging.9 Home modifications can reduce a person‗s risk for falling, these include: installation of bathroom grab bars, handicapped showers and ramps.37 Medication assessment is an important component as aging can increase sensitivity
to the side effects of medication and an increase in age also affects the distribution, absorption, and elimination of medications.37 Comprehensive vision examinations are also included in an ideal

Literature Review
program by a trained optometrist or ophthalmologist to ensure all types of vision problems are identified.37

Another important component to a successful fall prevention program is participation in effective exercises. Before beginning the exercise program, the professional must assess the participant‗s balance, strength and fitness and the exercise classes should small, with no more than 15 participants.37 Older adults indicated the strength and balance exercises should be enjoyable,
interesting and provide an opportunity for socialization.9 A combination of strength, balance, and aerobic activities can improve strength and mobility among older adults, and reduce their risk for falling.38 Exercise programs should be taught by a professional and tailored to meet the specific needs of older adults.38 It is recommended for exercises to be performed at least twice a week and progress in difficulty throughout the program.37 Participation in a weekly exercise group with supplemental home exercises reduced falls up to 40%, prevented injuries from falls, and improved balance for community-dwelling older adults.39 Additionally, a fall-prevention program should encompass dynamic balance exercises, as these activities transfer to improved balance during daily activities and are closely related to lifestyle and function.38 Programs to Prevent Falls The most effective fall-prevention programs for older adults involve a variety of tasks which challenge balance, such as multisensory balance training,40 a combination of balance and aerobic activities,38 and stepping programs.41 Programs which combine multisensory training and specific balance activities are more effective for improving balance when compared to traditional exercise programs that consist only of aerobics, strengthening, or flexibility exercises.40 A multisensory balance program, which required participants to bend, reach, and turn, while maintaining balance on various surfaces, was compared to a traditional balance program, which consisted of typical balance activities, such as marching in place, arm circles, gentle stretching activities, and stepping to the

Literature Review
side.40 The multisensory balance program provided additional vestibular stimulation and encouraged participants to increase their speed and size of movements to maintain balance, which resulted in increased strength, endurance, and reaction time.40 After the intervention, both groups had a significant reduction in falls and significant improvements on the TGUG; however, the multisensory balance group had more improvements in functional skills, measures of balance, and a reduced fear of falling.40 Stepping programs When a person loses his or her balance, the individual must take a rapid and lengthy step in the direction of the loss of balance, to prevent falling.42 A slow stepping response time is a strong predictor of a fall for older adults and impairments in stepping may be a contributing factor for falling.42 Research indicates a person‘s speed of stepping and reaction time for taking a quick step decreases with age.42 20 older adults participating in a stepping training program had significant improvements in their speed of stepping, and a quicker reaction time for stepping.41 This suggests a stepping program can be beneficial for older adults by improving balance, enhancing the quality of life, and reducing falls among older people.41 Though the specific task of walking is not effective for reducing falls, it is recommended to include walking in a comprehensive strength and balance program to reduce a person‗s risk for falling.38 Research indicates a reduction in falls when participating in a program that combines balance activities and muscle strengthening for 90 minutes a week, and walking for at least 60 minutes weekly. An individualized balance program that combines walking, balance, and strengthening exercises can reduce falls and fall-related injury up to 35% for community-dwelling older adults, and improve a person‘s balance, and reduce a fear-of-falling.43

Examintions The Berg Balance Scale assesses balance and has been extensively researched for identifying patients who are safe in ambulation and those that may need assistive devices. Scores

Literature Review below a 54 indicate an increased risk of falling and unsafe ambulation.44 The BBS scores the patient on a scale from 0 to 56, with the higher score suggesting better balance.45 The BBS consists of a 14-item test that uses a five-point ordinal scale to quantify the patient‘s performance in various tasks such as standing up, standing with eyes open or closed, and standing with feet together.45 Research has demonstrated a strong relationship between fall risk among older adults and the BBS.46 The TUG measures the time required to stand up from a standard (43 centimeters) chair, ambulate three meters, turn, walk back, and sit back in the chair.47 The patient then is asked to perform the same task again while turning in the opposite direction and the time is recorded. The times for the two trials are then averaged. The TUG has been shown by researchers to have a sensitivity of 87% for identifying older adults who are susceptible to falls.48 It has been considered a valid tool for measuring both functional mobility and risk of falling.48 Gait speed is an indication of overall health and walking performance49 and gait speed was measured using the 10-meter walk test, which requires the patient to walk 10 meters at his self-selected gait speed. The course is marked with three lines of tape; one of which is three meters before the 10-meter start line, a start line, and a finish line. The examiner does not start the stopwatch until the patient reaches the second line. This helps to eliminate measuring the time that it takes the patient to initiate gait, and allows for a more accurate measure of gait speed. During the trial no verbal encouragement was administered. One study found that elderly persons with a gait speed <0.55 meters per second (m/sec) are at risk for recurrent falls.50 The minimal detectable change score for comfortable gait speed is 0.18m/sec.49 The patient was also asked to complete the ABC scale which is used as a self-reported confidence rating scale when performing 16 different daily activities (0= no confidence, and

Literature Review 100= full confidence).51 If the patient does not currently perform the activity, the patient is then asked to imagine how confident he would be if he had to perform the activity.51 The use of ambulatory assistive devices to perform the activity is allowed when rating self-confidence.51 The ABC scale cut-off score of predicting falls in the elderly is below 67, with a sensitivity of 84.4%.51
Video Games in Rehabilitation

Visual biofeedback / force plate systems are used frequently in the rehabilitation of clients with impaired balance.45 However, because of the high cost of such equipment, many physical therapists do not have these systems available to them. Many of these force plate systems incorporate the body‘s COP as a biofeedback signal that gives instant visual feedback to the patient along with auditory feedback from the therapist.45 Recently, Nintendo released the Wii Fit platform* that includes a built-in COP sensor that is incorporated into balance games.45 This is the first publicly-available gaming system that uses such a force platform to provide feedback to participants.45 With the relatively inexpensive Nintendo Wii gaming system and the Wii Fit platform, physical therapists in all settings could have access to the COP biofeedback technology previously reserved for more expensive equipment.45 Individuals 49-to-69 years of age who had disabilities used a variety of video game programs,
including the Nintendo® Wii™ as part of a therapy program.52 Participants reported they enjoyed feedback provided by the video games, were distracted from their disability, and wanted to use the games in therapy, as opposed to performing repetitive, boring exercises.52 One study was interested in determining if video game-based exercises could improve sitting balance, and if participants were motivated and interested in performing the video game-based exercises.53 All participants had a decrease in fall rates after playing the game and reported a high level of enjoyment of the game and all participants.53

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Nintendo® WiiFit™ and Therapy

Balance training with the WiiFit board is achieved through activities that require the participant to avoid obstacles in activities such as roller-skating. Progression to a combination of balance and coordination training that involves upper limb and lower limb movements is practised with virtual tennis simulation.54 In the clinical setting, the potential use of gaming with visual feedback can facilitate the reduction of physical time that the therapist has to spend with the patient.54 Short-term visual feedback rehabilitation has also been found to be effective in improving functional status.55 One study demonstrated that the Wii-Fit program was as effective as the robust monitored walking program in improving balance, gait, and physical performance in subjects with mild AD.56 This result is consistent with a study on an elderly population which found improvement in balance (BBS score) and an increase in walking speed with the use of the balance games component of Wii-Fit.57 Nine elderly patients had an improvement in balance as measured with the BBS along with a decreased risk of falls after five-week use of Wii-Fit.58 Community-dwelling fallers over 70 years, improvement in balance (BBS score) was noted in a Wii-Fit group while no improvement in balance scores was noted in a standard care group.59 The use of the Nintendo Wii Fit as an exercise intervention was found to improve the timed up and go and Berg balance scale scores in an elderly woman status post CVA.60 Further literature supports this notion, as a subject with PD using the Nintendo WiiFit had their TUG score decrease by 12.3 seconds,61 which was a 34% improvement and surpassed the minimal detectable change (MDC) of 2 seconds.61 The subject‘s BBS score improved by 11 points61 which was a 25% improvement61 and surpassed the MDC of 5 points.62 Gait speed in this patient improved by 42% from pretest to posttest.61 A case study on an elderly man who experienced recurrent falls found that at the end of the two week training period the patient‘s balance had improved in all

Literature Review clinical measures.45 The BBS score increased by 12 points (from 13 to 25)45 The patient was able to improve his TUG score by 15 sec (approximately 24%),45 the ABC Scale score increased from 32% to 38%, and gait speed also improved after two weeks of training from 0.24 m/s to 0.39 m/s (approximately 62%) About the WiiFit Interventions Past literature has shown benefits with a program consisting of using the Nintendo Wii Fit two times per week for a total of eight weeks,62 although regular balance training programs have a mean duration of 3 months.63 All activities are chosen to address the subject‘s decreased gait speed, moderate risk of falling, decreased balance, and impaired functional mobility.62 Nintendo WiiFit activities to improve weight shift and trunk mobility include the Free Step, Penguin Slide, Torso Twists, Obstacle Course, Island Cycling, Rhythm Parade, and the Balance Bubble.62 The penguin slide promoted medial and lateral weight shifting challenging the subject‘s balance, which would ultimately improve the subject‘s gait.62 The Balance bubble and Tilt Table are similar to the Penguin slide but promote weight shifting in all directions.62 The Free Step requires the subject to step onto and off the balance board, mimicking reciprocal gait.62 The eccentric, concentric, and isometric contractions of the knee and hip extensors during the Chair activity simulate standing up from a sitting position and vice versa and thus likely contributed to the decreased TUG times.62 This strengthening, promoted mainly through isometric exercise, appears to strengthen the quadriceps for the function of performing a sit to stand transfer.62
A comprehensive approach to preventing falls among seniors typically includes assessment combined with interventions such as exercise programs, behaviour change, medication review and modification, treatment of contributing health conditions, assistive and protective devices, environmental modifications, and education ( Abernethy, G.D., Alley, D., Castle,
S.C., Diener, D.D., Hooker, S.P., Horton, et al. Preventing Falls in Older Californians: State of the Art. Sacramento, 2003:10. “California Blueprint for Falls Prevention: A background white paper for the conference” available at http://www.archstone.org/usr_doc/2004_PreConf_WhitePaper2.pdf)

Literature Review My proposed project is a randomized controlled trial that aims to examine the effects of a multi-factorial fall prevention program on falls.1 A 3-month risk-based multi-factorial fall prevention program which includes guidance on reducing the frequency of falls, geriatric assessment, home hazards assessment, and exercise programs will be implemented to determine whether it can reduce the incidence of falls. The subjects I would like to recruit would be community-dwelling older persons, which entails eliminating those involved in assisted-living as well as those residing in nursing homes. Therefore this study aims to evaluate participants who are living at home or within sheltered housing provided for elderly people who do not require full residential care. Those individuals who require occasional support and assistance from a resident staff member will not be excluded. I will aim to recruit patients who are 75 years of age or older of each sex, who have had at least three falls in the past 15 months. My reason for this is to eliminate the inclusion of those subjects who have only experienced one fall. It has been demonstrated that approximately 15% of falls that occur in the elderly population result from an external event that would have caused the majority of society to fall.2 Therefore, by implementing multiple falls into the inclusion criteria, we would eliminate the likelihood of having subjects who had fallen strictly as a result of an unavoidable external event. A fall will be defined as an event that caused an individual to come to rest on a lower-level surface with or without loss of consciousness or injury and without intent. Participants must score 44 or less on the Berg Balance Scale (BBS) which has been shown to be an accurate indicator of greater falling risk3, as well as be able to walk independently for 10 metres with or without walking aids.4 Participants will be recruited through local newspaper advertisements, community bulletin board postings, pharmacies, hospitals, and restaurants. Those who are willing to

Literature Review participate and fit within the inclusion criteria will be divided into an intervention group and a control group performed randomly. This random allocation will implement the sealed envelope method by an independent person to assign subjects to groups. Stratification will occur so that more women than men will participate, consistent with more women being at risk of falling.5 Primary outcome measures will be the incidence of falls amongst participants, as well as risk factors for falling. The risk factors which are hopefully reduced throughout this study are poor functional balance, poor static and dynamic balance, use of drugs that have been shown to increase falls, poor nutritional status, poor muscle strength, and poor eyesight. Secondary outcome measures will be physical function; examined via a 10-metre walk and examination of activities of daily living (ADLs), as well as health-related quality of life via the 15D instrument.6 The intervention program will focus on reducing the frequency of falls, geriatric assessment, home hazards assessment, and home exercise. Each member of the intervention group will have an assessment to examine the risk factors aforementioned in the previous paragraph. The Snellen Chart will be used to examine eye-sight, the BBS will be used to examine functional balance,7 an adjustable dynamometer chair will be used to examine muscle strength, a force platform will measure static as well as dynamic balance, and a mini nutritional assessment (MNA) will examine the participants‘ nutritional status. A trained medical professional will give the participants in the intervention group oral and written information regarding minimization of internal risk factors of falling, such as exposing oneself to a safe environment, eating well, as well as vitamin and mineral supplementation. A home hazards assessment will be performed using the Improving Independence in the Home Environment: Assessment and Intervention checklist by AgriLIFE Extension. Participants will then receive instructions for modifications to improve the safety of their environment.

Literature Review Subjects will be divided into exercise groups according to their physical function which will be assessed via the BBS, and muscle strength. Inspired by a physiotherapist, a video will be developed that will be distributed to all participants, following their participation in one group exercise session, which describes and demonstrates each exercise in a clear and concise manner. The one scheduled session will be used to educate the participants and any accompanying family or friends on how to properly use the Borg Rating of Perceived Exertion Scale at home as well as making sure the individuals can perform the desired exercises safely and in a desired environment. Subjects who are unable to complete the exercises safely will be excluded unless a modification to the movement can be made. Also, if a participant does not have the ideal home setting for the exercises, a modification will be made. For instance, brisk walking may be changed to marching on the spot or walking in a figure-eight pattern. The home sessions will be recommended to be performed three to four times per week at a length of 45 minutes and begin with a five-minute warm-up of brisk walking and upper-body movements.6 Balance and coordination exercises such as standing on one foot, bending down, and stepping sideways will also be performed. Muscle strength exercises will then be performed for 45 seconds each consisting of toe-to-heel rises, and sit-to-stand. Three circuits will be performed with three to five minute rest time between the circuits. A five to ten minute cool-down which includes stretching of the implemented muscle groups will end the sessions. The subjects will be encouraged to record their daily physical activity in exercise diaries.8 It will also be advised that participants should hold onto a rail when performing the exercises if they so desire. My literature review will start with a title page and begin with the heading ‗Background‘. Within this heading will be two main components; Topic Introduction, and Clinical Overview. Topic Introduction will entail a brief description on the topic of my proposed research study.

Literature Review Clinical Overview will examine how falling can have a negative effect on the health and independence of elderly people, thus displaying the importance of fall reduction interventions. ‗Reproducibility‘ will outline the methods to find relevant research and include the databases used, as well as key search words, and range of years along with my choice of referencing style which will be consistent throughout the project. My next heading will be ‗Recent Relevancy‘ which will incorporate how recent research has inspired my study, and why my proposed design is useful clinically. The next heading entitled ‗Pertinent‘, will address small holes in current research and incorporate positive aspects of various applicable studies, while hopefully reducing the limitations that were noticed in previous literature. Under the heading ‗Purpose‘ will be the justification of my choice for this study, the purpose of this study, and my hypothesis for its results. ‗Design‘ will examine the desired population, outcome variables and intervention. Using EBSCOhost and CINAHL headings I combined the keywords of falls prevention, seniors, and exercise to obtain 12 results from January 2000. I then determined falls prevention may not be a good choice for a keyword, so I changed my search to falls, AND intervention, AND exercise, AND seniors. Upon setting my results to only include studies from January 2000 to the present, I had access to six articles. Since this was not many results I decided to reduce the number of key words I was combining, and used many different combinations of the aforementioned keywords to much greater success. Initially, I was too narrow with my search. I also used another tactic which involved combining all of the falls assessment and reduction tools I could find as a main concept. Upon ―searching with AND‖ seniors, I obtained 66 helpful articles which were narrowed down via desired year. I also used the NCBI database with pubmed.gov and incorporated a similar strategy with this database as with EBSCOhost. Using the Sciencedirect database, as well as numerous other key words, did not yield desirable results.

Literature Review References
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Hendriks MR, Bleijlevens MH, van Haastregt JC, Crebolder HF, Diederiks JP, Evers SM, et al. Lack of effectiveness of a multidisciplinary fall prevention program in elderly people at risk: a randomized, controlled trial. Journal of the American Geriatrics Society. 2008;56:1390-1397

2

Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community based prospective study of people 70 years and older. Journal of Gerontology. 1989;44:112–117.

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Berg K, Wood-Dauphinee S, Williams J, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada. 1989;41:304–311.

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Sjösten NM, Salonoja M, Piirtola M, et al. A multifactorial fall prevention program in the home-dwelling aged: a randomized controlled trial. Public Health. 2007;121:308-18.

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Campbell, AJ, Spears GF, Borrie MJ. Examination by logistic regression of the variables which increase the relative risk of elderly women falling compared to elderly men. Journal of Clinical Epidemiology. 1990;43:1415–1420.

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Vaapio S, Salminen M, Vahlberg T et al. Effects of risk-based multifactorial fall prevention on health-related quality of life among the community-dwelling aged: A randomized controlled trial. Health and Quality of Life Outcomes. 2007;5:20.

7

Banez C, Tully S, Amaral L, Kwan D, Kung A, Mak K, Moghabghab R, Alibhai SM. Development, implementation, and evaluation of an Interprofessional Falls Prevention Program for older adults. Journal of the American Geriatrics Society. 2008;56:15491555.

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Salminen M, Vahlberg T, Sihvonen S et al. Effects of risk-based multifactorial fall prevention on postural balance in the community-dwelling aged: A randomized controlled trial. Archives of Gerontology and Geriatrics. 2009;48:22–27.

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Flicker L, MacInnis RJ, Mead K, Nowson CA, Scherer SC, Stein MS, Thomas J, Lowndes, Hopper JL, Wark JD. Should older people in residential care receive Vitamin D to prevent falls? Results of a randomized trial. Journal of the American Geriatrics Society. 2005;53(11), 18811888.
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Leveille SG, Jones RN, Kiely DK, Hausdorff JM, Shmerling RH, Guralnik JM, Kiel DP, Lipsitz LA, Bean JF. Chronic musculosketal pain and the occurrence of falls in an older population. Journal of the American Medical Association. 2009;302(20):2214-2221.
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