Safe Fall Recovery Education for Older Adults.

High fall rates among older adults in combination with prolonged time on the floor after a fall have created an urgent need to preventatively address fall recovery strategies. The purpose of this study is to describe the outcomes of a novel safe fall recovery (SFR) educational module provided by physical therapists to older adults in their homes. A pre- and post-test descriptive study used a convenience sample to recruit 30 adults (≥65 years). A baseline assessment and SFR in-home education were provided. Pre- and post-education measures included the Steps for Safe Fall Recovery (Steps for SFR) tool, the Activity Specific Balance Confidence (ABC) scale, and a fall confidence survey. The Wilcoxon matched-pairs signed-rank test determined significance (P < .05). Participants were age 77.2 (6.8) years and 20 females. Eight reported a fall during the prior year. Statistically significant improvements were identified in the Steps to SFR tool (P = .001), the ABC scale (P = .004), and the fall recovery confidence survey (P = .001). Integration of an SFR educational intervention delivered to an older adult population in their home demonstrated improved safety and confidence to recover from a fall.

Evaluation of a Physical Therapist-Delivered Technology Literacy Algorithm and Protocol for Older Adults: A Pilot Study.

Introduction Technology literacy is the ability to comfortably understand, use, and navigate digital devices. It is considered a "super social determinant of health", and yet 39% of adults aged 65+ report not using a smartphone, and 25% of seniors still lack internet access. The purpose of this study was to examine the applicability of a physical therapist-delivered clinical assessment tool related to technological literacy and to identify relationships between technology utilization and perceptions related to sociodemographic factors in community-dwelling older adults. Methods A prospective mixed-methods observational-descriptive study where physical therapists (PTs) administered a newly designed technology literacy algorithm to older adults and evaluated the results of the algorithm. A convenience sample of 30 participants aged 65 and older was evaluated for their technology literacy. The exclusion criteria were if the person had a vision deficit, lived in a nursing home or extended care facility, was unable to fluently read and understand the English language, or was not willing to have an in-home visit by a licensed PT. After informed consent was obtained, the participant completed a Past Experience with Technology Questionnaire assessing participant confidence with technology usage and a demographic questionnaire. A PT data collector visited participants' homes and administered a novel technology literacy algorithm. The PTs also provided subjective feedback after patient visits as to their perceptions of the algorithm. Inferential statistics were performed for key variables, including a Kruskal-Wallis test being utilized for variables with three or more levels and a two-sample Wilcoxon test being utilized for variables with two levels. The binary results were evaluated with chi-squared tests. Trends in distribution and measures of central tendency were analyzed for demographic data. Statistical significance was set at P<0.05 with a confidence interval of 95%. Results Participants (n=30) were evenly distributed with regard to age, and 66% of people had a college degree. Most were female, of the white race, and retired. There were statistically significant relationships between older age and decreased comfort level with using the internet (P=0.30) and sending messages (P=0.31), with individuals 80+ years old having a mean confidence of 6.78 out of 10. A statistically significant relationship was also found between higher income and increased confidence in browsing the internet (P = 0.07). Most qualitative data from physical therapist experiences included positive trends such as ease of use, efficiency, and confidence instilled. Constructive feedback included a lack of resources to assist with more advanced technology-related needs and recommendations to refine the algorithm when advanced needs were identified. Conclusion Technology literacy is a vital component of accessing health and medical care and maximizing the quality of that care, especially in the older adult population. The tools created may assist clinicians with identifying and addressing issues related to technology in older adults. This may help a patient navigate health issues that require the use of technology in their home. This study provided evidence that a PT-administered algorithm may be feasible to address technology literacy issues in the homes of older adults.

Effect of Robotic Delivery of Physical Activity and Fall Prevention Exercise in Older Adults: A Pilot Cohort Study.

Introduction The high prevalence of falls, lack of stability and balance, and general physical deconditioning are concerning issues for longevity and quality of life for adults aged 65 years and older. Although supervised delivery of the Otago Exercise Program (OEP) has demonstrated evidence of effectiveness in reducing fall risk of older adults, opportunities for ongoing unsupervised exercise performance are warranted. An option to facilitate exercise and performance of health behaviors may be via a social robot. The purpose of this study was to examine feasibility and initial outcomes of a robot-delivered fall prevention exercise program for community-dwelling older adults. Methods Five participants aged 65 years and older were recruited to receive robot-delivered modified OEP and walking program three times per week for four weeks. Outcomes of demographics, self-reported performance measures (Modified Falls Self-Efficacy Scale, Activities-specific Balance Confidence, and Almere Model assessing various constructs of acceptance of use of robotic technology), and physical performance measures (Timed Up and Go Test, Short Physical Performance Battery, Balance Tracking System [BTrackS] center of pressure sway) were collected. Data were analyzed descriptively and examined for trends in change. Measures of central tendency and distribution were used according to the distribution of the data. Results The mean age of the participants was 75 years (range: 66-83 years; four females and one male). The range of participant exercise session completion was 7-12 (mode=11, n=3). Constructs on the Almere Model that started and remained positive were Attitudes Toward Technology and Perceived Enjoyment with the robot. Anxiety improved from 3.80 to 4.68, while Social Presence of the robot improved from 2.80 to 3.56. The construct of Trust was somewhat negative among participants upon commencing the program and did not substantially change over time. Two participants improved their confidence on the Activities-specific Balance Confidence scale by more than 10%, while all participants showed some improvement in confidence in their balance. Mixed results were found with the Modified Falls Self-Efficacy Scale. Mean gait speed for the participants improved by 0.76 seconds over 3 meters. Improvement was also demonstrated for the Short Physical Performance Battery, with two participants improving scores by 2-3 points out of 12. No appreciable changes were found with the Timed Up and Go test and the BTrackS assessment. Conclusion Using a robot-led exercise program is an accessible and feasible way to deliver exercise to community-dwelling older adults in the home, but some technical constraints remain. Outcomes suggest that a four-week program is sufficient to elicit some positive trends in health outcomes and has the potential to reduce fall risk.

Medical Clearance of Older Adults Participating in Preventative Direct Access Physical Therapy.

Background The purpose of this study was to determine if the use of evidence-based cognitive and cardiovascular screening prior to initiating a prevention-focused exercise program that utilizes a physical therapist (PT) direct consumer access referral model is safe. Methods A retrospective descriptive analysis of data from a prior randomized controlled trial (RCT) was performed. Two data sets emerged: Group S was screened for study inclusion but not enrolled, and Group E was enrolled and participated in preventative exercise. Participant outcomes of cognitive screenings (Mini-Cog, Trail Making Test-Part B) and cardiovascular screening (American College of Sports Medicine Exercise Pre-participation Health Screening) were extracted. Descriptive statistics were generated for demographic and outcome variables and inferential statistics were analyzed (p < 0.05). Results Records from 70 individuals (Group S) and 144 individuals (Group E) were available for analysis. Overall, 18.6% (n = 13) in Group S were not enrolled due to medical instability or potential safety considerations. The need for medical clearance prior to initiating an exercise program was identified and then clearance was obtained for 40% (n = 58) of the participants in Group E. No adverse events related to program participation were reported. Conclusions A PT-led program utilizing direct access referrals from senior centers offers a safe option for older adults to participate in individualized preventative exercise programming.

Perceptions of Physical Therapists of Online Introduction and Training in the Home-based Older Persons Upstreaming Prevention Physical Therapy (HOP-UP-PT) Program: A Qualitative Study.

Introduction Traditionally, physical therapy has adopted a tertiary approach to preventative care. However, recent trends in fall-related injuries and deaths among older individuals suggest a dire need for earlier intervention. The Home-based Older Persons Upstreaming Prevention Physical Therapy (HOP-UP-PT) program has been developed to improve the health and overall function of community-dwelling older adults at risk of functional decline. As demand continually rises for HOP-UP-PT services, online training modules have been developed to safely and efficiently provide HOP-UP-PT competency to physical therapists. The purpose of this study was to examine self-reported experiences and perceptions of physical therapists after completing an asynchronous training program to deliver HOP-UP-PT. Methods After securing Oakland University IRB approval, a qualitative study using a sample of convenience used two structured focus group interviews. Inclusion criteria required participants to be licensed physical therapists (PTs) in the state of Michigan providing at least 20 hours of direct patient care per week. Participants completed eight 30-minute training modules, each with a corresponding quiz. Upon completion, PTs attended one of two video conference focus groups. Data was analyzed using the constant comparative method to develop themes and concepts based on responses about the training modules and the overall HOP-UP-PT program. Results Twelve PTs with a median age of 31-40 years participated. Analysis of two focus group sessions identified three concepts (Novel Approach to Physical Therapy Care, Integration of a Preventative Approach into Clinical Practice, and Knowledge Translation) and ten themes (Addressing an Unmet Need, Establishing a Working Relationship with Community Centers, Applicability to Various Settings, Shifting the Mindset to a Prevention-focused Paradigm, Applicability to Physical Therapists that Care for Older Adults, Patient Engagement and Prevention, Value for the Professional, Importance of Availability of Options in a Learning Platform, Ongoing Availability of Program Resources and Tools, and Clinical Application Practice). Conclusion PTs identified the HOP-UP-PT program as a novel, clinically applicable, and adding value to the profession. Furthermore, its upstream focus aligns with the growing role of preventative care by PTs; however, as HOP-UP-PT is not a traditional approach, additional training and clinical support materials may facilitate adoption and clinical application. HOP-UP-PT uses a preventative approach to clinical practice, but efforts to translate knowledge to PT are an important consideration. Additionally, the study identified a need for refinement and modifications to the existing HOP-UP-PT training modules.

State of the Art Physiotherapist-Led Approaches to Safe Aging in Place.

INTRODUCTION: Safe aging in place (SAIP) is when an older adult can successfully and comfortably remain in their home despite increasing barriers, including falls. Various physical, medical, psychological, and psychosocial factors may individually or cumulatively impact an older adult's ability to safely age in place. Physiotherapists should assess not only items traditionally considered within their scope of practice but should select efficient and effective outcome measures to quantify other domains of health. A comprehensive geriatric assessment (CGA) is an evidence-based clinical assessment which identifies medical, psychosocial, and functional limitations of an older person. The CGA is useful to dictate individualized exercise/intervention prescription to address identified areas of increased risk. PURPOSE AND IMPORTANCE TO PRACTICE: The purpose of this Masterclass is to describe key screening, assessments, and interventions to facilitate SAIP and to provide overviews of currently available programming and care delivery models applicable to physiotherapist practice. There are a wide variety of outcome measures and interventions that vary in depth, validity, and reliability. Measures selected for inclusion in this Masterclass were chosen based upon their clinical utility with respect to time and resource constraints and ease of administration during a comprehensive assessment for SAIP in community-dwelling older adults. Measures recommended for assessing physical function were the Short Physical Performance Battery, the Timed-Up-and-Go, the 30 second chair rise test, and the Four Test Balance Scale. Additionally, measures from the heath domain (e.g., Functional Comorbidity Index) and the environmental domain (e.g., Home FAST) are recommended. Relative to interventions, the Otago Exercise Program, motivational interviewing, home modifications, and leveraging technology are recommended. Partnerships with community-facing organizations facilitate utilization of resources for sustainable SAIP. The Home-based Older Person Upstreaming Prevention Physical Therapy (HOP-UP-PT) program is one approach led by physiotherapists framed in the screening, assessments, and interventions discussed in this Masterclass with strong scientific grounding. CONCLUSION: Programs integrating both community and healthcare approaches have the strongest evidence for their utility; however, implementation for these preventative approaches are lagging behind the increased need due to the substantial population growth of those over 65 years.

The Effect of Individualized Fall Prevention Programs on Community-Dwelling Older Adults: A Scoping Review.

An alarming rate of injurious falls among older adults warrants proactive measures to reduce falls and fall risk. The purpose of this article was to examine and synthesize the literature as it relates to programmatic components and clinical outcomes of individualized fall prevention programs on community-dwelling older adults. A literature search of four databases was performed using search strategies and terms unique to each database. Title, abstract, and full article reviews were performed to assure inclusion and exclusion criteria were met. Data were analyzed for type of study, program providers, interventions and strategies used to deliver the program, assessments used, and statistically significant outcomes. Queries resulted in 410 articles and 32 met all inclusion criteria (19 controlled trials and 13 quasi-experimental). Physical therapists were part of the provider team in 23 (72%) studies and the only provider in 10 (31%). There was substantial heterogeneity in procedures and outcome measures. Most common procedures were balance assessments (n=30), individualized balance exercises (n=29), cognition (n=21), home and vision assessments (n=16), specific educational modules (n=15), referrals to other providers/community programs (n=8), and motivational interviewing (n=7). Frequency of falls improved for eight of 13 (61.5%) controlled trials and four of five (80%) quasi-experimental studies. Balance and function improved in six of 11 (54.5%) controlled trials and in each of the six (100%) quasi-experimental studies. Strength improved in three of seven (43%) controlled trials and four of five (75%) quasi-experimental studies. While many programs improved falls and balance of older adults, there was no conclusive evidence as to which assessments and interventions were optimal to deliver as individualized fall prevention programming. The skill of a physical therapist and measures of fall frequency, balance, and function were common among the majority of studies reviewed. Despite the variability among programs, there is emerging evidence that individualized, multimodal fall prevention programs may improve fall risk of community-dwelling older adults and convenient access to these programs should be emphasized.

Implementing Home-based Prevention Physical Therapy: A Scoping Review and Path to Launch of HOP-UP-PT.

The purpose of this study was to conduct a scoping review of the available service delivery models related to home-based fall prevention programs led by rehabilitation professionals and to describe the path to launching one such program entitled Home-based Older Persons Upstreaming Prevention Physical Therapy (HOP-UP-PT). Topics of review included: Medicare and private billing structures available for current prevention programs and traditional rehabilitation, the Affordable Care Act and its application to reimbursement of preventive services and direct access care models, and a comparative review of CMS' Patient Driven Group Model (PDGM) home health benefit and Medicare Part B billing and reimbursement. Additionally, a path to launch one prevention-focused program, HOP-UP-PT, is described. There is emerging evidence that upstreaming fall prevention programs can help reduce falls and have money-saving downstream effects. A reimbursement model for this type of programming must be established in order ensure long-term sustainability. Although there is evidence that home-based prevention programs such as HOP-UP-PT can reduce falls and fall-risk metrics among an older adult population, there is not a clear and sustainable payment pathway, which limits proliferation of similar programs. Therefore, this preventative care model which has emerging evidence of cost savings will require reimbursement restructuring beyond what is available with existing payment models.

Impact of the HOP-UP-PT program on older adults at risk to fall: a randomized controlled trial.

BACKGROUND: Reduced falls and fall risks have been observed among older adults referred to the HOP-UP-PT (Home-based Older Persons Upstreaming Prevention-Physical Therapy) program. The purpose of this study was to describe outcomes of HOP-UP-PT program participants and then to compare these outcomes to non-participants. METHODS: Six Michigan senior centers referred adults ≥65 years who were at-risk for functional decline or falls. 144 participants (n = 72 per group) were randomized to either the experimental group (EG) or the control group (CG). Physical therapists (PTs) delivered physical, environmental, and health interventions to the EG over nine encounters (six in-person, three telerehabilitation) spanning seven months. The CG participants were told to continue their usual physical activity routines during the same time frame. Baseline and re-assessments were conducted at 0-, 3-, and 7-months in both groups. Descriptions and comparisons from each assessment encounter were analyzed. RESULTS: Participants ages were: EG = 76.6 (7.0) years and CG = 77.2 (8.2). Baseline measures were not significantly different apart from the Short Physical Performance Battery (SPPB) which favored the EG (P = 0.02). While no significant differences were identified in the survey outcomes or home environment assessments, significant differences in favor of the EG were identified in common fall risk indicators including the Timed Up and Go (P = 0.04), Four Test Balance Scale (P = 0.01), and the modified SPPB (P = 0.02) at the 3-month assessment visit. However, these differences were not sustained at the 7-month assessment as, notably, both groups demonstrated positive improvements in the Four Test Balance Score and SPPB. For individuals at a moderate/high fall risk at baseline, 47.8% of CG reported falling at seven months; whereas, only 6.3% of EG participants meeting the same criteria reported a fall after HOP-UP-PT participation. CONCLUSIONS: A prevention-focused multimodal program provided by PTs in older adults' homes proved beneficial and those with the highest fall risk demonstrated a significant decrease in falls. A collaboration between PTs and community senior centers resulted in upstreaming care delivery that may reduce both the financial and personal burdens associated with falls in an older adult population. TRIAL REGISTRATION: This study was retrospective registered at Clinical Trials.gov , TRN: NCT04814459 on 24/03/2021.

The Effects of Chemotherapy-Induced Polyneuropathy on Postural Balance.

While cancer prevalence and survival rates are increasing, cancer-treatment-related functional decline and decreased quality of life are on the rise. Adverse side effects such as polyneuropathy are commonly associated with neurotoxic chemotherapeutic agents (i.e., taxanes or platinums) resulting in a decrease in postural balance and an increased risk for falls. This case report highlights an adult with polyneuropathy who received five months of chemotherapy treatment for a breast cancer diagnosis. Measurements included sensory integration of balance control using the BTrackS modified Clinical Test of Sensory Integration and Balance (mCTSIB) protocol and the Timed Up and Go (TUG) test. Compared to normative data, the participant demonstrated poor balance control in all conditions. Specifically, the results indicated proprioception was the most compromised component of balance control. The participant also demonstrated a slower TUG time compared to women of similar age. Our findings highlight the value of quantitative assessment of balance control following chemotherapy. More research would be needed to further support the tailored therapeutic approaches to prevent falls following chemotherapy treatment.

Development and Feasibility of a Prehabilitation Protocol for Patients Diagnosed with Head and Neck Cancer.

BACKGROUND:  Head and neck (H&N) cancers account for 4% of total cancers diagnosed. However, quality of life (QoL) implications are more severe for this patient population due to the complexity, extent, and deformities resulting from treatment interventions. Principally debilitating complications include diminished functional walking capacity, reduced cervical range of motion (ROM), and scapular strength. An extensive literature search revealed a paucity of evidence utilizing physical therapy assessment and intervention for this population. The purpose of this study was to describe the development and clinical feasibility of a prehabilitation program aimed to thwart these complications for patients diagnosed with H&N cancer.  Methods: Inclusion criteria: male or female, 18+ years, speak and read the English language, ambulate independently, diagnosed with H&N cancer, and scheduled for surgical intervention. Institutional Review Board approval was obtained. Pre- and post-surgical measurements included the six-minute walk test (6MWT), cervical ROM, manual muscle testing for scapular strength, and three questionnaires: physical activity history, health behaviors questionnaire, and the Functional Assessment Cancer Therapy H&N QoL survey.  Results: Three participants were enrolled (two males and one female) all identifying as Caucasian and between 60-90 years of age. Pre- to post-cervical ROM demonstrated decline in extension/bilateral rotation for two of three participants. Two participants demonstrated decreased 6MWT distance while one increased. No participants experienced any adverse effects of the prehabilitation program.  Conclusion: This is the first study protocol to describe a physical therapist-administered H&N cancer prehabilitation program. Professionally administered education and exercise has potential to prevent, manage, and mitigate the adverse effects of cancer treatment. Additional research is needed to define the importance of prehabilitation relative to improved clinical outcomes and improved QoL. Patients with a cancer diagnosis are susceptible to impairments and functional limitations as a result of treatments and this prehabilitation program demonstrates potential to positively impact outcomes across the survivorship continuum. Due to their education and integration within the medical system, physical therapists are well-positioned to lead the effort to unify theory and clearly define parameters for oncology prehabilitation.