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Background

The prevention of falls among older adults is an urgent public health issue in Australia and internationally (Nyman & Skelton 2017; Gillespie et al. 2012).  The proportion of Australians aged 65 years and over is predicted to increase from 14% (3 million people) in 2010 to 23% (8.1 million people) by 2050 (Intergenerational Report 2010). By 2051, the Australian total annual health costs from fall-related injury are predicted to increase almost threefold to $1.4 billion (Moller 2003). Approximately 30% of adults aged 60 and older will fall during the period of a year (Tinetti 2003; Resnick 1999). Falls by older adults are a common occurrence and a leading cause of dependence (Stevens et al. 2006). Falls can result in injuries, reduced confidence, isolating social consequences, and a reluctance to continue physical activity that, not surprisingly, can be a precursor to other health-related complications. Nearly 30% of people over the age of 65 will sustain a fall every year in residential care facilities, and fall-related injuries are the leading cause of mortality and morbidity (Cakar et al. 2010). Notably, three quarters of injuries to older adults that require hospitalization are the result of falls (AIHW: Bradley 2013) The rate of falls by older adults in residential aged care facilities is nearly three times higher than the rate of falls in other settings (Shi 2014).

There is compelling evidence that physical activities to enhance balance and strength are among the most promising exercise-based interventions to prevent falls and fall-related injuries in older adults (Gillespie et al. 2012). Moreover, ‘widespread implementation of exercise as a single intervention seems to be the best approach to falls prevention’ (Sherrington et al. 2011, p. 78). Balance and strength training and lower limb resistance training is known to reduce falls in older adults (Sherrington et al. 2008). However, less than 10% of older people routinely engage in strength training and even less in activities that strengthen their balance (Clemson et al. 2012).

Research Question: What is the effectiveness of exercise-based interventions in reducing falls in older adults living in residential care facilities?

This research question is relevant for evidence-based clinical practice and professional knowledge.  If exercise-based intervention programs have positive effects on reducing falls among older people, then this approach could change the way older adults are cared for in residential care facilities. This research question could generate evidence to inform person-centred care planning regarding effective exercise-based interventions for falls prevention and targeted education for older adults living in residential care facilities (NMBA 2016). Findings could inform strategies that target audiences such as managers, nurses and families could implement to improve holistic care for older adults living in residential care facilities. Nurse educators could also use the evidence to teach effective strategies in the undergraduate nursing curriculum. The research question is therefore highly relevant to clinical practice and has wider implications for the provision of quality care and encouraging older adults to adopt effective self-care practices.

Select four (4) primary research articles (from the 8 articles provided) that provide relevant evidence to answer the research question. Write a 300 word summary of each primary research article using the three step format learned in Topic 2.

Paper 1

Paper 2

Paper 3

Paper 4

Compare and contrast the findings of the four (4) primary research articles using the approach learned in Topic 3. Ensure the analysis explains how the findings answer the research question. Identify any existing gaps in knowledge or practice. Discussion may be supported by additional relevant additional literature.

Summarise the major points in a non-repetitive manner, discuss future directions for research.

Background

Lim, J., Cho, J.J., Kim, J., Kim, Y. & Yoon, B., 2017. Design of virtual reality training program for prevention of falling in the elderly: A pilot study on complex versus balance exercises. European Journal of Integrative Medicine, vol. 15, pp.64-67.

According to Lim et al. (2017) falls result in serious health concerns among the elderly population, as a result of balance deficits and muscle weakness. Virtual reality exercise has been under scrutiny for its effectiveness as a program that can prevent falls in the elderly. The aim of the present research was to carry out an investigation of the effect of complex exercise with virtual reality (CEVR) such as muscle strength, endurance, flexibility, and balance exercises on dynamic postural ability and isokinetic knee muscle strength in the elderly. The research undertaken had the study design of single-blinded, randomized, comparative trial which was carried out over five weeks. The study participants were twenty individuals aged over sixty-five years, who were divided into a balance exercise with virtual reality (BEVR) group and a complex exercise with virtual reality (CEVR) group. The focus of BEVR was solely on balance exercise, whereas the focus of CEVR was on balance, endurance, flexibility and strengthening. Isokinetic peak torque and total work of knee muscles was measure prior to the sessions as well as after the one hour sessions with the help of a dynamometer. Evaluation of dynamic balance was done with the help of the ‘Timed Up & Go (TUG) test’. The results indicated that knee extension peak torque had been significantly enhanced for only the CEVR group (p < 0.05). However, there was no difference among the groups. Dynamic balance showed significance improvement for both the groups when measurement wad done with TUG after completion of the training sessions. Nevertheless, greater improvement was shown by the CEVR group as compared to the BEVR group (p < 0.05). It was therefore concluded from the research that virtual reality training when demonstrated in the form of complex exercise program produces superior results for improvement of muscle strength and balance in elderly. It was recommended that a virtual reality program can be implemented for strength, endurance, balance, and flexibility enhancement and preventing falls in elderly across settings

Sherrington, C., Fairhall, N., Kirkham, C., Clemson, L., Howard, K., Vogler, C., Close, J.C., Moseley, A.M., Cameron, I.D., Mak, J. & Sonnabend, D., 2016. Exercise and fall prevention self-management to reduce mobility-related disability and falls after fall-related lower limb fracture in older people: protocol for the RESTORE (Recovery Exercises and STepping On afteR fracturE) randomised controlled trial. BMC geriatrics, vol. 16, no. 1, p.34.

Research Question

Sherrington et al. (2016) stated that disability and further falls are costly and common problems faced by older individuals after suffering pelvic and lower limb fractures as a result of falls. It has been noted that exercise interventions can bring in rapid improvement in the mobility of individuals after they have suffered falls, thereby reducing the risks of further falls. Nevertheless, there is no much clarity regarding the optimal approach that can be considered for rehabilitation of pelvic and lower limb fracture after falls. The researchers outlined a randomized control trial with the aim of evaluating the impact of a self-management and exercise fall prevention intervention on mobility of older people who have been disabled as a result of falls. The cost effectiveness of the intervention was also to be investigated. The research paper focused on outlining the protocol for RESTORE (Recovery Exercises and Stepping On after fracture) randomized control trial. It was articulated that the randomized control trial would be conducted with concealed allocation and assessor blinding. Performance tests and intention-to-treat analysis would be considered. The participants would be three hundred and fifty individuals of age 60 years and above how have suffered pelvic or lower limb fracture as a result of falls. These individuals are to lie in low care residential aged care facility and must have previously undergone active rehabilitation. The participants are to be divided into two groups of intervention or normal care for one year. The physiotherapist would be visiting the intervention group for a total number of ten times for prescribing an individualized exercise program along with motivational interviewing. Fall prevention education would also be given through individualised advice at the group based “Stepping On” program which would be seven group sessions of two hours each. While the primary outcomes would be mobility-related disability and falls, secondary outcomes would include measures of balance and mobility, nutrition, falls risk, walking aid use, frailty, physical activity, pain, mood, falls efficacy, positive and negative effect, quality of life, assistance required, hospital readmission, and health-system and community-service contact. It was highlighted that the results attained from the study would be helpful for designing and implementing interventions for fall prevention in older adults.

Singh, D.K., Rajaratnam, B.S., Palaniswamy, V., Pearson, H., Raman, V.P. & Bong, P.S., 2012. Participating in a virtual reality balance exercise program can reduce risk and fear of falls. Maturitas, vol. 73, no. 1, pp.239-243.

In the paper of Singh et al. (2012) it has been mentioned that near about one third of older adults living in the community are likely to suffer at least one fall in a year. Research indicates that women are twice likely to suffer falls in old age as compared to men of the same age group. Virtual reality exercise games can act as a reliable rehabilitation tool for empowering adults to carry out exercises in a regular and independent manner. The aim of the present study was to carry out an evaluation of the effectiveness of taking part in six weeks long VRBG program as determined by reduction in risk of falls among postmenopausal women. Thirty six women with age above 56 years were recruited for the study and divided into two groups, experimental with exercises using VRBG and control with conventional balance exercises, on a random manner. The sessions were carried on for six weeks, twice a week, for one hour. Measurement of fear and risk of falls was done using Activity Specific Balance Scale (ABC-6) and Physiological Profile Approach (PPA). Examination of differences on pre and post intervention stages was considered using two way repeated measures ANOVA. The results of the study indicated that both conventional and VRBG balance exercise groups demonstrated significant decrease in PPA (p < 0.001) and ABC-6 (p < 0.01). There was however no significant effects between the groups in PPA (p = 0.18) and ABC-6 (p = 0.25). It was concluded from the study that taking part in VRBG enables a noteworthy increase in confidence related to balance among older women in community. The utility is that such program is capable of providing feedback to the individuals and therefore promotes engagement in physical activity on a regular basis.

Primary Research Articles

Cakar, E., Dincer, U., Kiralp, M., Cakar, D., Durmus, O., & Soydan, F. et al. 2010. Jumping combined exercise programs reduce fall risk and improve balance and life quality of elderly people who live in a long-term care facility. European Journal Of Physical And Rehabilitation Medicine, vol. 46, no.1, pp. 59-67.

According to Cakar et al. (2010) falls is a significant health concern among elderly population and fall rates of individuals living in residential care units is three times more than that of community dwelling individuals. The burden of falls on healthcare workers is immense, leading to their fatigue. The researchers considered carrying out a research for determining the usefulness of combined exercise program when taken up on a regular basis in relation to fall risk, balance improvement, enhancement of quality of life and depression. Such programs consider stretching, strength and aerobic exercises along with jumping training. The trial considered 78 168 participants who were assigned to combined exercise program (COM) including aerobic, strength and stretching exercise, and COM plus jumping (COMpJ) program. The six weeks long programs considered sessions three times in a week. The maximum time for the total exercises was 45 minutes. For assessing fall risk and dynamic balance, Biodex Balance system and Berg balance tests were considered. Short Form-36 was used for assessing quality of life. Lastly, depression status was assessed through Geriatric Depression Scale. The results indicated that reduction in fall risk and improvement in balance ability were improved in both the groups. Nevertheless, statistical significance was found in the COMpJ group. Further, quality of life in relation to health was better in both COMpJ and COM groups. The main inference drawn from the study was the group exercise program when carried out in a regular basis, can be effective in long term care process for elderly individuals. The benefits brought about are multifaceted and include balance improvement, enhancements in quality of life and fall reduction. 

Compare and contrastthe findings of the four (4) primary research articles using the approach learned in Topic 3. Ensure the analysis explains how the findings answer the research question. Identify any existing gaps in knowledge or practice. Discussion may be supported by additional relevant additional literature.

The above section on review of articles aimed at understanding the effectiveness of exercise-based interventions in reducing falls in older adults living in residential care facilities. The results of all the four studies aimed at addressing the research question in an appropriate manner. The study of Lim et al. (2017) and that of Singh et al. (2012) had considered evaluating the efficacy of virtual reality exercise program in promoting prevention of falls in elderly. The studies however had certain limitations, the key ones of the first study being small sample size and short duration of study. As opined by Parahoo (2014) larger sample size in research aids in generalizability of the study findings, thereby adding value to the research undertaken. The limitation of the second study was that there was no measurement undertaken of the physical activity level of the study participants at baseline. The results might have therefore been influenced considerably. The limitation of short duration of study was also marked for the study conducted by Cakar et al. (2010). The study further had limitation of using a computerized fall risk assessment device. Nevertheless, the findings of the all the four studies were pragmatic. 

Comparison of Primary Research Articles

The implications of implementing complex exercise with virtual reality (CEVR) were understood from the research of Lim et al. (2017), while the study of Singh et al. (2012) focused on reality balance games (VRBG). CEVR has been found to be superior in effectiveness in increasing knee muscle strength as well as dynamic balance when comparison is done with the general virtual reality training for balance. The findings presented that a CEVR focuses solely on balance to prevent falls in elderly individuals. Improvement in endurance, strength, flexibility and balance are evident in individuals undergoing this intervention. It might however be rational to state that VRBG places more demand on the cognitive organization and execution of individual motions when comparison is done with conventional therapy. Augmented feedback after repetitive sessions after engagement in VRBG sessions act as beneficial components of rehabilitation of disorders of neuromuscular system. Further, the process entails exact, quick and repetitive visual neuro-motor actions. VRBG might be considered as a leisure activity at home that improves compliance to the therapy to a good extent.

According to Dockx et al. (2017) VRBG might be highly mentally and physically challenging, limiting its implementation. The action requires the individual to move the center of pressure to a particular point so that strategies for hip and ankle postural control are generated. The nature of speed, range and direction of movement are found to be constantly changing. This would need central processing speed strategies, leading to inconvenience. As a result, greater challenges and demands might be placed on the neuromuscular system when comparison is done with conventional balance programs (Choi et al. 2017).

The findings of research of Cakar et al. (2010) can be considered at this juncture as an alternative of virtual balance programs who suggested that regular exercise programs are beneficial for addressing fall prevention. Jumping as an element of exercising protocol can ensure positive results for elderly living in long term facilities. As opined by Karinkata et al. (2015) jumping exercises can be advantageous for leading to better outcomes of bone fragility and functional decline in older patients through improved physical functioning, physical performance and bone strength. Nevertheless, future research must establish the effectiveness of the strategy. Sherrington et al. (2016) has highlighted that researchers are to find out optimal approaches for supporting rehabilitation after fall-related injuries. It is therefore indicated that different strategies for fall prevention have different limitations and strengths, each attempting to address balance level of individuals as the key to fall prevention.

Gaps in Knowledge or Practice

Conclusion

Summarise the major points in a non-repetitive manner, discuss future directions for research.

Fall prevention is a key concern in the healthcare facilities especially while caring for older adults. Injuries related to falls lead to increased healthcare costs and burden on the care providers. Fractures and injuries as a result of falls have a significant relationship with reduced functional capability and physical activity. Strategies for reducing falls among older adults have been examined since long. The present paper aimed at adding value to such research. The research focused on assessing the benefits of exercise-based interventions for bringing significant reduction in risk of falls for older adults living in residential care facilities. Out of the four studies considered for analysis, two studies brought about the benefits and challenges in implementing virtual reality exercise programs. The focus of such a program is to enhance balance confidence in individuals and bring improvement in overall functioning. Another study indicated the usefulness of jumping exercises in reducing risk of fall. The studies reporting on this regard have certain limitations such as gender bias and small sample population. It is therefore essential to carry out future research in this direction that can consider a more critical analysis of exercise programs. Confirmatory studies are warranted since these would highlight the implications of implementing exercise programs for individuals in healthcare settings as compared to those who are community-dwelling. It is noteworthy to mention that future studies are to consider larger sample size for coming up with more reliable studies. Also, studies are to be free of selection bias, especially in relation to gender bias.

References

AIHW: Bradley, C 2013,Trends in hospitalisations due to falls by older people, Australia 1999–00 to

2010–11. Injury research and statistics no. 84. Cat. no. INJCAT 160. Canberra: AIHW.

Cakar, E., Dincer, U., Kiralp, M., Cakar, D., Durmus, O., & Soydan, F. et al. 2010. Jumping combined exercise programs reduce fall risk and improve balance and life quality of elderly people who live in a long-term care facility. European Journal Of Physical And Rehabilitation Medicine, vol. 46, no. 6 pp. 59-67.

Choi, S.D., Guo, L., Kang, D. & Xiong, S., 2017. Exergame technology and interactive interventions for elderly fall prevention: a systematic literature review. Applied ergonomics, vol. 65, pp.570-581.

Clemson, L,Fiatarone Singh, M, Bundy, A, Cumming, R,Manollaras, K, O’Loughlin, P.& Black, D 2012, ‘Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial’,British Medical Journal,345:e4547doi: https://doi.org/10.1136/bmj.e4547

Future Directions for Research

Dockx, K., Alcock, L., Bekkers, E., Ginis, P., Reelick, M., Pelosin, E., Lagravinese, G., Hausdorff, J.M., Mirelman, A., Rochester, L. & Nieuwboer, A., 2017. Fall-prone older people's attitudes towards the use of virtual reality technology for fall prevention. Gerontology,vol. 63, no. 6, pp.590-598.

Gillespie, LD, Robertson, MC, Gillespie, WJ, Sherrington, C, Gates, S & Clemson, LM 2012,‘Interventions for preventing falls in older people living in the community’. Cochrane Database of Systematic Reviews, 9 Art. No. CD007146. doi: 10.1002/14651858.CD007146.pub3

Intergenerational Report 2010, ‘Australia to 2050: future challenges’. Canberra: Commonwealth of Australia

Karinkanta, S., Kannus, P., Uusi-Rasi, K., Heinonen, A. &Sievänen, H., 2015. Combined resistance and balance-jumping exercise reduces older women's injurious falls and fractures: 5-year follow-up study. Age and ageing, vol. 44, no. 5 pp.784-789.

Lim, J., Cho, J.J., Kim, J., Kim, Y. & Yoon, B., 2017. Design of virtual reality training program for prevention of falling in the elderly: A pilot study on complex versus balance exercises. European Journal of Integrative Medicine, vol. 15, pp.64-67.

Moller, J 2003, ‘Projected costs of fall related injury to older persons due to demographic change in Australia: Report to the Commonwealth Department of Health and Ageing’. Canberra: New Directions in Health and Safety.

Nursing and Midwifery Board of Australia 2016, Registered Nurse Standards for Practice, NMBA, Canberra, viewed 23 February 2017 https://www.nursingmidwiferyboard.gov.au/search.aspx?q=Registered%20Nurse%20Standards%20for%20Practice

Nyman, SR.&Skelton, DA 2017, ‘The case for Tai Chi in the repertoire of strategies to prevent falls among older people’,Perspectives in Public Health, vol.137, no. 2, pp. 85–86. doi:10.1177/1757913916685642.

Parahoo, K., 2014. Nursing research: principles, process and issues. Macmillan International Higher Education.

Resnick, B.1999, ‘Falls in a community of older adults: Putting research into practice’,Clinical Nursing Research, vol.8, no. 3, pp. 251–266.

Sherrington, C, Tiedemann, A, Fairhall, N, Close, J.& Lord, S 2011, ‘Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations’,NSW Public Health Bulletin, vol. 22, no. 3-4, pp. 78-83.

Sherrington, C, Whitney, JC, Lord, SR, Herbert, RD, Cumming, RG.& Close, JCT 2008,‘Effective exercise for the prevention of falls: a systematic review and meta-analysis’,Journal of American GeriatricSocietyvol. 56, pp. 2234-43.

Sherrington, C., Fairhall, N., Kirkham, C., Clemson, L., Howard, K., Vogler, C., Close, J.C., Moseley, A.M., Cameron, I.D., Mak, J. &Sonnabend, D., 2016. Exercise and fall prevention self-management to reduce mobility-related disability and falls after fall-related lower limb fracture in older people: protocol for the RESTORE (Recovery Exercises and STepping On afteR fracturE) randomised controlled trial. BMC geriatrics, vol. 16, no. 1 p.34.

Shi, CH 2014, 'Interventions for preventing falls in older people in care facilities and hospitals', Orthopedic Nursing, vol. 33, no. 1, pp. 48-9.

Singh, D.K., Rajaratnam, B.S., Palaniswamy, V., Pearson, H., Raman, V.P. & Bong, P.S., 2012. Participating in a virtual reality balance exercise program can reduce risk and fear of falls. Maturitas, vol. 73, no. 3, pp.239-243.

Stevens, J, Corso, P, Finkelstein, E.&Miller, T 2006, ‘The costs of fatal and non-fatal falls among older adults’ Injury Prevention, vol. 12, pp. 290–295. doi: 10.1136/ip.2005.011015

Tinetti, M 2003, ‘Preventing falls in elderly persons’. New England Journal of Medicine, vol. 348, pp. 42–49.

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