Scronce, Gabrielle DPT, PhD1; Zhang, Wanqing PhD, MD2; Smith, Matthew Lee PhD, MPH, CHES3; McCulloch, Karen Leigh PT, PhD, FAPTA4; Mercer, Vicki Stemmons PT, PhD4
ORIGINAL PUBLICATION:
JOURNALS OF GERIATRIC PHYSICAL THERAPY
OCTOBER/DECEMBER 2021 – doi: 10.1519/JPT.0000000000000283
Abstract
Background and Purpose:
Despite evidence that falls can be prevented with specific exercise interventions such as the Otago Exercise Program (OEP), translation of these programs into practice is limited in rural and medically underserved areas. The Community Health and Mobility Partnership (CHAMP) addresses this problem through a community-based implementation of the OEP in rural Appalachia where medical resources are scarce. The purpose of this study was to examine the effects of the CHAMP on physical performance and balance confidence in community-dwelling older adults.
Methods:
This study was a retrospective analysis of quasi-longitudinal data. Older adults received fall screenings at local senior centers. Those with increased fall risk received individualized OEP home exercises and were advised to return for monthly follow-up visits. Three physical performance measures—Timed Up and Go test (TUG), Four-Stage Balance Test (4SBT), and chair rise test (CRT)—and the Activities-specific Balance Confidence scale (ABC) were assessed at the initial visit (IV) and each follow-up visit. Two groups were created to distinguish participants who returned for their second follow-up (F2) visit within 3 months from those who returned between 3 and 6 months. Within-group change from IV to F2 was calculated using repeated-measures t tests. Repeated-measures 2-way analyses of variance were used to test for main and interaction effects of group and visit.
Results and Discussion:
One hundred thirty CHAMP participants aged 76.1 (SD = 8.1) years demonstrated statistically and clinically significant improvements in the 3 physical performance measures (mean 4SBT: IV 29.5 seconds, F2 31.5 second, P = .001), (mean TUG: IV 12.7 seconds, F2 11.9 seconds, P = .021), (mean CRT: IV 0.258 stands/second, F2 0.290 stands/second, P = .002), but not in balance confidence (mean ABC: IV 62.2, F2 64.4, P = .154). A significant interaction of group by visit for the TUG was observed, suggesting that better TUG performance was associated with quicker return for follow-up.
Conclusions:
Results indicated that program participants improved from IV to F2 in measures related to fall risk.
CLINICAL HIGHLIGHTS
The provision of evidence-based programs to reduce falls in older adults is severely limited in rural areas.
Participants in a community-based Otago Exercise Program (OEP) in rural Appalachia demonstrated statistically and clinically significant improvements in 3 physical performance measures strongly associated with fall risk: Timed Up and Go (TUG), Four-Stage Balance (4SBT), and chair rise (CRT) tests.
Alternative implementations of the OEP with fewer in-person visits may be beneficial for fall risk reduction in older adults with limited access to clinical providers.
INTRODUCTION
Falls are a well-known and growing threat to the health and independence of community-dwelling older adults.1 Falls are the primary cause of fatal and nonfatal injuries among adults 65 years and older in the United States.2 In 2014, nearly one-third of older adults in the United States reported falling at least once in the previous year, totaling around 29 million falls.3 By the year 2030, this number is expected to increase to over 49 million falls per year.4,5 Falls are problematic because they frequently result in morbidity and mortality and can lead to a cycle of negative physical and psychosocial consequences.6–8 After a fall, older adults frequently report increased fear of falling or reduced balance confidence. This can lead to activity restriction because of concerns about possible falls.9 Decreased activity, in turn, can result in muscle weakness and other physical health impairments, which further increase fall risk.7,10,11
Numerous randomized controlled trials have investigated interventions that combat the expanding problem of falls.12 Although targeting risk factors for falls such as psychotropic medication use, uncontrolled chronic health conditions, inappropriate footwear, or home safety hazards can help prevent falls,12 research supports the key role of exercise in fall prevention efforts. The overwhelming conclusion from the literature is that falls can be reduced with specific interventions that include functional lower extremity strengthening and balance-challenging exercises.13–15
Given the evidence to support specific exercise interventions to reduce falls among older adults, public health authorities including the Centers for Disease Control and Prevention (CDC), American Geriatrics Society, and United States Preventive Services Task Force have recommended that clinicians and wellness centers promote and provide evidence-based fall prevention interventions for older adults.16–18 The Otago Exercise Program (OEP) is an example of an evidence-based fall prevention intervention recommended by the CDC19,20 and Administration for Community
Living.21
The OEP is a home-based exercise program to improve balance and strength that was developed by Campbell, Robertson, and their colleagues in New Zealand (NZ) in the late 1990s.19,22–24 This original version of the OEP, “NZ OEP,” is delivered by a trained physical therapist (PT) or nurse who provides an individualized home exercise program to older adult participants in their homes. An OEP-trained provider administers assessments to an older adult participant and uses assessment results to select appropriate exercises from the OEP exercise set. The entire OEP exercise set consists of 5 active range-of-motion “warm-up” exercises, 5 lower extremity strengthening exercises in sitting and standing, and 12 balance exercises of progressively increasing difficulty.24,25 Participants receive handouts for each exercise and are instructed to perform exercises 3 days per week. At the provider’s discretion, a walking program consisting of walking for a total of 30 minutes is added to the participant’s home program.24 The home exercise program is progressed following reassessment at subsequent visits, which occur at 2, 4, and 8 weeks and again at 6- and 12-month time points. In addition, providers call participants by phone monthly from 3 to 5 months and from 7 to 11 months to promote adherence to the home exercise program.
Results from 2 meta-analyses of 8 trials demonstrated that participation in the NZ OEP significantly reduced fall rates, fall-related injuries, and risk of death over 12 months.22,26 These studies also showed that NZ OEP participation improved performance on objective measures of balance and functional lower extremity strength among older adults at risk for falls.22,26 This research found that greatest fall prevention benefits occurred among women older than 80 years who reported 1 or more falls in the previous year.22
Despite evidence demonstrating the benefits of the OEP and support for the OEP from public health authorities, dissemination of the OEP into practice in the United States has been limited.27,28 Barriers to widespread implementation of the OEP in the United States include challenges with reimbursement encountered by PTs providing the program29–32 and inadequate referral to the OEP from older adults’ primary care providers.27,33 Challenges to implementation may be even greater in rural areas with insufficient accessibility of health care resources for older adults.21,28,34 Barriers to dissemination of evidence-based fall prevention programs in these areas may also include limited availability of instructors, space, funding, transportation, and health care providers.34
Shubert et al31 demonstrated successful reach, adoption, and effectiveness of alternative methods of implementing the OEP that addressed specific barriers. The US OEP model described by Shubert et al30 offers solutions to implementation challenges by offering the OEP in either the participant’s home or an outpatient PT clinic, providing follow-up visits by either a PT or a PT assistant, utilizing support personnel to make follow-up phone calls or removing the phone calls altogether, and shortening the intervention to 8 weeks or 6 months instead of offering a 12-month follow-up visit.
Despite these successes, challenges of implementing the OEP and other evidence-based fall prevention programs persist in rural, medically underserved areas. The Community Health and Mobility Partnership (CHAMP) addresses these barriers in an interprofessional, community-based fall prevention program provided at no cost to participants.35,36 The idea for the CHAMP was developed by faculty at the University of North Carolina at Chapel Hill in an effort to improve the health and reduce risk for falls among older adults. The location for the CHAMP was selected because it was a medically underserved area with a high proportion of older adult residents. In particular, the emergency medical services director in the county where the CHAMP first began identified a high incidence of falls among older adults, and there was interest in addressing this problem from multiple community members and organizations.35 Utilizing collaborations among public universities, community colleges, private technical schools, local clinicians, nursing homes, senior centers, and wellness centers to secure space and volunteer providers, the CHAMP provides multifactorial fall risk assessment and intervention at easily accessible sites. The collaborative approach of the CHAMP engages multiple stakeholders to volunteer time and resources to offer fall prevention services, including the OEP. The CHAMP program also includes an educational component for health professional students and is intended to reach individuals living in rural, medically underserved areas. Since its inception in 2009, the CHAMP has been offered once per month from March to November to older adults living in areas of rural Appalachia, with expansion to additional locations. The successful reach, adoption, and maintenance of the CHAMP suggest that the program may offer a unique solution to the problem of limited dissemination of evidence-based fall prevention interventions. The essential next step in understanding and enhancing the effectiveness of CHAMP’s translation of the OEP to older adults living in underserved areas is to assess changes in falls-related measures among participants in the program.
The primary objective of this retrospective study was to examine the effects of the CHAMP on measures of physical performance and balance confidence among older adult participants. Based on research demonstrating improvements on measures of physical performance after 8 weeks of participation in the US OEP,25 we hypothesized that CHAMP participants would demonstrate improvements on key outcome measures from baseline to second follow-up (F2). Given that both the NZ and US OEP models recommend that the majority of follow-up occurs in the first 8 weeks after a participant’s initial assessment, we further hypothesized that completing the 2 recommended follow-up visits closer to this timeline would be associated with greater improvements. Specifically, the aims of this study were to determine: (1) whether all participants who received the CHAMP intervention for an initial visit (IV) and 2 follow-up visits within a 6-month period demonstrated improvements in physical performance and balance self-confidence; and (2) whether a subgroup of participants who completed the F2 visit within 3 months of the IV demonstrated greater improvements in physical performance and balance self-confidence compared with individuals who completed F2 3 to 6 months after the IV.
METHODS
This study was a retrospective analysis of 8 years (2009-2017) of quasi-longitudinal data collected from an ongoing, community-based fall prevention program (CHAMP).
Participants
Community Health and Mobility Partnership participants from 2009-2017 were community-dwelling older adults from 2 rural counties in western North Carolina. In 2017, the total populations of these 2 counties were 83 029 and 43 069, and the population 60 years and older was 20 816 and 11 491, respectively.37 Among the population 60 years and older in each county, approximately 55% were women, and the vast majority (93.4% and 95.8%) were White, non-Hispanic.37 Participants signed a consent form prior to participation.
Participants included in this analysis were CHAMP participants 60 years and older who were self-referred and subsequently completed an IV to the CHAMP, were recommended to return for follow-up to address fall risk factors, and who then returned for at least 2 follow-up visits within 6 months (Figure 1). Included in this analysis were data collected from these participants at their IV and at their F2 visits only. Groups were formed retrospectively to distinguish participants whose F2 visit occurred within 3 months of the IV (group 1) from those whose F2 visit occurred 3 to 6 months after their IV (group 2).
Figure 1. (Find Figures Here: JOURNALS OF GERIATRIC PHYSICAL THERAPY)
Figure 1.:
Screening, risk determination, and follow-up visits for CHAMP participants. CHAMP indicates Community Health and Mobility Partnership; OEP, Otago Exercise Program; F2, second follow-up visit.
Outcome Measures
Four key outcome measures were administered at the IV and were repeated at each follow-up visit. These measures were selected for use in accordance with the NZ and US OEP and following recommendations from the CDC.24,38,39 The Activities-specific Balance Confidence scale (ABC) was administered in interview format at the beginning of each visit.40 A validated and reliable measure of balance confidence, the ABC is scored on a scale of 0 to 100, with higher scores indicating greater balance confidence.40–42 Lajoie and Gallagher43 found that an ABC score of 67% and above could significantly differentiate participants with a history of falls from those with no history of falls.
Physical performance measures, administered after the ABC, included the Four-Stage Balance Test (4SBT),44 Timed Up and Go test (TUG),45 and the chair rise test (CRT).46 The 3 physical performance measures were selected based on their inclusion in the NZ and US implementations of the OEP and their association with incidence of falls among older adults.24,25,30,47,48 The 4SBT, a test of static balance when standing with a progressively smaller base of support, was performed following procedures recommended by the NZ and US OEP. Participants were asked to attain and then independently hold for 10 seconds each of the following foot positions: feet together, semi-tandem, tandem, and single-limb stance (SLS). Participants who were unable to maintain 1 stage of the test for the total 10-second period were allowed to attempt the next stage unless such an attempt was considered unsafe by a supervising PT. The 4SBT used in the CHAMP was then scored as the sum of time in seconds that a participant maintained each stage of the test, with a maximum score of 10 seconds for each stage and a maximum score of 40 for the total test score. Based on previous research, participants unable to maintain the SLS position for at least 5 seconds were considered to have increased risk for falls.49 Psychometric properties of the 4SBT as a whole and utilizing these particular scoring methods have not been published, but research indicates that a similar test, the Short Physical Performance Battery, is a valid, reliable, and responsive measure of physical performance among community-dwelling older adults.50,51
The TUG measures dynamic balance and functional mobility based on the time in seconds necessary for an individual to stand from sitting in a standard armchair, walk forward 3 m, turn and walk back to the chair, and return to sitting in the chair.45 At the CHAMP, participants performed the TUG 3 times (1 practice and 2 test trials), and results of the 2 test trials were averaged. Performance on the TUG is strongly associated with falls, and various cut-off scores have been suggested to maximize the test’s sensitivity and specificity for falls.47,48,52–54 From 2009-2015, CHAMP providers utilized a TUG cut-off score of 13.5 seconds to identify individuals at increased risk for falls.54 In 2016, CHAMP procedures were updated based on CDC recommendations, and a 12-second score on the TUG became the new cut-off for identifying increased risk for falls.18,53,55,56 Out of 82 participants who attended their IV to the CHAMP prior to this change, only 1 (1.2%) had a TUG score greater than 12 but less than 13.5 seconds. Lin et al48 showed that the TUG had excellent intrarater and interrater reliability among community-dwelling older adults, and Wright et al57 reported a minimal clinically important difference (MCID) of 0.8 to 1.4 seconds on the TUG for older adults with hip osteoarthritis.
The CRT is a measure of functional lower extremity strength in which a participant is asked to stand up and sit down from a standard-height chair without using their upper extremities for support or assistance. Community Health and Mobility Partnership methods have used 2 versions of this test. From 2009-2014, the CRT version used at the CHAMP was the 5 times sit-to-stand (5xSTS) as instructed in the NZ OEP.23,24 Previous research established that the 5xSTS has good to high test-retest reliability and an MCID of 2.3 seconds for the 5xSTS.58,59 Following CDC recommendations and in accordance with the US OEP, the CRT used at the CHAMP was changed to the 30-second sit-to-stand (30-s STS) in 2016.18,31 The 30-s STS has an MCID of 2.6 stands57 and is a valid and reliable test of functional lower extremity strength in community-dwelling older adults.46 Previous research has shown that these 2 measures are highly correlated.60 For this study, the measures were unified by dividing the total number of stands performed by the time elapsed or allowed, resulting in a common CRT variable with units of number of stands per second.60
CHAMP Personnel
Community Health and Mobility Partnership events were staffed by trained, volunteer clinicians and clinical students from multiple disciplines, including PT, speech and language pathology, nursing, and others. As described by Mercer et al,35 the CHAMP included an educational component by providing training and practical experience for clinicians and student volunteers. Volunteers were trained following specific, written protocols to perform assigned roles that differed depending upon their discipline. Volunteers from disciplines other than PT were trained in administration of questionnaires and in collection of demographic and medical history information. PT and PTA clinicians, faculty, and students participating in the CHAMP completed online training for the OEP recommended by the CDC38 and received in-person training about CHAMP protocols for performing physical assessments and providing fall prevention recommendations and the OEP intervention. Student volunteers received additional training and supervision from faculty and experienced clinicians at CHAMP events. At each CHAMP event, at least 1 licensed PT who had completed online training in OEP implementation and attended previous CHAMP events was available to supervise the administration of physical performance tests, prescribe OEP exercises for home performance, and provide other fall prevention recommendations specific to the individual participant’s needs.20 Training and supervision of volunteers has been described in more detail in a previous article by Mercer et al.35
CHAMP Procedures
All assessments were administered using standardized procedures and instructions.35 Times for physical performance tests were recorded to the nearest tenth of a second with use of a stopwatch. Test results were documented on paper forms and later transferred to an electronic spreadsheet.
At their first visit to the CHAMP, participants provided demographic and health history information on pen-and-paper forms, with assistance from CHAMP providers that included accommodations made for participants who could not read. Personal characteristics collected included age, gender, race, ethnicity, and level of education. Self-reported health information collected included height; presence or absence of cardiovascular disease, hypertension, arthritis, diabetes, cancer, osteoporosis, and stroke; and use and type of assistive device. Body weight was measured using a standard scale, and cognitive impairment was assessed with the Mini-Mental State Examination (MMSE).61 Self-reported fall history was recorded in response to the questions, “Have you experienced a fall (defined as unintentionally coming to rest on the ground or other lower surface) in the past 12 months?” and “If yes, how many falls?” Activity limitation was identified based on an affirmative response to the question, “Do you limit your activities because you are afraid you might fall?” Questionnaires and physical performance tests were scored by CHAMP providers, and scores were recorded on the participant’s paper form at the time of their visit. These data collected on pen-and-paper forms were later transferred to a secured, electronic database that de-identified CHAMP participants through the use of unique CHAMP identification numbers.
CHAMP Intervention
Initial visits to the CHAMP lasted approximately 1 hour and began with administration of the assessments described earlier. Providers evaluated assessment results to identify each participant’s risk factors for falls and subsequently provided participants with their results and recommendations. Participants were considered to have an increased risk for falls if they had 1 or more of the following characteristics: 1 or more fall in the previous 12 months, activity limitations because of fear of falling, SLS time less than 5 seconds, or TUG score indicating increased risk for falls (≥13.5 seconds from 2009-2015 and ≥12 seconds since 2016).
Participants identified as having health issues that could not be addressed by the CHAMP, such as vestibular disorders or uncontrolled hypertension, were referred to other providers or programs. Participants considered to be at low risk for falls were encouraged to maintain healthy behaviors and to return to the CHAMP at a later date if concerns about balance arose.
Participants at increased risk were provided with individualized, evidence-based recommendations to prevent falls. Examples of recommendations included home safety modifications, comprehensive foot assessment and provision of appropriate footwear, and comprehensive gait evaluation. Individuals with increased risk for falls also received the NZ OEP home exercise program designed by Campbell et al.23–25 This home exercise program was the primary intervention provided by the CHAMP to older adults at risk for falls. At each the CHAMP visit, after reviewing the participant’s performance on strength and balance measures and considering their health and falls history, a PT selected 3 to 5 balance and strength exercises from the OEP to best suit the needs of each individual participant.23,38 Following instruction, demonstration, and practice of the OEP exercises prescribed for home performance, the participant received a handout with written and visual instructions for each exercise as well as instructions to perform the exercises at home on their own 3 days per week for strengthening exercises and daily for balance exercises.38 Exercises prescribed were recorded and kept in the participant’s CHAMP records for reference at later visits. Participants were not required to track their performance of these exercises at home.
Community Health and Mobility Partnership participants with increased risk for falls who received OEP exercises were advised to return for follow-up visits, which occurred once per month from March to November. At follow-up visits, physical performance measures and the ABC were reassessed, and the falls risk algorithm was reapplied. Similar to the IV, participants who remained in the “increased risk for falls” category received individualized fall prevention recommendations. Participants’ OEP home exercises were reviewed and progressed or updated by a PT. Participants were advised to continue to return to the CHAMP each month until their performance on falls-risk measures had improved sufficiently to indicate low risk for falls. As shown in Table 1, the OEP provided by the CHAMP differed from the NZ and US OEP in that clinician involvement occurred only in the community setting (not in the individual’s home or as part of a clinic visit) and follow-up visits occurred at most once per month (not at 1 and 2 weeks).
Table 1. – Comparison of Otago Exercise Program Implementations
(Find Table Here: JOURNALS OF GERIATRIC PHYSICAL THERAPY)
NZ OEP19 US OEP30 CHAMP35
Referral Physician recruitment Physician referral Self-referral
Setting Participant’s home Participant’s home or outpatient PT clinic Community center (senior center or wellness center)
Delivered by PT or nurse PT, with option for PTA to perform follow-up visits PT and PTA clinicians, faculty, and students
Measures 4SBT, CRT (5xSTS) 4SBT, CRT (30-sSTS), TUG 4SBT, CRT (5xSTS or 30-sSTS), TUG
Frequency and schedule of visits Initial, wk 1, 2, 4, and 8 then mo 6 and 12 Initial, wk 1, 2, 4, and 8, then 0-2 more visits within 24 mo Initial with recommended follow-ups once per month until fall risk is sufficiently decreased
Exercise intervention NZ OEP exercises; walking program NZ OEP exercises; walking program NZ OEP exercises; walking program
Other interventions None Potential referral to other providers or programs Recommendations to address other fall risk factors
Abbreviations: CHAMP, Community Health and Mobility Partnership; CRT, chair rise test; 5xSTS, 5 times sit-to-stand test; 4SBT, Four-Stage Balance Test; NZ, New Zealand; OEP, Otago Exercise Program; PT, physical therapist; PTA, physical therapy assistant; 30-sSTS, 30-second chair stand test; TUG, Timed Up and Go test; US, United States.
Statistical Analysis
G*Power62 was used to calculate sample size needed to detect a medium effect (0.6) of the CHAMP intervention on TUG results with 80% power at significance level .05 in a 2-tailed, between-group comparison. A sample size of 96 participants consisting of groups of 37 and 59 participants was determined to be sufficient. The TUG was the measure used for this calculation because the TUG score was the most sensitive measure used in terms of variability, as it was measured as a continuous variable with values to the 10th of a second with no subsequent data reduction.
Descriptive statistics were used to examine participant characteristics and baseline measures of 4 key outcome measures (ABC, 4SBT, TUG, and CRT). Between-group differences at baseline were calculated for continuous variables using independent-samples t tests and for categorical variables using the χ2 or Fisher exact test when appropriate. One-way multivariate analysis of variance (MANOVA) was initially conducted to ascertain whether a statistically significant linear composite of the 4 outcome measures was present between the 2 groups. As per our research aim, we were interested in the distinct contributions of each of these 4 outcome measures. Therefore, within-group change was assessed using repeated-measures t tests for each key outcome measure at initial and F2 visits for the total sample (n = 130) as well as for each of the 2 groups formed from this sample. Then, repeated-measures 2-way analyses of variance (ANOVA) with group (group 1, group 2) as the between-group factor and visit (initial, F2) as the within-group factor were used to test for main and interaction effects of group and visit for each of the 4 key outcome measures. These relationships were also examined using analyses of covariance (ANCOVAs) with covariates of age and number of falls reported at IV.
Effect sizes were calculated using Cohen’s d, and common conventions were used to classify values.63 Clinical meaning of results was calculated using frequencies of change in performance on outcome measures exceeding the test’s MCID as well as frequencies of change in performance from one risk category to another. Missing values were excluded case-wise, and frequencies and percentages were reported for nonmissing data only. Data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp, Armonk, New York) with a 2-sided significance level of < .05 for all analyses.
RESULTS
As depicted in Figure 1, 483 individuals attended a CHAMP IV. Seven of these participants were unable to complete their IV (3 for unknown reasons and 4 because of medical issues identified during screening requiring immediate medical attention). Twenty-one individuals who attended a CHAMP IV were excluded from this analysis because they were younger than 60 years. Three hundred fifty-three individuals were identified as having increased risk for falls. These 353 individuals were provided with OEP exercises and individualized fall prevention recommendations and advised to return for follow-up once per month from March to November. Two hundred forty-one participants returned for at least 1 follow-up visit (mean = 2.7, SD = 2.3, follow-up visits), with the time from IV to most recent visit ranging from 1 month to several years. Inclusion in this study was limited to 130 individuals who attended at least 2 follow-up visits within 6 months of their IV. Of these participants, 78 attended F2 within 3 months of the IV (group 1), and 52 attended F2 3 to 6 months after the IV (group 2). Demographic and health characteristics of individuals in the total sample and each group are shown in Table 2. No statistically significant differences were observed between groups for any demographic or health characteristics or for IV performance on key outcome measures (Figure 2). The MANOVA resulted in Wilks’ lambda value of P < .001.
Figure 2. (Find Figure Here: JOURNALS OF GERIATRIC PHYSICAL THERAPY)
Performance on key outcome measures at initial and second follow-up visits for total sample and each group.
Table 2. – Baseline Characteristics of Participants
(Find Figure Here: JOURNALS OF GERIATRIC PHYSICAL THERAPY)
Abbreviations: BMI, body mass index; GED, General Educational Development; HS, high school; mean (SD), mean (standard deviation) for continuous data; MMSE, Mini-mental State Examination; N, sample size; n (%), frequency (valid percent) for categorical data; Valid N, sample size with missing data excluded.
Figure 2 shows performance on outcome measures at initial and F2 visits for the entire sample and each group. Results of paired sample t tests and associated effect size from the IV to F2 for the total sample and each group are listed in Table 3. The total sample demonstrated statistically significant improvement from the IV to F2 in all 3 physical performance measures: (mean 4SBT: IV 29.5 seconds, F2 31.5 seconds, P = .001), (mean TUG: IV 12.7 seconds, F2 11.9 seconds, P = .021), and (mean CRT: IV 0.258 stands/second, F2 0.290 stands/second, P = .002). Change in balance confidence was not significant (mean ABC: IV 62.2, F2 64.4, P = .154).
Table 3. – Mean Scores on 4 Key Outcome Measures at Initial and Second Follow-up Visits
(Find Table Here: JOURNALS OF GERIATRIC PHYSICAL THERAPY)
Abbreviations: ABC, Activities-specific Balance Confidence scale; CRT, chair rise test; F2, follow-up visit; 4SBT, Four-Stage Balance Test; IV, initial visit; TUG, Timed Up and Go test.
As shown in Table 4, the 2-way ANOVA results for scores on the ABC indicated no statistically significant effects of group, visit, or their interaction for balance confidence. Significant main effects of visit were present for both 4SBT, F(1, 125) = 11.04, P = .001 and CRT, F(1, 112) = 8.92, P = .003. No significant main effects of group or group-by-visit interaction effects were present for the 4SBT or the CRT. However, a significant interaction was observed for the TUG, F(1, 126) = 5.02, P = .027. While TUG scores for group 1 participants improved from 12.6 (5.7) seconds at the IV to 11.2 (3.8) seconds at F2, scores for group 2 remained essentially unchanged (12.8, SD = 5.1, seconds at IV, 12.9, SD = 6.2, seconds at F2). Repeated-measures ANCOVAs, with age and number of falls reported at IV as covariates, produced the same findings as ANOVAs with respect to significance of main and interaction effects for all 4 outcomes.
Table 4. – Main and Interaction Effects of Group and Visit on 4 Key Outcome Measures
(Find Table Here: JOURNALS OF GERIATRIC PHYSICAL THERAPY)
Outcome Measure Group Main Effects (Group 1 vs Group 2) Visit Main Effects (IV to F2) Group × Visit Interaction Effects
Activities-Specific Balance Confidence scale F = 0.452, P = .503 F = 1.822, P = .180 F = 0.447, P = .505
Four-Stage Balance Test F = 1.503, P = .223 F = 11.043, P = .001a F = 0.697, P = .405
Timed Up and Go test F = 1.142, P = .287 F = 3.689, P = .057 F = 5.015, P = .027a
Chair rise test F = 3.357, P = .070 F = 8.915, P = .003a F = 0.923, P = .339
Abbreviations: F2, follow-up visit; IV, initial visit.
aDenotes statistical significance at P < .05.
Initially, 93 (72.1%) of the 129 participants with IV 4SBT scores were at increased risk for falls based on SLS time of less than 5 seconds. Twenty-seven (29.0%) of these individuals successfully improved SLS performance to greater than 5 seconds, suggesting a decrease in their risk for falls. Nine of the 36 participants (25.0%) with initial SLS score greater than 5 seconds had a decline in SLS performance at F2 placing them in the increased risk category based on F2 SLS score less than 5 seconds.
In the total sample of 128 participants with both IV and F2 TUG scores, 58 (45.3%) demonstrated improvement in the TUG that exceeded the MCID of 0.8 seconds.57 Twenty-eight participants (21.9%) had a decline in TUG performance from IV to F2 that exceeded the MCID.57 At the IV, 52 participants performed the TUG in greater than 12 seconds, the cut-off score recommended by the CDC to identify individuals at increased risk for falls.18,53,55,56 Of these 52 participants, 14 (26.9%) improved TUG performance to less than 12 seconds, indicating that these individuals were no longer at increased risk. Comparatively, of the 78 participants whose initial TUG score was less than 12 seconds, 6 (7.7%) had a TUG score greater than 12 seconds at F2.
For the CRT, 58 participants completed the 5xSTS at the initial and F2 visits. Twenty-four (41.4%) improved by more than the 2.3-second MCID.58 Five individuals (8.6%) worsened by at least 2.3 seconds, and 29 (50.0%) did not change by as much as 2.3 seconds.58 Of the 43 participants who completed the 30-s STS test at the initial and F2 visits, 7 (16.3%) demonstrated improved performance at F2 based on improvement greater than the 2.6-stand MCID.57 Thirty-one (72.1%) individuals did not change by as much as the MCID in either direction, and 5 (11.6%) demonstrated a decrease in score from IV to F2 that exceeded the MCID.
DISCUSSION
The objectives of this study were first to determine the effects of a community-based implementation of the OEP on physical performance and balance confidence among older adult participants and then to compare the effects among participants who completed 2 follow-up visits within 3 versus 6 months of their IV. Participants demonstrated statistically and clinically significant improvements on physical performance measures (4SBT, TUG, and CRT) from IV to F2. Improvement in balance confidence measured by the ABC was not significant. These results may simply be expected for an intervention that targets physical performance but not balance confidence. Otago Exercise Program exercises prescribed to participants as part of the CHAMP intervention were intended to improve participants’ strength and balance, and the success of these exercises was reflected in the significant improvement in the 4SBT, TUG, and CRT. The Otago Exercise Program, however, does not specifically incorporate a psychological component to address balance confidence.24
In addition to the fact that CHAMP interventions did not specifically target balance confidence, the lack of improvement in this construct as measured by the ABC may have reflected participants’ heightened awareness of their risk of falls. This program provided participants with feedback about their balance, which may have lowered confidence levels for some participants who initially presented with an overly optimistic perception of their balance abilities. Participants who had increased risk for falls were informed about this result and received an intervention to reduce their falls risk. Receiving this finding at the IV could have decreased participants’ balance confidence, and this reduced confidence may have been captured by the ABC completed at F2. In fact, the ABC test was always administered immediately upon a participant’s arrival to the CHAMP. This timing of the ABC prior to physical performance tests meant that participants did not have knowledge of any improvements that may have occurred in their physical performance until after completing the ABC.
An evidence-based program shown to improve balance confidence among older adults is a Matter of Balance (MOB) program.64 Although the MOB was not available in the rural areas evaluated in this study during the time that these data were collected, it has been offered in 1 of the 2 communities described in this study since 2017. As a result, referrals to the MOB are now a part of the evidence-based fall prevention recommendations provided to CHAMP participants who demonstrate poor balance confidence based on their ABC scores. Future research can determine whether participation in both the CHAMP and the MOB is more effective than the CHAMP alone in improving balance confidence.
Improvement on the 3 physical performance measures was statistically significant, and the associated effect sizes were comparable to those found by Shubert et al25 in a study with a much larger sample size. This finding supports that similar outcomes can be expected with the CHAMP participation compared with participation in other OEP interventions. Furthermore, many participants in this study had clinically meaningful improvements. Nearly half (45.3%) of the total participants in this study had an improvement on the TUG that exceeded the MCID.57 More than a quarter (26.9%) of participants initially with increased risk for falls based on the TUG score had improvement in the TUG sufficient to change to the “not at increased risk” category for this measure. This clinically significant improvement for the TUG occurred within a 6-month period and with a total of only 3 CHAMP visits. These findings suggest that the CHAMP is an effective modification of the OEP to a medically underserved area where older adults have limited access to such evidence-based programs. An important next step is to identify characteristics of those CHAMP participants who made this change in risk category so that we can determine which subgroup(s) to target for this community-based fall prevention program.
Functional lower extremity strength and power are expected to decrease with aging.65 However, the majority of CHAMP participants included in these analyses improved or maintained their functional lower extremity strength from initial to F2 visits. Among CHAMP participants whose functional lower extremity strength was measured at the initial and F2 visits using the 5xSTS, 41.4% had improvement that exceeded the MCID of 2.3 seconds, 50.0% maintained their baseline performance, and only 8.6% demonstrated a clinically significant decline in performance. Among participants whose functional lower extremity strength was measured by the 30-s STS test, 16.3% had clinically significant improvement, 72.1% maintained their initial strength, and 11.6% had lower scores at F2. The greater percentage of individuals showing clinically significant improvement in the 5xSTS compared with the 30-s STS is likely a result of the difference in methods between the 2 tests and their similarities to the chair stand exercise from the OEP. The chair stand exercise is commonly prescribed for home exercise in the CHAMP intervention, particularly if a participant performs poorly on the initial CRT. As a home exercise, an individual is asked to complete 5 to 10 repetitions of the exercise in a manner that closely resembles the 5xSTS. Performing the chair stand exercise as prescribed in the CHAMP intervention, therefore, is more likely to result in improvement on the 5xSTS.
Standing with a narrow base of support is often challenging for older adults, and performance of SLS is expected to decline with age.66 CHAMP participants had statistically significant improvement in the 4SBT. It is likely that participants were able to improve their performance of static balance within a narrow base of support because of the use of OEP exercises in the CHAMP intervention. Participants were frequently prescribed the SLS and tandem stance OEP exercises, which likely provided the opportunity to practice these challenging stance positions that participants might otherwise have avoided.
We expected the timing of CHAMP participants’ return for F2 to significantly influence change in all 4 key outcome measures. Contrary to our hypothesis, improvement in only 1 measure, the TUG, had a statistically significant group-by-visit interaction, with groups formed based on F2 within 3 months as compared to 3 to 6 months after IV. A possible reason for the significant effect of the time to return for F2 on the TUG could be simply that individuals who returned sooner for F2 were “getting up and going” to CHAMP visits at a greater frequency and therefore getting more practice in a shorter period of time. Additionally, the TUG, compared to the 4SBT or CRT, measures an individual’s performance not only in an activity that could be prescribed for home exercise from the OEP but in a more complex combination of actions requiring functional lower extremity strength and dynamic balance. Improvement in this more comprehensive measure may require more frequent follow-up with less time between visits than is necessary for improvement in static standing balance or repeated chair rises. This finding supports the clinical use of multiple outcome measures when assessing older adults’ change in physical performance over time.
Findings from this study have many direct implications for fall prevention programming for older adults. Given the potential of dose-response effects and greater effects for more frequent CHAMP visits, efforts are needed to increase the frequency of CHAMP visits among participants within the first 6 months of enrollment. This may require utilizing strategies from other evidence-based fall prevention programs to better recruit participants likely to benefit from the intervention and enhance participant retention (eg, appropriate site selection).67,68 Because statistically significant findings were not observed for fall confidence, opportunities exist to refine the program content to bolster knowledge and skills associated with fall prevention and management. Improving self-efficacy has been documented to improve physical performance among older adults who participate in fall prevention programming.31,69 Additional tailored support from intervention facilitators is needed that so participants can incrementally progress the difficulty of program exercises, which may assist them to initially obtain and then maintain intended outcomes.25
Limitations
This study examined a real-world, community-based intervention that necessarily included limitations related to lack of a control group, inability to control for selection of participants, timing of return visits, and changes to assessments and cut-off scores over time. Participants were self-selected from 2 rural communities that have minimal diversity of race, ethnicity, and education, particularly among adults older than 60 years.37 The lack of diversity in the sample for this study limits generalizability to other populations. Furthermore, this analysis could be performed only for individuals who were identified as having increased risk for falls at an IV and then returned for 2 additional follow-up visits, adding an additional layer to self-selection bias inherent in community-based interventions. Insights into why participants did or did not return as well as the degree to which returning participants adhered to program recommendations would be helpful for future projects to assess the CHAMP program. Other limitations of this study include not tracking participants’ adherence to OEP exercises and other fall prevention recommendations and not collecting information about participants’ activities beyond the CHAMP, which may have affected their performance on outcome measures.
Although several of these limitations are unavoidable for community-based research, future studies could include outreach to individuals who did not return to the CHAMP, evaluating effectiveness of the CHAMP offered in different areas with different populations, and including a measurement of actual falls in addition to measures of fall risk. In fact, the finding of statistically and clinically significant improvement in 3 physical performance measures despite these limitations supports the need for additional research to understand the effects of CHAMP participation on falls and falls-related measures among older adults at risk for falls.
CONCLUSIONS
Individuals who participated in an interprofessional, community-based implementation of the OEP had significant improvement in physical measures related to falls from an initial to a second follow-up visit within 6 months. Although further research is needed, this study may suggest that alternative implementations of the OEP with fewer in-person clinical visits may be beneficial for older adults living in areas where access to clinical providers is limited. Describing characteristics of individuals most likely to benefit from the CHAMP will be important in maximizing the benefits of this approach to preventing falls among older adults.
ACKNOWLEDGMENTS
We thank Leslie K. Allison for her suggestions regarding methodology and her assistance with revisions. We also thank the many CHAMP volunteers and participants who made this study possible. Special thanks to Martha Zimmerman and Muff Blankenship for their dedication to the CHAMP and to preventing falls among older adults.
REFERENCES
1. Verma SK, Willetts JL, Corns HL, Marucci-Wellman HR, Lombardi DA, Courtney TK. Falls and fall-related injuries among community-dwelling adults in the United States. PLoS One. 2016;11(3):e0150939.
2. Houry D, Florence C, Baldwin G, Stevens J, McClure R. The CDC Injury Centers response to the growing public health problem of falls among older adults. Am J Lifestyle Med. 2016;10(1):74–77.
3. Centers for Disease Control and Prevention. CDC – STEADI – Older Adult Falls – Home and Recreational Safety – Injury Center. Atlanta, GA: Centers for Disease Control and Prevention; 2015.
Keywords:
community-based; exercise; fall prevention; falls; older adults; Otago Exercise Program
© 2021 APTA Geriatrics, An Academy of the American Physical Therapy Association.
