The appeal of the Functional Fitness MOT to older adults and health professionals in an outpatient setting: a mixed-method feasibility study

Purpose: To understand the views and perceptions regarding the Functional Fitness MOT (FFMOT), a battery of functional tests followed by a brief motivational interview, of both the older people undergoing it and the health professionals delivering it. Patients and methods: Physically inactive older adults (n=29) underwent the FFMOT and subsequently attended focus groups to share their perceptions of it and to discuss the barriers, motivators, health behavior change, and scope to improve physical activity (PA) levels. PA levels were recorded at baseline and again at 12 weeks together with a post-intervention questionnaire concerning behavior change. Participating physiotherapists and technical instructors were interviewed. Results: Most participants felt they had learned about their abilities and comparisons with their peers, had a change in perception about the importance of good balance and strength, and felt the FFMOT helped raise their awareness of local and self-directed physical activity opportunities. Most felt their awareness of the need for PA had not changed, but 25% of participants started a new organized PA opportunity. The health professionals perceived the FFMOT as being easy to administer, educating, and motivating for participants to increase their PA. Space, time, finances, and insecurity about having the necessary skills to conduct the FFMOTs were seen as barriers in implementing the FFMOT in daily practice. Conclusion: Over half of those offered the FFMOT accepted it, suggesting it is appealing. However, most participants felt they were already active enough and that their awareness of the need for PA had not changed. There were positive perceptions of the FFMOT from both professionals and older people, but both felt the FFMOT could be held in a community venue. The overall findings suggest that the FFMOT is feasible in the clinical setting, but its effectiveness has yet to be determined

Frailty predicts short-term incidence of future falls among British community-dwelling older people: a prospective cohort study nested within a randomised controlled trial

BACKGROUND: Although population-based studies have shown frailty predicted future falls, their follow-up periods were one year or longer and short-term fall risks associated with frailty are unknown. METHODS: A prospective cohort study nested within a randomised controlled trial was conducted to examine associations between frailty and short-term incident future falls among community-dwelling older people. Two hundred forty eight community-dwelling people > =65 years without history of > =three falls and allocated to a usual care arm of exercise intervention trial were prospectively monitored for falls over 24 weeks. Frailty index (FI) was constructed from 40 deficits at baseline. The future fall risks according to frailty status was examined using logistic regression models. RESULTS: Of 248 participants, 46 were classified as frail and 57 had one or more falls during follow-up. Both each 0.01 increase in FI and frailty defined as FI > =0.25 were significantly associated with higher risks of future falls in multivariate logistic regression models adjusted for age, gender and history of two falls in the previous year (odds ratio (OR) = 1.05, 95 % confidence interval (95 % CI) = 1.02-1.07, p < 0.001; OR = 3.04, 95 % CI = 1.53-6.02, p = 0.001, respectively). Receiver operating characteristic (ROC) curve analysis showed FI predicted future falls with fair accuracy with area under ROC curve of 0.62 (95 % CI = 0.53-0.71, p < 0.01). CONCLUSIONS: Frailty was a significant and independent predictor of short-term future falls among community-dwelling older people who had volunteered for a physical activity study. It is important for healthcare practitioners to recognise frailty as a risk factor of imminent future falling even in older people who appear to be ageing well

Feasibility of trial procedures for a randomised controlled trial of a community based group exercise intervention for falls prevention for visually impaired older people: the VIOLET study

Background Visually impaired older people (VIOP) have a higher risk of falling than their sighted peers, and are likely to avoid physical activity. The aim was to adapt the existing Falls Management Exercise (FaME) programme for VIOP, delivered in the community, and to investigate the feasibility of conducting a definitive randomised controlled trial (RCT) of this adapted intervention. Methods Two-centre randomised mixed methods pilot trial and economic evaluation of the adapted group-based FaME programme for VIOP versus usual care. A one hour exercise programme ran weekly over 12 weeks at the study sites (Newcastle and Glasgow), delivered by third sector (voluntary and community) organisations. Participants were advised to exercise at home for an additional two hours over the week. Those randomised to the usual activities group received no intervention. Outcome measures were completed at baseline, 12 and 24 weeks. The potential primary outcome was the Short Form Falls Efficacy Scale – International (SFES-I). Participants’ adherence was assessed by reviewing attendance records and self-reported compliance to the home exercises. Adherence with the course content (fidelity) by instructors was assessed by a researcher. Adverse events were collected in a weekly phone call. Results Eighteen participants, drawn from community-living VIOP were screened; 68 met the inclusion criteria; 64 participants were randomised with 33 allocated to the intervention and 31 to the usual activities arm. 94% of participants provided data at the 12 week visit and 92% at 24 weeks. Adherence was high. The intervention was found to be safe with 76% attending nine or more classes. Median time for home exercise was 50 min per week. There was little or no evidence that fear of falling, balance and falls risk, physical activity, emotional, attitudinal or quality of life outcomes differed between trial arms at follow-up. Conclusions The intervention, FaME, was implemented successfully for VIOP and all progression criteria for a main trial were met. The lack of difference between groups on fear of falling was unsurprising given it was a pilot study but there may have been other contributory factors including suboptimal exercise dose and apparent low risk of falls in participants. These issues need addressing for a future trial

Does the timed up and go test predict future falls among British community-dwelling older people? Prospective cohort study nested within a randomised controlled trial

Background Falling is common among older people. The Timed-Up-and-Go Test (TUG) is recommended as a screening tool for falls but its predictive value has been challenged. The objectives of this study were to examine the ability of TUG to predict future falls and to estimate the optimal cut-off point to identify those with higher risk for future falls. Methods This is a prospective cohort study nested within a randomised controlled trial including 259 British community-dwelling older people ≥65 years undergoing usual care. TUG was measured at baseline. Prospective diaries captured falls over 24 weeks. A Receiver Operating Characteristic curve analysis determined the optimal cut-off point to classify future falls risk with sensitivity, specificity, and predictive values of TUG times. Logistic regression models examined future falls risk by TUG time. Results Sixty participants (23%) fell during the 24 weeks. The area under the curve was 0.58 (95% confidence interval (95% CI) = 0.49-0.67, p = 0.06), suggesting limited predictive value. The optimal cut-off point was 12.6 seconds and the corresponding sensitivity, specificity, and positive and negative predictive values were 30.5%, 89.5%, 46.2%, and 81.4%. Logistic regression models showed each second increase in TUG time (adjusted for age, gender, comorbidities, medications and past history of two falls) was significantly associated with future falls (adjusted odds ratio (OR) = 1.09, 95% CI = 1.00-1.19, p = 0.05). A TUG time ≥12.6 seconds (adjusted OR = 3.94, 95% CI = 1.69-9.21, p = 0.002) was significantly associated with future falls, after the same adjustments. Conclusions TUG times were significantly and independently associated with future falls. The ability of TUG to predict future falls was limited but with high specificity and negative predictive value. TUG may be most useful in ruling in those with a high risk of falling rather than as a primary measure in the ascertainment of risk

Lasten ja nuorten kenkien valinta : verkko-ohjausmateriaali lastenneuvolan ja kouluterveydenhuollon henkilökunnalle

Opinnäytetyön tarkoituksena oli tuottaa Suomen Terveydenhoitajaliiton verkkosivuille jä-senten käyttöön materiaalia kengistä lasten ja nuorten jalkaterveyden edistämiseksi. Opin-näytetyö tehtiin yhteistyössä Suomen Terveydenhoitajaliitto ry:n kanssa. Tutkimuksellinen lähestymistapa verkkomateriaalin kehittämisessä oli sekä laadullinen että määrällinen. Aineistona käytettiin kattavaa kirjallisuuskatsausta sekä terveydenhoitajille kohdennettuja kyselyjä. Kirjallisuuskatsausaineisto kerättiin PubMed-, Medline- ja Chinal-tietokannoista. Kyselyn kohderyhmä koostui Suomen Terveydenhoitajaliitto ry:n Helsingin alueen neuvola- ja kouuluterveydenhenkilöstöstä. Kirjallisuuskatsauksen artikkelit analysoi-tiin teoriaohjaavan sisällönanalyysin avulla. Kyselylomakkeiden avoimiin kysymyksiin tulleet vastaukset analysoitiin aineistolähtöistä sisällön analyysia käyttäen. Tulosten mukaan lasten ja nuorten kenkien tulisi olla sopivat kooltaan, mukailla jalkaterän mallia, materiaaliltaan hengittävät, korottomat, joustavat, kevyet ja pohjaltaan ohuet ja taipuisat. Kengillä kävelyn tulisi mukailla paljasjaloin kävelyä, jolloin jalkaterät saavat toimia luonnollisella tavalla. Kyselyn perusteella terveydenhoitajat tarvitsevat työssään tietoa ken-gän hyvistä ominaisuuksista: muun muassa koon arvioimisesta, pohjan ja lestin malleista ja materiaalista. Kyselyyn vastanneet halusivat enemmän tietoa pihtipolvista, ylipainon merki-tyksestä sekä kenkien vaikutuksista alaraajojen kasvuun ja kehitykseen. Verkko-ohjausmateriaali kehitettiin terveydenhoitajien työn apuvälineeksi. Palautekyselyn perusteella terveydenhoitajat olivat tyytyväisiä verkko-ohjausmateriaaliin. Muutoksia toivot-tiin palstojen jäsentelyyn, fonttiin, otsikoiden numerointiin sekä taulukoiden selkiyttämi-seen. Verkkomateriaalia voivat hyödyntää kaikki Suomen Terveydenhoitajaliitto ry:n jäsenet. Verkko-ohjausmateriaali antaa tietoa lasten ja nuorten jalkaterveyttä edistävien kenkien valinnasta ja alaraajoihin vaikuttavista tekijöistä. Tulostettava ohjausmateriaali antaa tukea vanhemmille lasten ja nuorten kenkien valintaan. Kaikki moniammatillisissa työyhteisöissä työskentelevät saavat uusinta tieteellistä tietoa lasten kengistä ja niiden vaikutuksista ala-raaja- ja jalkaterveyteen ja voivat hyödyntää sitä lasten vanhempien ohjauksessa.The aim of this study, carried out in cooperation with the National Union of Public Health Nurses, was to promote children’s and young people’s foot health by producing material about shoes for the web pages of National Union of Public Health Nurses. The online material was developed using both qualitative and quantitative methodological approaches. The data was collected from a literature review and a questionnaire to public health nurses. The literature was gathered from the following databases: PubMed-, Med-line and Chinal. The questionnaire was targeted at family centre and school health service personnel in the Helsinki area. The literature review articles were analyzed using theory-based content analysis whereas the answers to open questions in the questionnaire were analyzed using data-based content analysis. The results show that shoes for children and young people should be well-fitting, adapt to each foot form, made of breathable material, heelless, flexible, light and with thin and flexible soles. Walking with shoes should imitate walking barefoot allowing the natural functions of the foot. According to the survey, in their work public health nurses need information on the properties of a good shoe; for instance on the designs and materials of the sole and last and also how to estimate correct shoe size. The respondents wanted more information on knock-knees, the significance of overweight and the effect shoes have on the growth and development of lower limbs. The online guidance material was developed to help public health nurses in their work and feedback shows it was met with satisfaction. The nurses suggested changes in the column structure, the font, the numbering of titles and the clarity of tables. The material, available to all members of the National Union of Public Health Nurses, gives information on factors that influence the lower limbs and on choosing shoes which pro-mote children’s and young people’s foot health. The material can be printed out to help parents choose shoes for their children. Podiatrists can benefit from the newest scientific information on children’s shoes and their effect on lower limbs and foot health by using the information to give advice to parents and in practice with multiprofessional work communities

Lessons learnt during a complex, multicentre cluster randomised controlled trial:the ProAct65+ trial

BACKGROUND: Failure to recruit to target or schedule is common in randomized controlled trials (RCTs). Innovative interventions are not always fully developed before being tested, and maintenance of fidelity to the intervention during trials can be problematic. Missing data can compromise analyses, and inaccurate capture of risks to participants can influence reporting of intervention harms and benefits. In this paper we describe how challenges of recruitment and retention of participants, standardisation and quality control of interventions and capture of adverse events were overcome in the ProAct65+ cluster RCT. This trial compared class-based and home-based exercise with usual care in people aged 65 years and over, recruited through general practice. The home-based exercise participants were supported by Peer Mentors. RESULTS: (1) Organisational factors, including room availability in general practices, slowed participant recruitment so the recruitment period was extended and the number invited to participate increased. (2) Telephone pre-screening was introduced to exclude potential participants who were already very active and those who were frequent fallers. (3) Recruitment of volunteer peer mentors was difficult and time consuming and their acceptable case load less than expected. Lowering the age limit for peer mentors and reducing their contact schedule with participants did not improve recruitment. (4) Fidelity to the group intervention was optimised by introducing quality assurance observation of classes by experienced exercise instructors. (5) Diaries were used to capture data on falls, service use and other exercise-related costs, but completion was variable so their frequency was reduced. (6) Classification of adverse events differed between research sites so all events were assessed by both sites and discrepancies discussed. CONCLUSIONS: Recruitment rates for trials in general practice may be limited by organisational factors and longer recruitment periods should be allowed for. Exercise studies may be attractive to those who least need them; additional screening measures can be employed to avoid assessment of ineligible participants. Enrolment of peer mentors for intervention support is challenging and needs to be separately tested for feasibility. Standardisation of exercise interventions is problematic when exercise programmes are tailored to participants’ capabilities; quality assurance observations may assure fidelity of the intervention. Data collection by diaries can be burdensome to participants, resulting in variable and incomplete data capture; compromises in completion frequency may reduce missing data. Risk assessments are essential in exercise promotion studies, but categorisation of risks can vary between assessors; methods for their standardisation can be developed. TRIAL REGISTRATION: ISRCTN4345377

PERHEYRITYKSEN SUKUPOLVENVAIHDOS : Esimerkkinä Oulaisten SisustusPiste Ay

Opinnäytetyöni toimeksiantaja oli Pohjois-Pohjanmaalla sijaitseva Oulaisten SisustusPiste Ay, joka on yksityinen yritys ja kuuluu vuonna 1953 perustettuun Värisilmä-ketjuun. Värisilmä-ketju on Suomen johtava sisustuksen pintamateriaaleihin erikoistunut ketju. Suuret väestöryhmät ikääntyvät ja väistämättä yrityksillä on edessään sukupolvenvaihdos, mikäli liiketoimintaa halutaan jatkaa ja pitää yritys elossa. Työni keskeisenä aiheena oli sukupolvenvaihdos perheyrityksessä. Tavoitteenani oli tutustua sukupolvenvaihdosprosessiin kokonaisuutena ja selvittää erilaisia tapoja toteuttaa sukupolvenvaihdos onnistuneesti. Tietoperustassa käsiteltiin perheyrityksen määritelmää, sukupolvenvaihdosta, erilaisia toimintamalleja sukupolvenvaihdokseen sekä verotukseen liittyviä seikkoja. Työtäni täydentävän tutkimuksen tiedonkeruumuotona olivat haastattelut esimerkkiyrityksen osapuolille sekä pankin ja tilitoimiston henkilökunnalle. Tutkimusotteeni oli laadullinen ja tavoitteenani oli kartoittaa yrityksen sukupolvenvaihdokseen liittyviä huomioitavia asioita. Lähdeaineiston, teoreettisen viitekehyksen ja osapuolten haastattelujen pohjalta laadin yritykselle alustavan sukupolvenvaihdossuunnitelman, joka ei sisällä verotuksellisia yksityiskohtia tai taloudellisia laskelmia. Mielestäni toimeksianto oli mielenkiintoinen sekä aihe ajankohtainen.This thesis was commissioned by SisustusPiste Ay, which is located in Oulainen, Northern Ostrobotnia. SisustusPiste Ay is private company that belongs to Värisilmä-chain, established in 1953. Värisilmä-chain is the leading chain in Finland among the companies that are specialized in coating. Large demographic groups are getting older and the companies are inevitably facing a change of generation to keep the business alive and running. The key subjects in this thesis were the change of generation and rather small family companies. The goal was to get acquainted with the generation change process on the whole and also to explore different ways of successfully carrying out the generation change. The definitions of a family business, the change of generation, tax-related issues and the methods of the change of generation. The data supporting my work were collected by conducting interviews of the staff in a bank, accounting company and the example company. The research was qualitative and the goal was to survey the important matters related to the company’s change of generation. The client company needed an information package which would help processing the company’s change of generation. The assigment was interesting and the subject was current

Exercise for reducing fear of falling in older people living in the community

Background: Fear of falling is common in older people and associated with serious physical and psychosocial consequences. Exercise (planned, structured, repetitive and purposive physical activity aimed at improving physical fitness) may reduce fear of falling by improving strength, gait, balance and mood, and reducing the occurrence of falls. Objectives: To assess the effects (benefits, harms and costs) of exercise interventions for reducing fear of falling in older people living in the community. Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2013), the Central Register of Controlled Trials (CENTRAL 2013, Issue 7), MEDLINE (1946 to July Week 3 2013), EMBASE (1980 to 2013 Week 30), CINAHL (1982 to July 2013), PsycINFO (1967 to August 2013), AMED (1985 to August 2013), the World Health Organization International Clinical Trials Registry Platform (accessed 7 August 2013) and Current Controlled Trials (accessed 7 August 2013). We applied no language restrictions. We handsearched reference lists and consulted experts. Selection criteria: We included randomised and quasi-randomised trials that recruited community-dwelling people (where the majority were aged 65 and over) and were not restricted to specific medical conditions (e.g. stroke, hip fracture). We included trials that evaluated exercise interventions compared with no intervention or a non-exercise intervention (e.g. social visits), and that measured fear of falling. Exercise interventions were varied; for example, they could be 'prescriptions' or recommendations, group-based or individual, supervised or unsupervised. Data collection and analysis: Pairs of review authors independently assessed studies for inclusion, assessed the risk of bias in the studies and extracted data. We combined effect sizes across studies using the fixed-effect model, with the random-effect model used where significant statistical heterogeneity was present. We estimated risk ratios (RR) for dichotomous outcomes and incidence rate ratios (IRR) for rate outcomes. We estimated mean differences (MD) where studies used the same continuous measures and standardised mean differences (SMD) where different measures or different formats of the same measure were used. Where possible, we performed various, usually prespecified, sensitivity and subgroup analyses. Main results: We included 30 studies, which evaluated 3D exercise (Tai Chi and yoga), balance training or strength and resistance training. Two of these were cluster-randomised trials, two were cross-over trials and one was quasi-randomised. The studies included a total of 2878 participants with a mean age ranging from 68 to 85 years. Most studies included more women than men, with four studies recruiting women only. Twelve studies recruited participants at increased risk of falls; three of these recruited participants who also had fear of falling. Poor reporting of the allocation methods in the trials made it difficult to assess the risk of selection bias in most studies. All of the studies were at high risk of performance and detection biases as there was no blinding of participants and outcome assessors and the outcomes were self reported. Twelve studies were at high risk of attrition bias. Using GRADE criteria, we judged the quality of evidence to be 'low' for fear of falling immediately post intervention and 'very low' for fear of falling at short or long-term follow-up and all other outcomes. Exercise interventions were associated with a small to moderate reduction in fear of falling immediately post intervention (SMD 0.37 favouring exercise, 95% confidence interval (CI) 0.18 to 0.56; 24 studies; 1692 participants, low quality evidence). Pooled effect sizes did not differ significantly between the different scales used to measure fear of falling. Although none of the sensitivity analyses changed the direction of effect, the greatest reduction in the size of the effect was on removal of an extreme outlier study with 73 participants (SMD 0.24 favouring exercise, 95% CI 0.12 to 0.36). None of our subgroup analyses provided robust evidence of differences in effect in terms of either the study primary aim (reduction of fear of falling or other aim), the study population (recruitment on the basis of increased falls risk or not), the characteristics of the study exercise intervention or the study control intervention (no treatment or alternative intervention). However, there was some weak evidence of a smaller effect, which included no reduction, of exercise when compared with an alternative control. There was very low quality evidence that exercise interventions may be associated with a small reduction in fear of falling up to six months post intervention (SMD 0.17, 95% CI -0.05 to 0.38; four studies, 356 participants) and more than six months post intervention (SMD 0.20, 95% CI -0.01 to 0.41; three studies, 386 participants). Very low quality evidence suggests exercise interventions in these studies that also reported on fear of falling reduced the risk of falling measured either as participants incurring at least one fall during follow-up or the number of falls during follow-up. Very low quality evidence from four studies indicated that exercise interventions did not appear to reduce symptoms of depression or increase physical activity. The only study reporting the effects of exercise interventions on anxiety found no difference between groups. No studies reported the effects of exercise interventions on activity avoidance or costs. It is important to remember that our included studies do not represent the totality of the evidence of the effect of exercise interventions on falls, depression, anxiety or physical activity as our review only includes studies that reported fear of falling. Authors' conclusions: Exercise interventions in community-dwelling older people probably reduce fear of falling to a limited extent immediately after the intervention, without increasing the risk or frequency of falls. There is insufficient evidence to determine whether exercise interventions reduce fear of falling beyond the end of the intervention or their effect on other outcomes. Although further evidence from well-designed randomised trials is required, priority should be given to establishing a core set of outcomes that includes fear of falling for all trials examining the effects of exercise interventions in older people living in the community