Beyond “#endpjparalysis”, tackling sedentary behaviour in health care

Reducing sedentary behaviour after hospitalization starts with reducing sedentary behaviour whilst in hospital. Although we have eradicated immobilisation as a therapeutic tool due to its potent detrimental effects, it is still in systemic use within health care systems and hospitals. Evidence shows that when in hospital, patients spend most of their time sedentary. In this editorial, we explore the determinants of, and a system-based approach to, reducing sedentary behaviour in health care

An explorative study of current strategies to reduce sedentary behaviour in hospital wards

Prolonged sitting (or sedentary behaviour—SB) has profound detrimental effects on health and is associated with increased risk of chronic disease, hospitalisation and premature death. However, while in hospital, a person will spend the vast majority of the day sitting or lying down. A number of strategies have started to be implemented to counteract this phenomenon and get patients up and moving. This is the first explorative study that used device-based measurements of the postural physical activity of older hospitalised adults taking part in such initiatives. A total of 43 patients, mean age 83.8y (SD 8.3), wore a waterproofed activity monitor (activPAL3) for 4 days (including overnight); physical activity was analysed for waking hours. Interventions designed to get patients up and moving were introduced sequentially. Participants were grouped based on the highest level of intervention they received. There were 4 groups: “control” (n = 12), “education” (advice on SB reduction via infographics on the ward noticeboards, n = 12), “#endpjparalysis” (up and dressed by the nurses before 11: 30 am, n = 9), “personalised activity passports” (agreed by Occupational Therapists and other members of the multidisciplinary team with patients, on SB reduction, n = 10). ANOVA revealed the absence of any differences between the 4 groups for total sitting time (p = 0.989), time spent upright (standing and walking) (p = 0.700), number of sitting events (i.e. sit to stand transitions) (p = 0.418) and longest upright period (p = 0.915). This small explorative study of sequential initiatives within a ward setting to reduce SB found they were not successful. The cross-sectional service-improvement nature of the study limited the ability to assess change in individuals as interventions were introduced. Further work is warranted to untangle the determinants of SB in hospital settings and implement interventions of sustainable SB change in this setting

Environmental and behavioural interventions for reducing physical activity limitation and preventing falls in older people with visual impairment

BACKGROUND: Impairment of vision is associated with a decrease in activities of daily living. Avoidance of physical activity in older adults with visual impairment can lead to functional decline and is an important risk factor for falls. The rate of falls and fractures is higher in older people with visual impairment than in age‐matched visually normal older people. Possible interventions to reduce activity restriction and prevent falls include environmental and behavioral interventions. OBJECTIVES: We aimed to assess the effectiveness and safety of environmental and behavioral interventions in reducing physical activity limitation, preventing falls and improving quality of life amongst visually impaired older people. SEARCH METHODS: We searched CENTRAL (including the Cochrane Eyes and Vision Trials Register) (Issue 2, 2020), Ovid MEDLINE, Embase and eight other databases to 4 February 2020, with no language restrictions. SELECTION CRITERIA: Eligible studies were randomized controlled trials (RCTs) and quasi‐randomized controlled trials (Q‐RCTs) that compared environmental interventions, behavioral interventions or both, versus control (usual care or no intervention); or that compared different types of environmental or behavioral interventions. Eligible study populations were older people (aged 60 and over) with irreversible visual impairment, living in their own homes or in residential settings. To be eligible for inclusion, studies must have included a measure of physical activity or falls, the two primary outcomes of interest. Secondary outcomes included fear of falling, and quality of life. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included six RCTs (686 participants) conducted in five countries (Australia, Hungary, New Zealand, UK, US) with follow‐up periods ranging from two to 12 months. Participants in these trials included older adults (mean age 80 years) and were mostly female (69%), with visual impairments of varying severity and underlying causes. Participants mostly lived in their homes and were physically independent. We classified all trials as having high risk of bias for masking of participants, and three trials as having high or unclear risk of bias for all other domains. The included trials evaluated various intervention strategies (e.g. an exercise program versus home safety modifications). Heterogeneity of study characteristics, including interventions and outcomes, (e.g. different fall measures), precluded any meta‐analysis. Two trials compared the home safety modification by occupational therapists versus social/home visits. One trial (28 participants) reported physical activity at six months and showed no evidence of a difference in mean estimates between groups (step counts: mean difference (MD) = 321, 95% confidence interval (CI) ‐1981 to 2623; average walking time (minutes): MD 1.70, 95% CI ‐24.03 to 27.43; telephone questionnaire for self‐reported physical activity: MD ‐3.68 scores, 95% CI ‐20.6 to 13.24; low‐certainty of evidence for each outcome). Two trials reported the proportion of participants who fell at six months (risk ratio (RR) 0.76, 95% CI 0.38 to 1.51; 28 participants) and 12 months (RR 0.59, 95% CI 0.43 to 0.80, 196 participants) with low‐certainty of evidence for each outcome. One trial (28 participants) reported fear of falling at six months, using the Short Falls Efficacy Scale‐International, and found no evidence of a difference in mean estimates between groups (MD 2.55 scores, 95% CI ‐0.51 to 5.61; low‐certainty of evidence). This trial also reported quality of life at six months using 12‐Item Short Form Health Survey, and showed no evidence of a difference in mean estimates between groups (MD ‐3.14 scores, 95% CI ‐10.86 to 4.58; low‐certainty of evidence). Five trials compared a behavioral intervention (exercise) versus usual activity or social/home visits. One trial (59 participants) assessed self‐reported physical activity at six months and showed no evidence of a difference between groups (MD 9.10 scores, 95% CI ‐13.85 to 32.5; low‐certainty of evidence). Three trials investigated different fall measures at six or 12 months, and found no evidence of a difference in effect estimates (RRs for proportion of fallers ranged from 0.54 (95% CI 0.29 to 1.01; 41 participants); to 0.93 (95% CI 0.61 to 1.39; 120 participants); low‐certainty of evidence for each outcome). Three trials assessed the fear of falling using Short Falls Efficacy Scale‐International or the Illinois Fear of Falling Measure from two to 12 months, and found no evidence of a difference in mean estimates between groups (the estimates ranged from ‐0.88 score (95% CI ‐2.72 to 0.96, 114 participants) to 1.00 score (95% CI ‐0.13 to 2.13; 59 participants); low‐certainty of evidence). One trial (59 participants) assessed the European Quality of Life scale at six months (MD ‐0.15 score, 95% CI ‐0.29 to ‐0.01), and found no evidence of a clinical difference between groups (low‐certainty of evidence). AUTHORS' CONCLUSIONS: There is no evidence of effect for most of the environmental or behavioral interventions studied for reducing physical activity limitation and preventing falls in visually impaired older people. The certainty of evidence is generally low due to poor methodological quality and heterogeneous outcome measurements. Researchers should form a consensus to adopt standard ways of measuring physical activity and falls reliably in older people with visual impairments. Fall prevention trials should plan to use objectively measured or self‐reported physical activity as outcome measures of reduced activity limitation. Future research should evaluate the acceptability and applicability of interventions, and use validated questionnaires to assess the adherence to rehabilitative strategies and performance during activities of daily living