Life After Falls prevention therapy involving ExeRcise (LAFTER)

Background: Exercise programmes addressing problems of gait, balance and lower limb strength, are effective in reducing rate and risk of falls in community-dwelling older people. There is a lack of evidence regarding the long-term effects of falls prevention exercises. Aim: To investigate whether a falls prevention exercise intervention had any long-term effects on health-related outcomes compared to advice only, in older adults who have participated in a falls prevention clinical trial. Methods: This study used mixed methods. A cohort study followed-up a subset of 4891/9803 (50%) older people recruited to a larger RCT; The Prevention of Fall Injury Trial (PreFIT). Data on falls, health-related quality of life, frailty, cognition and general health were collected from participants allocated to advice only and advice plus exercise, up to six-years after randomisation. Interviews were undertaken with 23 participants randomised to the exercise intervention to explore their experiences of the trial. Results: 2980/4891 (61%) participants responded to a postal survey (advice: n=1507; exercise: n=1473). At six years, there were no long-term effects of exercise on falls or other health outcomes. There were no differences by treatment arm or by adherence to exercise. Overall health of the whole cohort gradually declined over time, in multiple domains. Analysis of interviews identified five themes: happy to help; exercise behaviours; “It keeps me going”; “It wasn’t a real fall”; and loss. Participants were no longer undertaking the strength and balance exercises prescribed during their intervention. They preferred walking as their main form of exercise, and no-one reported preventing falls as a motivator to continuing to exercise. Conclusions: There were no long-term effects of falls prevention exercises in this cohort of older people. This may be because older people stop their specific strength and balance exercises when their supervised intervention comes to an end

Long-term follow-up of exercise interventions aimed at preventing falls in older people living in the community : a systematic review and meta-analysis

Background Fall related injuries are the leading cause of accident - related mortality for older adults, with 30% of those aged 65 years and over falling annually. Exercise is effective in reducing rate and risk of falls in community - dwelling adults; however, there is lack of evidence for the long - term effects of exercise. Objectives To assess the long-term effect of exercise interventions on preventing falls in community - dwelling older adults. Data Sources Searches were undertaken on MEDLINE, EMBASE, AMED, CINAHL, psycINFO, the Physiotherapy Evidence Database (PEDro) and The Cochrane Library from inception to April 2017. Study selection Randomised controlled trials (RCTs), cohort studies or secondary analyses of RCTs with long - term follow - up (>12 months) of exercise interventions involving community - dwelling older adults (65 and over) compared to a control group. Data extraction/Data synthesis Pairs of review authors independently extracted data. Review Manager (RevMan 5.1) was used for meta - analysis and data were extracted using rate ratio (RaR) and risk ratio (RR). Results Twenty - four studies (7818 participants) were included. The overall pooled estimate of the effect of exercise on rate of falling beyond 12 - month follow - up was rate ratio (RaR) 0.79 (95% confidence interval (CI) 0.71 to 0.88) and risk of falling was risk ratio (RR) 0.83 (95% CI 0.76 to 0.92) Subgroup analyses revealed that there was no sustained effect on rate or risk of falling beyond two years post - intervention. Conclusions Falls prevention exercise programmes have sustained long - term effects on the number of people falling and the number of falls for up to two years after an exercise intervention

What enables older people to continue with their falls prevention exercises? A qualitative systematic review

Objectives To review the qualitative literature that explores the barriers and facilitators to continued participation in falls prevention exercise after completion of a structured exercise programme Design A systematic literature review with thematic synthesis of qualitative studies exploring older adults’ experiences of continued participation in falls prevention exercise Data sources Comprehensive searches were conducted in MEDLINE, PSYCHinfo, AMED, ASSIA, CINAHL and EMBASE from inception until November 2017. Additional studies were identified via searches of reference lists and citation tracking of relevant studies Eligibility criteria Qualitative or mixed methods studies exploring experiences of community-dwelling older adults (65 years and over) participation in a falls prevention exercise programme including their experience of ongoing participation in exercise after the completion of a structured exercise programme. Data extraction and synthesis Key characteristics including aim, participant characteristics, method of data collection, underpinning qualitative methodology and analytical approach were extracted and independently checked. Thematic synthesis was used to integrate findings Results From studies involving 425 participants, we identified three descriptive themes: identity, motivators/deterrentsand nature of the intervention and one overarching analytical theme: agency. Conclusions Older people have their own individual and meaningful rationale for either continuing or stopping exercise after completion of a structured falls prevention exercise programme. Exploring these barriers and facilitators to continued exercise is key during the intervention phase. It is important that health care professionals get to know the older person’s rationale and offer the best evidence-based practice and support to individuals, to ensure a smooth transition from their structured intervention towards longer-term exercise-related behaviou

Exercise rehabilitation programmes for pulmonary hypertension – a systematic review of intervention components and reporting quality

Objectives: To identify the components, and assess the reporting quality, of exercise training interventions for people living with pulmonary hypertension. Design: Systematic review with analysis of intervention reporting quality using the Consensus on Exercise Reporting Template (CERT). Data sources: Eligible studies in the Cochrane Systematic Review of exercise-based rehabilitation for pulmonary hypertension, updated with a new search of relevant databases from 1st August 2016 to 15th January 2018. Eligibility criteria: Peer reviewed journal articles of randomised and non-randomised controlled trials, and non-controlled prospective observational studies, investigating dynamic exercise training interventions in adult humans with diagnosed pulmonary hypertension, reporting on at least one physiological and/or psychosocial outcome. Results: Interventions typically involved cycle ergometry and walking. They were delivered as three-week in-patient, or out-patient and/or home-based programmes, lasting for four to 15 weeks. Components relating specifically to exercise prescription were described satisfactorily and in more detail than motivational/behavioural change strategies, adherence and fidelity. Mean Consensus on Exercise Reporting Template (CERT) score was 13.1 (range 8 to 17) out of a possible maximum score of 19. No studies fully reported every aspect of an exercise intervention to the standard recommended by CERT. Summary/conclusion: Considerable variability was evident in the components and reporting quality of interventions for exercise rehabilitation studies in pulmonary hypertension. Interventional studies using exercise training should pay greater attention to describing motivational/ behavioural change strategies, adherence and fidelity. Detailed description of these parameters is essential for the safe and effective replication of exercise rehabilitation interventions for pulmonary hypertension in clinical practice. Trial registration number: This systematic review is registered with PROSPERO 2018 CRD4201808555

Life after falls prevention exercise – experiences of older people taking part in a clinical trial

Background: There is little evidence about the lived experience of older people who have completed a falls prevention exercise programme and their life beyond their intervention. Method: A phenomenological interview study with 23 participants (12 females), mean age 81 years (range 74-93 years), residing in their own homes across England, who had participated in a falls prevention exercise intervention within the Prevention of Falls Injury Trial (PreFIT). The aims were to explore their experiences of: i. being in a clinical trial involving exercise. ii. exercise once their falls prevention intervention had finished. Interpretative data analysis was informed by van Manen’s (1997) framework for phenomenological data. Results: Analysis of interviews about experiences of participating in PreFIT and what happened once the falls intervention ended identified five themes: Happy to help; Exercise behaviours; “It keeps me going”; “It wasn’t a real fall”; and Loss. Participants did not continue their specific exercises after they had completed the intervention. They preferred walking as their main exercise, and none reported preventing falls as a motivator to continue exercising. Participant experiences suggest that they have their own ideas about what constitutes a fall and there is disparity between their interpretation and the definition used by healthcare professionals and researchers. Conclusion: Despite good intentions and perceived benefits, on-going participation in falls prevention exercises beyond a structured, supervised intervention was not a priority for these older people. Promoting continuation of falls prevention exercises post-intervention is just as challenging as promoting uptake to and adherence during exercise programmes

Development and delivery of an exercise programme for falls prevention: the Prevention of Falls Injury Trial (PreFIT)

This paper describes the development and implementation of an exercise intervention to prevent falls within The Prevention of Fall Injury Trial (PreFIT), which is a large multi-centred randomised controlled trial based in the UK National Health Service (NHS).Using the template for intervention description and replication (TIDieR) checklist, to describe the rationale and processes for treatment selection and delivery of the PreFIT exercise intervention.Based on the results of a validated falls and balance survey, participants were eligible for the exercise intervention if they were at moderate or high risk of falling.Intervention development was informed using the current evidence base, published guidelines, and pre-existing surveys of clinical practice, a pilot study and consensus work with therapists and practitioners. The exercise programme targets lower limb strength and balance, which are known, modifiable risk factors for falling. Treatment was individually tailored and progressive, with seven recommended contacts over a six-month period. Clinical Trials Registry (ISCTRN 71002650)

Moderators of cognitive outcomes from an exercise programme in people with mild to moderate dementia

BACKGROUND/OBJECTIVES: Our aim was to estimate whether baseline participant variables were able to moderate the effect of an exercise intervention on cognition in patients with mild to moderate dementia. DESIGN: Subgroup analysis of a multicenter pragmatic randomized controlled trial. SETTING: Community-based gym/rehabilitation centers. PARTICIPANTS: A total of 494 community-dwelling participants with mild to moderate dementia. INTERVENTION: Participants were randomized to a moderate- to high-intensity aerobic and strength exercise program or a usual care control group. Experimental group participants attended twice weekly 60- to 90-minute gym sessions for 4 months. Participants were prescribed home exercises for an additional hour per week during the supervised period and 150 minutes each week after the supervised period. MEASUREMENTS: Multilevel regression model analyses were undertaken to identify individual moderators of cognitive function measured through the Alzheimer Disease Assessment Scale-Cognitive Subscale score at 12 months. RESULTS: When tested for a formal interaction effect, only cognitive function assessed by the baseline number cancellation test demonstrated a statistically significant interaction effect (−2.7 points; 95% confidence interval = −5.14 to −0.21). CONCLUSION: People with worse number cancellation test scores may experience greater progression of cognitive decline in response to a moderate- to high-intensity exercise program. Further analyses to examine whether these findings can be replicated in planned sufficiently powered analyses are indicated

Comparison of alternative falls data collection methods in the Prevention of Falls Injury Trial (PreFIT)

Background and Objectives: Prospective, monthly diaries are recommended for collecting falls data but are burdensome and expensive. The aim of the article was to compare characteristics of fallers and estimates of fall rates by method of data collection.Study Design and Setting: A methodology study nested within a large cluster randomized controlled trial. We randomized 9,803 older adults from 63 general practices across England to receive one of three fall prevention interventions. Participants provided a retrospective report of falls in postal questionnaires mailed every 4 months. A separate randomization allocated participants to receive prospective monthly falls diaries for one simultaneous 4-month period. Results: Falls diaries were returned by 7,762 of 9,375 (83%); of which 6,306 (67%) participants reported the same number of falls on both data sources. Diary nonresponders were older and had poorer levels of physical and mental health. Analysis of time points where both data sources were available showed the falls rate on diaries was consistently higher than on the questionnaire (mean rate: 0.16 vs. 0.12 falls per person-month observation). Diary allocation was associated with a higher rate of withdrawal from the main trial. Conclusion: Diary completion was associated with sample attrition. We found on average a 32% difference in falls rates between the two data sources. Retrospective and prospective falls data are not consistently reported when collected simultaneously

Aerobic and strength training exercise programme for cognitive impairment in people with mild to moderate dementia : the DAPA RCT

Background Approximately 670,000 people in the UK have dementia. Previous literature suggests that physical exercise could slow dementia symptom progression. Objectives To estimate the clinical effectiveness and cost-effectiveness of a bespoke exercise programme, in addition to usual care, on the cognitive impairment (primary outcome), function and health-related quality of life (HRQoL) of people with mild to moderate dementia (MMD) and carer burden and HRQoL. Design Intervention development, systematic review, multicentred, randomised controlled trial (RCT) with a parallel economic evaluation and qualitative study. Setting 15 English regions. Participants People with MMD living in the community. Intervention A 4-month moderate- to high-intensity, structured exercise programme designed specifically for people with MMD, with support to continue unsupervised physical activity thereafter. Exercises were individually prescribed and progressed, and participants were supervised in groups. The comparator was usual practice. Main outcome measures The primary outcome was the Alzheimer’s Disease Assessment Scale – Cognitive Subscale (ADAS-Cog). The secondary outcomes were function [as measured using the Bristol Activities of Daily Living Scale (BADLS)], generic HRQoL [as measured using the EuroQol-5 Dimensions, three-level version (EQ-5D-3L)], dementia-related QoL [as measured using the Quality of Life in Alzheimer’s Disease (QoL-AD) scale], behavioural symptoms [as measured using the Neuropsychiatric Inventory (NPI)], falls and fractures, physical fitness (as measured using the 6-minute walk test) and muscle strength. Carer outcomes were HRQoL (Quality of Life in Alzheimer’s Disease) (as measured using the EQ-5D-3L) and carer burden (as measured using the Zarit Burden Interview). The economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year (QALY) gained from a NHS and Personal Social Services perspective. We measured health and social care use with the Client Services Receipt Inventory. Participants were followed up for 12 months. Results Between February 2013 and June 2015, 494 participants were randomised with an intentional unequal allocation ratio: 165 to usual care and 329 to the intervention. The mean age of participants was 77 years [standard deviation (SD) 7.9 years], 39% (193/494) were female and the mean baseline ADAS-Cog score was 21.5 (SD 9.0). Participants in the intervention arm achieved high compliance rates, with 65% (214/329) attending between 75% and 100% of sessions. Outcome data were obtained for 85% (418/494) of participants at 12 months, at which point a small, statistically significant negative treatment effect was found in the primary outcome, ADAS-Cog (patient reported), with a mean difference of –1.4 [95% confidence interval (CI) –2.62 to –0.17]. There were no treatment effects for any of the other secondary outcome measures for participants or carers: for the BADLS there was a mean difference of –0.6 (95% CI –2.05 to 0.78), for the EQ-5D-3L a mean difference of –0.002 (95% CI –0.04 to 0.04), for the QoL-AD scale a mean difference of 0.7 (95% CI –0.21 to 1.65) and for the NPI a mean difference of –2.1 (95% CI –4.83 to 0.65). Four serious adverse events were reported. The exercise intervention was dominated in health economic terms. Limitations In the absence of definitive guidance and rationale, we used a mixed exercise programme. Neither intervention providers nor participants could be masked to treatment allocation. Conclusions This is a large well-conducted RCT, with good compliance to exercise and research procedures. A structured exercise programme did not produce any clinically meaningful benefit in function or HRQoL in people with dementia or on carer burden