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Ebp Sri 5
Ebp Sri 5
Abstract
Background: Lasting disability and further falls are common and costly problems in older people following fall-
related lower limb and pelvic fractures. Exercise interventions can improve mobility after fracture and reduce falls in
older people, however the optimal approach to rehabilitation after fall-related lower limb and pelvic fracture is
unclear. This randomised controlled trial aims to evaluate the effects of an exercise and fall prevention self-
management intervention on mobility-related disability and falls in older people following fall-related lower limb or
pelvic fracture. Cost-effectiveness of the intervention will also be investigated.
Methods/Design: A randomised controlled trial with concealed allocation, assessor blinding for physical
performance tests and intention-to-treat analysis will be conducted. Three hundred and fifty people aged 60 years
and over with a fall-related lower limb or pelvic fracture, who are living at home or in a low care residential aged
care facility and have completed active rehabilitation, will be recruited. Participants will be randomised to receive a
12-month intervention or usual care. The intervention group will receive ten home visits from a physiotherapist to
prescribe an individualised exercise program with motivational interviewing, plus fall prevention education through
individualised advice from the physiotherapist or attendance at the group based “Stepping On” program (seven
two-hour group sessions). Participants will be followed for a 12-month period. Primary outcome measures will be
mobility-related disability and falls. Secondary outcomes will include measures of balance and mobility, falls risk,
physical activity, walking aid use, frailty, pain, nutrition, falls efficacy, mood, positive and negative affect, quality of
life, assistance required, hospital readmission, and health-system and community-service contact.
(Continued on next page)
* Correspondence: csherrington@georgeinstitute.org.au
1
The George Institute for Global Health, Sydney Medical School, The
University of Sydney, Sydney, Australia
Full list of author information is available at the end of the article
© 2016 Sherrington et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Sherrington et al. BMC Geriatrics (2016) 16:34 Page 2 of 10
We will conduct a trial that aims to determine the ef- care on balance and mobility, falls risk, physical ac-
fect of this exercise and fall prevention self-management tivity, walking aid use, frailty, pain, nutrition, falls ef-
training program on mobility-related disability and falls ficacy, mood, positive and negative affect, quality of
in people with a recent fall-related lower limb or pelvic life, assistance from others, hospital readmission,
fracture: the Recovery Exercises and Stepping On after and health-system and community-service contact
fracture trial (RESTORE) trial. To our knowledge, this is in older people with a recent fall-related lower limb
the first study to examine the effect of an exercise and or pelvic fracture.
fall prevention self-management program on mobility To establish the cost-effectiveness and cost-utility of
and falls in older people with a recent lower limb or the intervention approach, compared with that of
pelvic fracture. Unlike previous post-fracture studies, the usual care, from the perspective of the health and
intervention and follow-up will be long-term, and the community care funder.
majority of exercise will be undertaken independently, To describe the safety and tolerability of the
aiming for a balance between sufficient intensity for program.
effectiveness and reduced cost for feasibility of To determine features associated with uptake of the
implementation. intervention.
Recruitment
screening
Baseline
assessment
Concealed random
allocation
n=350
Intervention group
n=175
will give written informed consent prior to randomisa- intervention status, and all exercise equipment will be
tion. The study adheres to the CONSORT guidelines removed prior to assessment. It is acknowledged that as
[25] and is registered with the Australia New Zealand falls are self-reported, blinding of assessors is not pos-
Clinical Trials Register ACTRN12610000805077. sible for this outcome.
Participants Intervention
Participants will be recruited from Royal North Shore, Prior to commencement of the intervention, medical
Prince of Wales, Manly, St George, Mona Vale, Gosford, clearance for study participation will be obtained from
War Memorial, John Hunter, Royal Newcastle, Longue- each participant's medical practitioner.
ville Private, Greenwich and Orange Hospitals - all in
New South Wales, Australia. Potential participants will Home exercise program
be identified in hospital via discussion with hospital staff Participants randomised to the intervention group will
and review of ward lists. In addition, letters will be sent each receive 10 home visits and five phone calls from a
to potentially eligible people identified from hospital da- physiotherapist in the 12-month study period. There will
tabases, and general advertisement in hospitals, commu- be six visits in the first three months after randomisation
nity centres and newspapers will be undertaken. and four visits over the following nine months, with each
Participants who meet the following inclusion criteria visit lasting 45-60 minutes. Five follow-up phone calls will
will be invited to participate: female or male; aged be made to review progress and address participants’ con-
60 years or older; fall-related lower limb or pelvic frac- cerns. The physiotherapist will prescribe an individualised
ture in the past two years; no marked cognitive impair- exercise program and use motivational interviewing and
ment (Mini-Mental State Examination score [26] ≥ 24); goal setting to encourage behaviour change with regard to
living at home or in a hostel (low care residential acre exercise. Participants will be encouraged to perform the
facility where residents generally live in their own units exercise program for 20-30 minutes, three times per week
but meals are provided and assistance with showering at home, for 12 months. The choice of exercises, degree of
and dressing in available), in the Sydney, Central Coast, difficulty and number of repetitions will be prescribed
Hunter or Orange regions of New South Wales, based upon assessment of the individual participant’s abil-
Australia. ities and negotiated with participants. The lower limb
People will be ineligible to participate in the trial if they strengthening and balance exercises are based on the
meet the exclusion criteria: insufficient English language Weight Bearing Exercise for Better Balance (WEBB) pro-
skills to complete the study assessment and interventions; gram, developed by investigator CS and colleagues (http://
unable to walk 10 metres despite assistance from a walk- www.webb.org.au). The exercises target strength and con-
ing aid or another person; progressive neurological disease trol of the lower limb extensor muscles (hip and knee ex-
(e.g., Parkinson’s disease); a medical condition precluding tensors, ankle plantarflexors) with exercises including
exercise e.g., unstable cardiac disease, uncontrolled hyper- repetitions of the sit-to-stand movement, semi-squats
tension, uncontrolled metabolic diseases, large abdominal from a standing position, stepping up onto blocks and
aortic aneurysm; currently receiving a treatment program heel raises whilst standing on a wedge. Resistance will be
from a rehabilitation facility. applied via body weight, weight-belts or weighted vests as
appropriate. Exercises targeting balance will be performed
Randomisation and blinding in standing with a progressively narrowed base (feet
After consent and completion of the baseline assess- together, tandem stance, single leg stance), will in-
ment, participants will be formally entered into the study volve reaching, stepping, and forward, backward and
and randomised to intervention or control groups. Ran- sideways walking. Upper limb support will be mini-
domisation order will be determined using a computer mised in order to adequately challenge balance, but
generated random number schedule with randomly per- to ensure safety the environment will be set up with
muted block sizes. Allocation will be concealed by using stable supports (e.g. bench or table) close by that can
central randomisation performed by an investigator (CS) be held as necessary. At each visit the physiotherapist
not involved in assessments or recruitment, and the will review and adjust the type and intensity of exercises
treatment allocation tables will be inaccessible to recruit- to ensure the intervention remains appropriate and chal-
ment staff. Staff performing outcome measurement and lenging for each participant throughout the study period.
data analysis for the primary outcomes will be blinded to Progression will be negotiated with participants. Resist-
group allocation. However, due to the nature of the ance applied via weight vests or weight belts will start at
intervention, it is not possible to blind the staff adminis- approximately 2 % of body weight and will be gradually
tering interventions or the participants. Participants will increased so the Borg Rate of Perceived Exertion scale is
be instructed not to inform the assessors of their ‘hard’ (i.e., a rating of 14-16). Maintaining safety while
Sherrington et al. BMC Geriatrics (2016) 16:34 Page 5 of 10
exercising will be a prime consideration when level of dif- scheduled home visits [32]. Verbal advice on fall preven-
ficulty of exercises is prescribed. tion will be provided to intervention group participants
The study physiotherapists will be experienced in pre- during most home visits.
scribing exercise for older people. Strategies to optimise
adherence to the intervention include goal setting and Control group
review at each home visit, scheduling exercise, provision Participants assigned to the control group will receive the
of a home exercise manual that can be updated at each usual care available to older people from their medical
visit by the physiotherapist, and an exercise diary. Fur- practitioners and community services. In the catchment
ther strategies to increase adherence are outlined in areas for the trial, usual care for non-institutionalised
Additional file 1. If a participant becomes unwell or is older people may involve allied health input, medical man-
admitted to hospital, the program will be resumed when agement of health conditions, assessment of care needs,
the participant feels able and the relevant treating pro- and provision of care. Full documentation of usual care is
fessionals deem the participant well enough to partici- beyond the scope of this trial.
pate again.
Data collection
Fall prevention education Data will be collected from medical records (where pos-
Intervention group participants will also be offered the sible), participant interviews in person and by telephone,
“Stepping On” program [24] (http://www.steppingon.com) physical assessments, and calendars mailed to the re-
as implemented by the New South Wales Ministry of search centre. Participants will undergo two home-based
Health (i.e., weekly 2-hour group sessions for seven assessments; one prior to randomisation and the other
weeks). The “Stepping On” program is a multi-faceted 12 months after randomisation. A physiotherapist or a
community based program co-ordinated by an occupa- trained research assistant who is unaware of group allo-
tional therapist or other health professional in a small- cation will perform the assessments. Each assessment
group learning environment. It uses a variety of strategies will take about one hour to complete.
to increase self-efficacy in fall-risk situations, [27] incorpo- Details of fracture, comorbidities and hospital stays
rates a decision-making model to explore barriers and will be obtained from the medical records where pos-
options for reducing risk of falls [28], and uses adult learn- sible. From participant interviews we will obtain baseline
ing principles to self-manage risk [29]. The “Stepping On” information on pre-fracture daily task independence,
content is relevant to people with fall-related lower limb fracture details, medical conditions, cognition (using the
or pelvic fracture and will cover coping with visual loss Short Portable Mental Status Questionnaire) [33], nutri-
and regular visual screening, medication management, tion (Mini Nutritional Assessment) [34], medications,
environmental and behavioural home safety, and commu- and fracture interventions (including surgical fixation,
nity safety [30]. Group sessions will be held in rooms at occupational therapy home visits and physiotherapy).
local community centres or hospitals. Transport will be The primary and secondary outcomes will be adminis-
arranged for those who would otherwise be unable to at- tered at baseline and 12-month assessments.
tend the sessions. Each program will be attended by up to All participants will receive 12 one-month calendars
13 people. The group session will be completed within the and questionnaires at the time of the baseline assess-
12-month study period, with the timing depending on ment. Participants will be asked to record falls (primary
availability of a “Stepping On” program. The “Stepping outcome) and use of health and community services on
On” program encourages the older person to take control the calendars and to return completed calendars in pre-
and explore different coping behaviours, and encourages paid envelopes to the research centre each month. If cal-
follow-through of safety strategies in everyday life. The endars are not returned, participants will be telephoned
program addresses each of the eight aspects of the Health to ask about their fall history for that month. Any fall re-
Education Impact Questionnaire [31]: positive and active ported on the calendars will be followed up with a
engagement in life, health-directed behaviour, skill and phone call to obtain further information about the de-
technique acquisition, constructive attitudes and ap- tails and consequences of the fall. All participants will be
proaches, self-monitoring and insight, health service navi- telephoned at three, six, nine and twelve months for as-
gation, social integration and support, and emotional sessment of the Boston University Activity Measure for
wellbeing. Post Acute Care (AM-PAC; primary outcome) [35], and
If participants are unable or unwilling to attend the European Quality of Life-5 dimensions quality of life as-
group-based “Stepping On” program, the physiotherapist sessment (EQ-5D-5 L; secondary outcome) [36]. Staff
will provide them with individualised advice, the weekly who receive calendars and questionnaires, make follow
“Stepping On” handouts and/or, if deemed appropriate, up phone calls and enter data will be unaware of group
a publication targeting falls prevention during the allocation.
Sherrington et al. BMC Geriatrics (2016) 16:34 Page 6 of 10
and determine features associated with uptake of the A strength of this study is that the intervention program
intervention. This will be undertaken via calendars, ver- could be delivered as part of routine care. While the pro-
bal reports, questionnaires and a qualitative sub-study. gram does not have as much contract with health profes-
Adherence to the prescribed intervention will be mon- sionals as interventions previously shown to be successful
itored with home exercise diaries and verbal reports in increasing mobility after hip fracture [10, 11], we believe
from participants in the intervention group. The total it is sufficiently intense to be effective, yet inexpensive
repetitions of home exercise performed will be divided enough to be implemented in real-life healthcare systems.
by total repetitions prescribed. Global level of adherence The novel intervention combines an individualised exercise
will be estimated as a percentage. Participants will also program with a self-management approach and is based on
be asked to identify reasons for adoption and adherence the highest level of evidence for the prescription of exercise
as well as non-adoption and non-adherence. for older people. The exercise component, the WEBB pro-
Participants’ experience of the intervention will be in- gram, was designed using evidence from systematic reviews
vestigated using three questionnaires. A modified ver- and randomised trials that have demonstrated improved
sion of the Exercise Benefits/Barriers Scale [47] explores strength, balance and mobility in older people. The WEBB
the perceived facilitators and barriers to exercise; five program increases mobility in older people with frailty [49],
items measure the individual’s confidence in their ability Parkinson’s Disease [50], stroke [51], and recent hospitalisa-
to persist with exercising in various situations [48]; and tion [22]. Of concern, in our previous trail of the WEBB
nine questions explore the acceptability and enjoyment program in older people recently discharged from hospital
of the intervention. the rate of falls was statistically significantly greater in the
In a subset of participants, a qualitative study will fur- intervention group compared to the control group.22 The
ther explore the participants’ experiences of recovery reason for increased falls is unclear, however it may be that
from fall related fracture and participation in the study home exercise as a single intervention may be insufficient
intervention program. to reduce falls in this high-risk post hospital population.
The addition of the fall prevention component in the
Sample size calculation current study addresses this finding by specifically targeting
A total of 350 participants (175 per group) will be re- fall risk and falls self-efficacy.
cruited. The study will have 80 % power to detect as sig- Additional strengths of the study are powering the
nificant, at the 5 % level, a 30 % decrease in the rate of study for the falls primary outcome, broad inclusion cri-
falls (i.e. an IRR of 0.70 using negative binomial regres- teria, and the robust, but pragmatic, clinical trial design.
sion analysis) over the 12-month study period. This sam- Unlike most previous studies following lower limb frac-
ple size will provide 90 % power to detect a statistically ture, this study is designed to detect a between-group
significant between-group difference of 10 % in lower difference in falls and is conducted over a one-year
extremity continuous summary performance score [46] period. Importantly, the study will identify predictors of
For these calculations, we assumed an α of 0.05, non- adherence to the program and will also include a com-
compliance of 15 % and a dropout rate of 15 %. prehensive economic analysis. If effective, the interven-
tion being examined could be readily implemented in
Timeframe the hospital aged care and/or community health services
Recruitment commenced in March 2010. Follow-up as- settings.
sessment will conclude in December 2015. Falls and fractures are costly to individuals, their
carers, the health system and society. Despite this
Discussion cost, to our knowledge there has been no research to
Many people who have suffered a lower limb fracture date examining the cost-effectiveness of intervention
are left with long-term disability and increased risk of designed to enhance mobility and reduce falls after
future falls, however there is no clear evidence for a suc- lower limb or pelvic fracture. In the older population,
cessful and cost-effective program to reduce mobility- cost-benefit analysis showed the “Stepping On” pro-
related disability and falls in fracture survivors. This ran- gram has positive net benefits and is cost saving [52].
domised trial will determine whether a 12-month home The economic analysis conducted alongside this trial
exercise and falls prevention self-management program aims to establish the cost-effectiveness and cost-utility
reduces mobility-related disability and falls among older of the intervention approach, compared with that of
men and women who live in the community following a usual care, from the perspective of the health and
lower limb or pelvic fracture. There will be far-reaching community care funder.
benefits for older people, their carers and the commu- The study is not without limitations. Participants cannot
nity if this program can assist in minimising mobility- be blinded to group allocation due to the complex nature
related disability and falls in this high-risk population. of the intervention, so the potential for differential
Sherrington et al. BMC Geriatrics (2016) 16:34 Page 9 of 10
reporting of falls is a potential source of bias. However, Sydney, Australia. 6Prince of Wales Clinical School, University of New South
blinding of assessors to the other primary outcome (i.e., Wales, Sydney, Australia. 7Neuroscience Research Australia, University of New
South Wales, Sydney, Australia. 8John Walsh Centre for Rehabilitation
lower extremity performance score) means this outcome Research, Sydney Medical School Northern, The University of Sydney, St
is at a lower risk of bias. Also, there is no frequency- Leonards, Australia. 9Department of Geriatric Medicine, Gosford Hospital,
matched control group intervention, so we will be unable Gosford, Australia.
to determine whether social aspects of the program im- Received: 22 November 2015 Accepted: 25 January 2016
pact upon any difference between groups.
If this exercise and fall prevention self-management
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