Hälso- och sjukvårdens utveckling har lett fram till ett marknadsstyrt system. För att kunna jämföra olika vårdgivare och utveckla kvalitén har ett flertal kvalitetsindikatorer och uppföljningsområden införts. Fallrisk är ett av dessa uppföljningsområden. I Sverige är Downton Fall Risk Index förstahandsval som fallriskbedömningsinstrument. Hälso- och sjukvård ska utformas och genomföras i samråd med patienterna. Den traditionella rollfördelningen mellan patienterna och sjuksköterskorna håller på att förändras till att patienternas rätt till delaktighet uppmärksammas. Syftet med denna uppsats var att belysa sjuksköterskornas erfarenhet av och syn på patienternas delaktighet i fallriskbedömningen. Det här är en intervjustudie med kvalitativ ansats. Åtta sjuksköterskor som arbetar på ett akutsjukhus i mellersta Sverige och använder sig av Downton Fall Risk Index vid fallriskbedömningen har intervjuats. Kvalitativ innehållsanalys som inspirerats av Graneheim och Lundman har använts. Den teoretiska utgångspunkten är Peplaus syn på relationen mellan sjuksköterskorna och patienterna som en av de viktigaste grundstenarna inom omvårdnaden. Studien kom fram till följande fem teman: fallrisk är sjuksköterskornas bedömning, standardmall har ett eget liv, fallrisk - skrämselpropaganda eller verklighet, sjuksköterskornas svårigheter med att involvera patienterna och sjuksköterskornas syn på patienternas delaktighet. Det standardiserade arbetssättet uppmuntrar inte till utvecklingen av reflektionsförmågan och kliniska blicken bland nyutbildade sjuksköterskor därför behövs det en kompetensstege för sjuksköterskor. Sjuksköterskor hittar inte plats varken för sin egen eller för patienternas delaktighet i Downton Fall Risk Index. Frågan som kan ställas är om rätt instrument har valts för fallriskbedömningen i akutsjukvården.

As aging occurs, safely maintaining an active lifestyle is critical for health and independence. Independent mobility is influenced by one???s ability to perform three essential tasks of daily living: transitioning from a seated to standing posture, maintaining upright stance and walking. In spite of the apparent similarities in the predictive utility of these different tasks, there are few studies that have explored the specific relationship between these tasks that define independent mobility within individuals to determine if they reflect unique challenges to control. The thesis focused on two studies to advance understanding of the determinants of independent mobility in older adults. Study 1 explored the association between measures of standing, transitions and walking in 28 older adults. An important element was the assessment using portable low-cost measurement technology (Wii force boards and wearable accelerometers) so that testing could be done in the community. The results of this study revealed the potential importance of sit-to-stand performance as an independent measure of function in older adults. One important outcome was the need for a more detailed measurement of the sit-to-stand task, which is characterized by different phases that have unique control challenges. As a result, Study 2 was designed to evaluate different measurements of the sit-to-stand phases in order to provide a measurement tool that could be used in community and clinical testing. Ground reaction forces were found capable of identifying the different sit-to-stand phases and therefore afford the ability to quantify this behavior using portable technology. Identifying the underlying control mechanisms and relationships between these mechanisms allows clinicians to prescribe targeted and potentially more effective interventions focused on behavior specific control challenges.

Falls are the most serious problems facing the ageing community. The goal of the current project was to carry out a simplified analysis using kinematic parameters like joint angles and spatial temporal parameters in order to analyse the age related changes in functional gait as well as to identify the biomechanics indicators of locomotion alterations that can help determined fall risk levels in the ageing community. / Οι πτώσεις είναι ένα από τα σοβαρότερα προβλήματα που αντιμετωπίζει σήμερα ο ηλικιωμένος πληθυσμός. Στόχος της εργασίας είναι να γίνει μια ανάλυση των κινητικών παραμέτρων όπως των γωνιών των αρθρώσεων και των χωροχρονικών παραμέτρων ώστε να αναλυθούν οι αλλαγές λόγω ηλικίας στη κίνηση καθώς και να αναγνωριστούν οι εμβιομηχανικοί δείκτες των κινητικών προβλημάτων οι οποίοι βοηθούν στο να καθοριστούν τα επίπεδα του κινδύνου πτώσης στους ηλικιωμένους ανθρώπους.

The objectives of the study were to determine the incidence of falls, the prevalence of fear of falling and fall risk factors and consequences in adults with rheumatoid arthritis (RA). 559 community dwelling adults with RA, aged 18 to 88 years (mean age 62; 69% female) participated in this prospective cohort study. Patients were recruited from four outpatient clinics in the Northwest of England and followed for 1 year after clinical assessment, using monthly falls calendars and telephone calls. Outcome measures included fall occurrence, reason for fall, type and severity of injuries, fractures, fall location, lie-times, use of health services and functional ability. Risk factors for falls included lower limb muscle strength, postural stability, number of swollen and tender joints, functional status, history of falling, fear of falling, pain, fatigue and medication. Data on demographics, vision, co-morbidities, history of surgery, fractures, and joint replacements were also recorded.535 participants followed for one year had a total of 598 falls. 36.4% participants (95% CI 32% to 41%) reported falling with an incidence rate of 1313/1000 person-years at risk or 1.11 falls per person. Over one third of the falls were reportedly caused by hips, knees or ankle joints giving way. Over half of all the falls resulted in moderate injuries, including head injuries (n=27) and fractures (n=26). Univariate logistic regression showed that falls risk was independent of age and gender. A history of falls in the previous one year was a strong medical fall predictor with an odds ratio (OR) for a single fall=3.3 and for multiple falls OR=4.3. Fear of falling was an important self-reported psychological predictor, with the risk increasing by 10% with each point above 7 (up to 28) in the Short FES-I score. The inability to complete the Four Test Balance Scale due to poor balance was a strong postural fall predictor (OR 2.3). The most significant functional predictor of falls was the functional Health Assessment Questionnaire score, and each additional point attained in the score (1-4) nearly doubled the risk of further falls. Multivariate logistic regression revealed that when taken in combination with other factors, a history of multiple falls in the previous one year was the most significant predictive risk factor (OR=5.3) and overall the model accounted for 71% of variation. The most significant modifiable risk factors were swollen and tender lower limb joints (hip, knee and ankle) (OR=1.7), psychotropic medication (OR=1.8) and increasing fatigue (OR=1.13) with this model accounting for 68% of variation. Adults of all ages with RA are at high risk of falls and fall-related injuries, fractures and head injuries. In clinical practice, high risk falls patients with RA can be identified by asking whether patients have fallen in the past year. The management of swollen and tender lower limb joints, fatigue and consideration of psychotropic medicines may be the most effective strategy to reduce falls in this group of patients. Fear of falling, pain, lower limb strength and poor balance are other useful clinical indicators that may be modified to prevent falls.

The current body of work aims to apply Processing Efficiency Theory (PET) and Attentional Control Theory (ACT) to novel dynamic settings by examining how anxiety influences perceptual-cognitive and perceptual-motor skills. Sporting domains and fall-risk in older adults are studied. Applying ACT to a tennis anticipation paradigm examines whether state anxiety influences processing efficiency and the use of contextual information during anticipation. Processing efficiency was reduced under anxiety, while overall response accuracy was unchanged. Furthermore, skilled performers were seemingly less able to utilise contextual information when anxious. Studies in Chapters 4 and 5 sought to test the predictions of PET and ACT compared with those of Reinvestment Theory (RT) in the field of fall-risk in older adults. In Chapter 4, trait anxiety, alongside increasing dual-task demands, produced processing and motoric inefficiencies through reduced visual planning and mean gait velocity. Furthermore, greater and more variable gait velocity reductions were found in those with higher trait anxiety. By contrast, greater reinvestment levels were associated with poorer visuospatial recall, higher stepping accuracy, plus larger and less variable gait velocity reductions. Chapter 5 further investigates the motoric inefficiencies observed in anxious older adults’ gait. The influences of trait anxiety, movement specific reinvestment, and falls efficacy on body segmental control during adaptive turning are studied. Trait anxiety and falls efficacy were mainly shown to influence differing facets of turning behaviour, though both were associated with greater coupling of body segments (en-bloc rotations), whereas, limited support was offered for RT. Overall, PET and ACT were supported when applied to these new dynamic domains. However, discrepancies are discussed due to testing theoretical hypotheses in more representative environments.

Purpose of study: To examine change in balance-related fall risk and daily functional abilities in the first 2 postoperative weeks and up to 6 weeks after gynecologic surgery. Materials and methods: Prospective cohort study in gynecologic surgery patients age 65 and older. Balance confidence (Activities-specific Balance Confidence Scale) and functional status (basic and instrumental activities of daily living) were recorded pre-and post-operatively daily for 1 week and twice the second week. Physical performance balance and functional mobility were measured pre-and 1 week post-operatively using the Tinetti Fall Risk Scale, Timed Up and Go, and 6-Minute Walk test. Measures were repeated 6 weeks after surgery. Nonparametric tests for paired data were used comparing scores baseline to post-operative (POD) 7 and to POD 42. Results: Median age was 72 years (range 65-88). Fall risk was elevated during the first 2 post-operative weeks, greatest on the median discharge day, POD 2 (p < 0.01). Balance performance and functional mobility at 1 week were significantly lower than baseline (p < 0.01). Functional abilities declined, including new dependence in medication management at home in 22% of these independent and cognitively intact women. Conclusions: After gynecologic surgery, older women's fall risk is highest on POD 2 and remains elevated from baseline for 2 weeks. Functional limitations in the early home recovery period include the anticipated (bathing, cooking, etc.) and some unanticipated (medication management) ones. This information may help with postoperative discharge planning.

Falls are a leading cause of injury and accidental injury death worldwide. Fall-risk prevention techniques exist but fall-risk identification can be difficult. While clinical assessment tools are the standard for identifying fall risk, wearable-sensors and machine learning could improve outcomes with automated and efficient techniques. Machine learning research has focused on older adults. Since people with lower limb amputations have greater falling and injury risk than the elderly, research is needed to evaluate these approaches with the amputee population. In this thesis, random forest and fully connected feedforward artificial neural network (ANN) machine learning models were developed and optimized for fall-risk identification in amputee populations, using smartphone sensor data (phone at posterior pelvis) from 89 people with various levels of lower-limb amputation who completed a 6-minute walk test (6MWT). The best model was a random forest with 500 trees, using turn data and a feature set selected using correlation-based feature selection (81.3% accuracy, 57.2% sensitivity, 94.9% specificity, 0.59 Matthews correlation coefficient, 0.83 F1 score). After extensive ANN optimization with the best ranked 50 features from an Extra Trees Classifier, the best ANN model achieved 69.7% accuracy, 53.1% sensitivity, 78.9% specificity, 0.33 Matthews correlation coefficient, and 0.62 F1 score. Features from a single smartphone during a 6MWT can be used with random forest machine learning for fall-risk classification in lower limb amputees. Model performance was similarly effective or better than the Timed Up and Go and Four Square Step Test. This model could be used clinically to identify fall-risk individuals during a 6MWT, thereby finding people who were not intended for fall screening. Since model specificity was very high, the risk of accidentally misclassifying people who are a no fall-risk individual is quite low, and few people would incorrectly be entered into fall mitigation programs based on the test outcomes.

Background: Healthcare workers are ranked among one of the top occupations for musculoskeletal disorder (MSD) injuries that affect the muscles, the bones, the nervous system and due to repetitive motion tasks (Centers for Disease Control and Prevention, 2017). Numerous high-risk patient handling tasks such as lifting, transferring, ambulating and repositioning of patients cause injuries that can be prevented when evidence-based solutions are used for safe patient handling and mobility (SPHM) tasks. Purpose: The purpose of this quality improvement project was to evaluate the knowledge and attitudes of orthopedic nurses regarding the use of SPHM algorithms as the standard of care when transferring patients. Theoretical Framework. Lewin’s Theory of Change Methods. A quasi-experimental pretest-post-test design was utilized in this evidenced-based practice project. Results. Descriptive statistics that evaluated pre and post questionnaires of the orthopedic nurses noted nurses displayed behavioral and attitudinal intent to use the SPHM algorithms as the standard of care to improve patient outcomes by decreasing falls. Although the behavioral beliefs and attitudes reflected acknowledgement of SPHM skills and knowledge, nursing did not improve in their documentation of SPH fall risk as two separate tools were required on each patient. Conclusions: SPHM evidenced-based standards do guide staff to critically examine how to safely transfer and mobilize a patient. Patient fall rates did decrease during educational sessions, prompting the need for on-going education of all staff on the unit that transfers patients. The findings from this quality project may encourage future practice approaches to use of the safe patient handling (SPH) fall risk assessment tool for all patients to prevent patient falls.

abstract: There are many inconsistencies in the literature regarding how to estimate the Lyapunov Exponent (LyE) for gait. In the last decade, many papers have been published using Lyapunov Exponents to determine differences between young healthy and elderly adults and healthy and frail older adults. However, the differences in methodologies of data collection, input parameters, and algorithms used for the LyE calculation has led to conflicting numerical values for the literature to build upon. Without a unified methodology for calculating the LyE, researchers can only look at the trends found in studies. For instance, LyE is generally lower for young adults compared to elderly adults, but these values cannot be correlated across studies to create a classifier for individuals that are healthy or at-risk of falling. These issues could potentially be solved by standardizing the process of computing the LyE. This dissertation examined several hurdles that must be overcome to create a standardized method of calculating the LyE for gait data when collected with an accelerometer. In each of the following investigations, both the Rosenstein et al. and Wolf et al. algorithms as well as three normalization methods were applied in order to understand the extent at which these factors affect the LyE. First, the a priori parameters of time delay and embedding dimension which are required for phase space reconstruction were investigated. This study found that the time delay can be standardized to a value of 10 and that an embedding dimension of 5 or 7 should be used for the Rosenstein and Wolf algorithm respectively. Next, the effect of data length on the LyE was examined using 30 to 1300 strides of gait data. This analysis found that comparisons across papers are only possible when similar amounts of data are used but comparing across normalization methods is not recommended. And finally, the reliability and minimum required number of strides for each of the 6 algorithm-normalization method combinations in both young healthy and elderly adults was evaluated. This research found that the Rosenstein algorithm was more reliable and required fewer strides for the calculation of the LyE for an accelerometer. / Dissertation/Thesis / Appendix A / Doctoral Dissertation Biomedical Engineering 2019

Introduction: Fall risk, occurrence and injury is increasing as the world ages, and Africa and other emerging regions will not be spared. Similarly, the rise of noncommunicable diseases, compressed morbidity and lack of physical activity present major challenges. This novel feasibility study explored the use of an exergaming technology compared with a conventional, evidence-based exercise programme (Otago Exercise Programme) to reduce fall risk by improving balance, and to inform a large-scale randomised control trial. Methodology: Mixed methods study in independent older adults with established fall risk. The quantitative component employed feasibility RCT methodology. Cluster randomisation assigned interventions to sites. Single blinding was used. Both interventions were offered for six months. A variety of balance-related endpoints (e.g., Timed Up and Go, Dynamic Gait Index, Mini-BESTest) were used to find the most applicable. Patient-centred variables included questionnaires regarding depression, physical activity levels, quality of life and estimates of self-efficacy for exercise. Qualitative focus groups explored participants' experiences of falls and the exergaming intervention using a phenomenology lens. Results: Site and participant recruitment was simple and readily achievable, with low numbers need to screen required. Eligibility criteria were confirmed and more added. Adherence and attrition were major challenges. Cluster randomisation appeared to exacerbate between-group differences at baseline. The exergaming intervention produced preliminary evidence in its favour, with results approaching Minimal Clinically Important Difference compared with the evidence-based intervention. The experience of the exergaming intervention was regarded as positive by focus group participants. Barriers and facilitators are reported. Discussion: Methodological issues in the literature have prevented firm consensus on the use of exergaming in falls prevention, although studies are abundant. The current study used rigorous methodology in the novel context of a developing region, which offers numerous challenges for older adults. Implications for a large-scale, fully funded RCT are discussed. Lessons learned can be used to scale up service delivery for an under-served population; and promote the aim of well-being for all at all ages.