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Physio findings - research that’s relevant to physiotherapists

Janet Wright reports on the latest clinical findings

Older people

What really causes falls?
Falling down is the biggest cause of accidental injuries in people over 65. It leads to 90 per cent of their hip and wrist fractures and 60 per cent of head injuries.

Understanding what causes a fall is essential in reducing this toll. Now a Canadian study published in the Lancet suggests that most falls may not be happening the way researchers thought.

Half of those older people in long-term care facilities fall at least once a year, as do 30 per cent of those living in their own homes.

Most studies have been based on interviews, reports and behaviour studied in laboratories, where researchers tend to focus on falls caused by slipping.

But Stephen Robinovitch, of Simon Fraser University in British Columbia, and colleagues studied video footage from care homes.

They found that only three per cent of the real-life falls they watched started with a slip. Simply moving off-balance turned out to be the biggest problem.

‘Up to now, the general scarcity of reliable information has hindered the development of safer environments for older people and fall prevention programmes,’ said Professor Robinovitch.  

Cameras were placed in two homes in British Columbia from April 2007 to June 2010. Staff were asked to complete an incident report after each fall and contact the researchers.

In all, the videos showed 227 falls by 130 residents, with an average age of 78.

The cameras covered common areas such as dining rooms, lounges and halls, which is where about half of care-home falls are believed to occur. (They did not cover non-public areas including bathrooms, however, where there is an increased risk of slipping.)

The most common problem turned out to be incorrect weight shifting, when people moved their centre of gravity beyond their base of support. This led to 41 per cent of falls.

Tripping or stumbling caused another 21 per cent, and a quarter of these happened when the person tripped over a table or chair leg. Bumps, loss of support and collapse each caused 11 per cent of falls.

A fall was most likely to happen when the person was walking forwards (24 per cent), standing quietly (13 per cent) or sitting down (12 per cent).

Earlier studies had suggested older people had more falls while they were walking and fewer when standing.

‘Our study provides long-missing objective evidence of the causes and circumstances of falls in elderly people, and should open up new avenues for the prevention of fall injury in long-term care,’ said Professor Robinovitch.

For example, staff in care homes should be alert to residents’ risk of tripping over furniture.
Robinovitch SN et al. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet 2012; doi:10.1016/S0140-6736(12)61263-X

Obesity

Fitness counts more than weight
Regular exercise could be good for obese people even if it doesn’t help them shift unwanted weight, a new study suggests.

An international team studied US data from the Aerobics Center Longitudinal Study on 43,000 people of all sizes, average age 44.

They found that metabolic health is more important than weight in assessing the risk of heart disease and early death.

Among those who were obese, more than half had metabolic syndrome – a group of factors that increase the risk of diabetes and coronary heart disease.

Those factors include high blood pressure, high blood sugar, high triglyceride levels and low levels of high-density lipoproteins.

The obese but metabolically normal subjects were found to be fitter than those with metabolic syndrome.

And they were no more likely to develop heart disease, or to die of any cause, than people of normal weight.
Ortega FB et al. The intriguing metabolically healthy but obese phenotype: cardiovascular prognosis and role of fitness. European Heart Journal 2012; doi: 10.1093/eurheartj/ehs174

Stroke

Cochrane review confirms that early supported discharge works

Early supported discharge (ESD) schemes are both good for stroke patients and cost-effective, a Cochrane review shows.

Patients with less severe strokes backed by a well organised ESD team make the best progress, according to the report, which confirms and updates the findings of a 2005 review.

Researchers analysed 14 randomised controlled trials covering 1957 patients, most of them older people with moderate disability.

The ESD group left hospital a week earlier, on average, than other stroke patients.

They were more likely to regain independence and stay in their own homes than patients receiving conventional treatment during a longer hospital stay.

The authors note, however, that the benefits were no longer statistically significant at five-year follow-up.

‘Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay,’ said the authors.

‘We observed no adverse impact on the mood or subjective health status of patients or carers.’
Fearon P et al. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews 2012; doi: 10.1002/14651858.CD000443.pub3

Comments & conclusions

In a study of 48 full-time office workers, those who had a cup of coffee before starting a 90-minute computer task felt less pain in their arms, neck and shoulders as they worked than those who hadn’t drunk coffee.
Strøm V. BMC Research Notes 2012; 5: 480, doi:10.1186/1756-0500-5-480

Sitting for long periods of time increases the risk of heart disease and, especially, of diabetes, even among people who also exercise, according to a review of 18 studies covering 794,000 people.
Wilmot EG et al. Diabetologia 2012; 55: 2895-2905, doi: 10.1007/s00125-012-2677-z

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