Effects of Fall Prevention Program on the Number of Falls Among Elderly Following Total Knee Replacement

Study Overview
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Brief Summary
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the aim of the proposed research is to investigate the short and long-term effects of integrating a comprehensive fall prevention programme into conventional physiotherapy on the number of falls, balance, and functional ability among elderly following TKR. the investigator hypothesize that conventional physiotherapy integrated with a fall prevention program is more effective than conventional physiotherapy alone in improving balance and functional ability and preventing the occurrence of falls among elderly following TKR. Study type: The proposed study is a parallel group prospective (24 weeks) randomised single-blinded pragmatic controlled trial. Participants: Older adults operated for TKR at Al-Razi orthopedic hospital, who met the inclusion criteria.

Detailed Description
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Falls constitute a serious and common threat to the health and well-being of older individuals, and this threat increases with aging. Falls in older individuals place a significant burden on the health care system as well as the caregivers (i.e., family). Importantly, however, many falls could be prevented. Osteoarthritis (OA) of the knee is a common degenerative musculoskeletal condition among elderly that results in ambulatory dysfunction. This progressive degenerative disorder is usually associated with pain, muscle weakness, and poor balance, all of which are considered primary risk factors for falling among older adults. Total knee replacement (TKR) is the most replicable and effective orthopaedic procedure used to treat advanced-stage knee OA. The goal of TKR is to relieve pain, increase knee mobility, and improve functional ability and the overall quality of life. Despite the promising results of TKR surgery, it is associated with a high prevalence of falls. In this regard, falls rate have been reported to be between 6.2% and 42.6% in the first 12 months following TKR. Persistence of muscle weakness and poor balance may contribute to the high fall rate following TKR. This highlights the importance of targeting muscle strength and balance during rehabilitation, considering the short-term implications that could reflect on long-term recovery. A substantial amount of evidence supports the use of exercise-based interventions (i.e., muscle strengthening and balance training) to prevent falls and fall-related injuries. A Cochrane systematic review by on 108 RCTs (n=23,407) provided high-certainty evidence that exercises, particularly balance and functional based-exercises, are more effective in reducing the falls rate compared to the control interventions. Moreover, exercise-based interventions have been shown to be superior to other interventions for mitigating age-related decline and reducing falls and falls-related injuries with the least harm and greatest cost-effectiveness. Conventional physiotherapy following TKR involves, primarily, strengthening and knee range of motion exercises and gait re-education. However, there is a lack of balance training/exercises in the rehabilitation program. Given the high prevalence of falls following TKR, integrating a comprehensive fall prevention program into conventional physiotherapy may be of importance. Thus, the aim of the proposed research is to investigate the short and long-term effects of integrating a comprehensive fall prevention programme into conventional physiotherapy on the number of falls, balance, and functional ability among elderly following TKR.

Official Title
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The Short- and Long-term Effects of Fall Prevention Program on the Number of Falls Among Elderly Following Total Knee Replacement: a Pragmatic Single-blinded Randomized Controlled Trial.

Conditions
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Fall, Osteo Arthritis Knee, Total Knee Replacement

Intervention / Treatment
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* Other: fall prevention programe


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Female gender. Aged 60 years and older. Diagnosed with primary osteoarthritis of the knee. Underwent unilateral TKR. Exclusion Criteria: revision TKR surgery history of systemic inflammatory conditions (i.e., rheumatoid arthritis, Lupus erythematosus), neurological disorders (i.e., multiple sclerosis, Parkinson's disease, stroke) lower limb surgery/trauma in the past 12 months have cognitive and/or vision impairments post-surgical complications (e.g., infection, intraoperative fracture) any health condition that may preclude them from undertaking physiotherapy.

Ages Eligible for Study
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Minimum Age: 60 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: parallel group prospective (24 weeks) randomised single-blinded pragmatic controlled trial.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: control group<br>Patients in the control group will receive a conventional physiotherapy treatment (guided by the post-TKR protocol followed at Al-Razi Orthopedic Hospital). The treatment will be delivered by four allocated physiotherapists,The treatment will be delivered by four allocated physiotherapists, and will consist of: Blood circulation exercise (i.e., ankle pumps) Quadriceps isometric exercises (i.e., quad sets). Knee ROM exercises (i.e., knee flexion and extension). Lower limb strengthening exercises (e.g., straight leg raising, short/ long arch exercises) Stretching exercises for the hamstring and calf muscles. Gait training (with and without the assistive device). Parallel bars exercises (e.g., standing hip abduction/adduction, knee flexion, squatting). Ascending/descending stairs. Home program. | |
| Experimental: intervention (treatment) group<br>Patients in the experimental group will receive a comprehensive fall prevention program (described below) integrated into the conventional physiotherapy treatment. The fall prevention program will consist of: Otago balance exercise for 12 weeks integrated with conventional physiotherapy treatment (described in the control group). Individualized advice on assistive device usage based on the participant's Berg Balance Score (BBS) revised at the 3 data collection timepoints. Environmental hazard checklist. Advice on getting their eyes checked and the use of appropriate footwear to ensure the elimination of other risk factors. Home program (consists of balance and strength training exercises). The treatment will be delivered by four allocated physiotherapists. The physiotherapists will receive an introductory/training session on the fall prevention program prior to the commencement of the trial. | Other: fall prevention programe<br>* Patients in the experimental group will receive a comprehensive fall prevention program (guided by the post-TKR protocol followed at Al-Razi Orthopedic Hospital) into the conventional physiotherapy treatment<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| falls rate | The primary outcome measure in this trial will be the number of reported falls during the study period.The patients will be given a falls' diary to record the number of falls (if any), time of falling (e.g., early morning or late night), and the cause of falling (e.g., slippery floor, dizziness, tripping over). | baseline | 
| falls rate | The primary outcome measure in this trial will be the number of reported falls during the study period.The patients will be given a falls' diary to record the number of falls (if any), time of falling (e.g., early morning or late night), and the cause of falling (e.g., slippery floor, dizziness, tripping over). | 12 weeks | 
| falls rate | The primary outcome measure in this trial will be the number of reported falls during the study period.The patients will be given a falls' diary to record the number of falls (if any), time of falling (e.g., early morning or late night), and the cause of falling (e.g., slippery floor, dizziness, tripping over). | 24weeks | 
| falls rate | The primary outcome measure in this trial will be the number of reported falls during the study period.The patients will be given a falls' diary to record the number of falls (if any), time of falling (e.g., early morning or late night), and the cause of falling (e.g., slippery floor, dizziness, tripping over). | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Knee range of motion (ROM) | This will be measured using goniometer while the patient is laying in supine position with the operated knee fully extended. The patient will be requested to bend her knee 2-3 times before the actual measurements are taken. Then, the investigator will take three consecutive measurements of knee flexion range. | baseline | 
| Knee range of motion (ROM) | This will be measured using goniometer while the patient is laying in supine position with the operated knee fully extended. The patient will be requested to bend her knee 2-3 times before the actual measurements are taken. Then, the investigator will take three consecutive measurements of knee flexion range. | 12 weeks | 
| Knee range of motion (ROM) | This will be measured using goniometer while the patient is laying in supine position with the operated knee fully extended. The patient will be requested to bend her knee 2-3 times before the actual measurements are taken. Then, the investigator will take three consecutive measurements of knee flexion range. | 24 weeks | 
| Patient's satisfaction | In response to the question 'how satisfied are you with the results of physiotherapy treatment?'. Patients will be asked to grade their level of satisfaction on a 5-point Likert scale (1: not at all satisfied, 2: dissatisfied, 3: neutral, 4: satisfied, or 5: very satisfied). | 12 weeks | 
| Patient's satisfaction | In response to the question 'how satisfied are you with the results of physiotherapy treatment?'. Patients will be asked to grade their level of satisfaction on a 5-point Likert scale (1: not at all satisfied, 2: dissatisfied, 3: neutral, 4: satisfied, or 5: very satisfied). | 24 weeks | 
| Adherence: | Adherence to the prescribed home-program: Patient's adherence to the prescribed exercise/home program will be measured by a retrospective patient self-report scale, a simple method that has been implemented by other researchers to measure patient's adherence to the prescribed exercise. (Mallows et al., 2020, Bassett, 2003) In response to the question If you have been requested by your physiotherapist to do exercises at home, please indicates the extent you have followed the instructions?, participants responded using a 5-point Likert scale ranging from 1 (not at all) to 5 (as advised). Adherence to physiotherapy attendance: The total number of treatment sessions received by the patient will be recorded by the treating physiotherapist. | 12 weeks | 
| Adherence: | Adherence to the prescribed home-program: Patient's adherence to the prescribed exercise/home program will be measured by a retrospective patient self-report scale, a simple method that has been implemented by other researchers to measure patient's adherence to the prescribed exercise. (Mallows et al., 2020, Bassett, 2003) In response to the question If you have been requested by your physiotherapist to do exercises at home, please indicates the extent you have followed the instructions?, participants responded using a 5-point Likert scale ranging from 1 (not at all) to 5 (as advised). Adherence to physiotherapy attendance: The total number of treatment sessions received by the patient will be recorded by the treating physiotherapist. | 24 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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fall, older people, fall prevention, TKR, rehabilitation