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BACKGROUND: Little is known about associations between performance-based measurements and self-reported scales, nor about ceiling effects or sensitivity to change to evaluate effects in the target population for self-managed exercise interventions. This study aimed to explore the feasibility of using performance-based outcomes for gait speed, functional leg strength and balance, and self-reported outcomes of falls-efficacy and functional ability in two self-managed falls prevention exercise interventions for community dwelling older adults.

METHODS: Independent living, community-dwelling older adults (n = 67) exercised with one of two self-managed falls prevention exercise programmes, a digital programme (DP) or a paper booklet (PB) in a 4-month participant preference trial. Pre- and post-assessments, by blinded assessors, included Short Physical Performance Battery (SPPB) and 30s Chair stand test (30s CST). Participants completed self-reported questionnaires: Activities-specific and Balance Confidence scale (ABC), Iconographical Falls Efficacy Scale (Icon-FES), Late-Life Function and Disability Instrument Function Component (LLFDI-FC). In addition, improvement in balance and leg strength was also self-rated at post-assessment. Participants' mean age was 76 ± 4 years and 72% were women.

RESULTS: Ceiling effects were evident for the balance sub-component of the SPPB, and also indicated for ABC and Icon-FES in this high functioning population. In SPPB, gait speed, 30s CST, and LLFDI-FC, 21-56% of participants did not change their scores beyond the Minimal Clinically Important Difference (MCID). At pre-assessment all performance-based tests correlated significantly with the self-reported scales, however, no such significant correlations were seen with change-scores. Improvement of performance-based functional leg strength with substantial effect sizes and significant correlations with self-reported exercise time was shown. There were no differences in outcomes between the exercise programmes except that DP users reported improved change of leg strength to a higher degree than PB users.

CONCLUSION: The LLFDI-FC and sit-to-stand tests were feasible and sensitive to change in this specific population. The balance sub-component of SPPB and self-reported measures ABC and Icon-FES indicated ceiling effects and might not be suitable as outcome measures for use in a high functioning older population. Development and evaluation of new outcome measures are needed for self-managed fall-preventive interventions with high functioning community-dwelling older adults.

As the numbers of older adults grow, fall prevention is vital to reduce health care needs due to falls and to increase quality of life. Balance and strength exercises have been found to be effective in fall prevention, however, long-term adherence is often poor. The growth of digital technology in society has generated opportunities for fall prevention with eHealth. The aim of this thesis was to evaluate the feasibility and use of a new digital fall prevention exercise programme, and to develop and investigate a smartphone self-test application for balance and leg strength. 

Three different studies included community-dwelling older adults ≥ 70 years, who were able to rise from a chair and stand without support. A feasibility study evaluated a new digital exercise programme (DP) compared to a paper booklet exercise programme (PB) for self-managed fall prevention in a four-month controlled participant preference trial (n = 67) (Paper I & II). Self-reported data on adherence, falls efficacy, and functional ability were collected and analysed, along with performance-based measures of gait speed, balance, and chair stand test. In Paper II the feasibility was explored of using the self-reported scales and performance-based outcome measures. A self-test application was also developed (Paper III) in co-creation with 10 participants, who met during five sessions to design the application’s instructions and user interface. The participants’ preference for and their contribution to the application design was analysed with qualitative content analysis with a deductive-inductive approach. A concurrent validity study (n = 31) (Paper IV) assessed the correlations between variables from the self-test prototype and outcome measures from clinical instruments. 

Results from the feasibility study show that 43% chose the DP and 57% PB, and the attrition rate was 17% and 37% respectively. Both groups had similar adherence, but for the subgroup that exercised most, participants in the DP group reported significantly more exercise time (Paper I). Participants in both groups reported a boost in balance after the intervention, and in the DP group also improved leg strength. Significantly more participants continued to use the DP at 12 months. The self-managed exercise intervention (Paper II) resulted in improvements in functional leg strength, which positively correlated with exercise time, but no other performance-based outcomes showed any significant improvements. Performance-based measurements of balance as well as the self- reported balance confidence and fear of falling revealed ceiling effects. Pre-assessments of self-reported outcomes and performance-based measures showed significant but low correlations, no such correlations were seen in change scores. The deductive-inductive analysis of the co-creation process resulted in 17 subcategories within the seven facets of the Optimized Honeycomb model for iii user experience (Paper III). The main results were that participants desired clear and appropriate information to understand why things were done in a certain way, and their contributions enhanced the user experience of the self-test. The concurrent validity testing of the self-test prototype (IV) showed low to moderate correlations for the strength test but limited correlations for the balance test. 

In conclusion the DP group showed comparable adherence to the programme as the PB group, as well as to previous studies, indicating it was feasible to use the new DP. DP participants also reported better exercise maintenance after 12 months. Positive self-reported effects were expressed in addition to leg strength improvement. Outcome measures for balance and falls efficacy revealed ceiling effects, consequently, these instruments might not be suitable for assessments in all community-dwelling older adults. In particular, for balance related outcomes there is a need for new more sensitive measurements. The co-creation of the smartphone self-test was feasible and valuable for user experience, but further validity and reliability testing are needed before it can serve as an independent assessment tool. 

Enkel sammanfattning på svenska

När antalet äldre i världen ökar blir fallprevention en viktig insats, både för att minska behovet av vård och för att öka livskvalitén för individer så att de kan leva ett rikt liv upp i åldrarna. Forskning har visat att träningsprogram med balans- och styrkeövningar är effektiva för att förhindra fall, men genomförandet av olika träningsprogram är ofta svårt att upprätthålla på lång sikt. Den ökande användningen av digital teknik i samhället skapar däremot nya möjligheter att erbjuda seniorer stöd att genomföra träning för att förebygga fall. Syftet med denna avhandling var att undersöka möjligheten att använda digital teknik för fallpreventiva insatser, dels genom att testa ett nyutvecklat digitalt självtränings- program ”Säkra steg”, dels genom att utveckla och undersöka en mobilapp med självtest för att mäta balans och benmuskelstyrka med hjälp av en mobil där man kan ladda ner appar. I avhandlingens tre olika datainsamlingar har personer som var 70 år eller äldre deltagit. Alla var hemmaboende och kunde resa sig upp från en stol utan stöd. 

Samma studie låg till grund för delarbete I och II, där deltagarna var en grupp relativt aktiva seniorer. Medelåldern var 77 år och 72 % var kvinnor. I delarbete I utvärderades deltagande och följsamhet under fyra månaders självträning, där ett digitalt träningsprogram jämfördes med ett träningsprogram som utfördes med hjälp av ett pappershäfte. I delarbete II undersöktes lämpligheten i de instrument som användes för att utvärdera träningsstudien. Deltagarna fick själva välja program innan start och 67 personer påbörjade studien. Av dessa valde 29 det digitala programmet och 38 valde det så kallade pappersprogrammet, där övningarna presenterades i ett häfte med text och bild. Båda programmen bestod av en samling övningar som skulle komponeras ihop till egna individuella program bestående av tio övningar. Rekommendationen var byta ut övningar under perioden för att anpassa programmet så att det upplevdes som tillräckligt utmanande under hela träningsperioden. Deltagarna rekommenderades att träna minst 30 minuter 3 dagar i veckan. Data om deras träning inhämtades från deltagarna månadsvis genom en träningsdagbok. I början och slutet av träningsperioden svarade deltagarna på enkäter om sin funktion, fallrädsla och tillit till sin balansförmåga samt deltog i mätningar av gånghastighet, balans och förmåga att resa sig från en stol. 

Totalt 83 % av deltagarna som använde det digitala programmet fullföljde studien, motsvarande andel var 63 % för pappersprogrammet. Båda användes i liknande omfattning av de som fullföljde, dock användes det digitala programmet i större grad i den grupp av deltagare som tränade mest. Vidare visade granskningen av utvärderingsinstrumenten på begränsning i att kunna mäta förbättring eftersom höga värden uppmättes redan vid start, en så kallad takeffekt. Detta var fallet för 2 av 3 enkäter och för balansmätningen i de fysiska testerna. Det påvisades ett visst samband mellan de självrapporterade enkätsvaren och de fysiska testerna vid studiens start. Resultatet av fyra månaders träning visade på uppmätta förbättringar i benstyrka i båda grupperna och att deltagare som tränat med det digitala programmet i högre grad uppgav att de själva iakttagit en förbättring av styrkan i benen. Efter 12 månader svarade deltagarna på en uppföljningsenkät och signifikant fler deltagare som använde det digitala programmet rapporterade att de fortsatt att träna med programmet. 

I delarbete III utvecklades en självtestapp som innehåller två olika test. Det första är ett balanstest där man testar sig i två positioner under 30 sekunder, att stå med fötterna ihop samt att stå i semitandem med ena foten lite framför den andra. Det andra testet innefattar att man reser sig upp från en stol upprepade gånger. Utvecklingsarbetet skedde tillsammans med tio seniorer som vid fem tillfällen bidrog till innehåll och utseende av appens information och användargränssnitt. Medelåldern var 76 år och 60 % var kvinnor. Deltagarnas förslag och åsikter analyserades med kvalitativ innehållsanalys med hjälp av en modell för användarupplevelse (Optimized Honeycomb model). Resultatet visade att deltagarna ville få enkla och tydliga instruktioner för att veta hur självtestet skulle göras samt motiveringar till varför. Med hjälp av deltagarnas synpunkter och idéer skapades en app med enkla symboler och tydliga kontraster för enkel navigering, samt likaledes konkreta och korta instruktioner för testgenomförandet. Deltagarna uttryckte förväntan att de och andra seniorer som behöver träna sin balans kan använda appen i framtiden. 

I delarbete IV undersöktes om data som samlats in med prototypen av den nya självtestappen överensstämde med resultaten från kliniska tester. Studien genomfördes med 31 deltagare som hade en medelålder på 79 år och där 77 % var kvinnor. En fysioterapeut utförde flera kliniska tester för att mäta balans och benmuskelstyrka samt utförde mätningar med mobilen, vilka sedan jämfördes för att se om mätningarna överensstämde, en validitetstestning. Ett visst samband påvisades för styrketesterna men för balanstesterna visades endast ett mindre eller inget samband. Dock visades visst samband för balans med frekvensvariabler, vid positionen ”fötter ihop”. 

Denna forskning visar att seniorer kan använda och har ett intresse för fallprevention med digital teknik och att självträning med båda programmen är genomförbart. Trots att både det digitala- och pappersprogrammet användes i liknande omfattning, uppgav deltagare med det digitala programmet i högre grad att de var nöjda och upplevde ett stöd av programmet. Dessutom var det en större andel som fortsatte att träna med det digitala programmet efter 12 månader jämfört med pappersprogrammet. Den brist på känslighet som utvärderingsinstrumenten påvisade i delarbete II pekar på att det finns ett behov av nya, mer vi känsliga mätinstrument för att utvärdera balansförmåga. Detta behov skulle kunna tillgodoses med ett självtest i mobilen, som också skulle kunna vara användbart för att följa utvecklingen av fallpreventionsträning. Självtestet som utvecklades och designades tillsammans med en grupp seniorer upplevdes som användbart och värdefullt för deltagarna. Självtestappens begränsade överensstämmelse med de kliniska testerna förklaras till viss del av att olika aspekter av balans mäts i de olika testerna, framför allt i balanstesten. Prototypen behöver testas ytterligare innan den kan användas som ett självtest på den egna mobilen, både med hänseende till användarupplevelse samt validitet och reliabilitet. 

The evolving use of sensors to objectively assess movements is a potentially valuable addition to clinical assessments. We have developed a new self-test application prototype, MyBalance, in the context of fall prevention aimed for use by older adults in order to independently assess balance and functional leg strength. The objective of this study was to investigate the new self-test application for concurrent validity between clinical instruments and variables collected with a smartphone. The prototype has two test procedures: static standing balance test in two positions, and leg strength test performed as a sit-to-stand test. Thirty-one older adults were assessed for balance and functional leg strength, in an outpatient physiotherapy setting, using seven different clinical assessments and three sensor-tests. The results show that clinical instruments and sensor measurements correlate to a higher degree for the smartphone leg strength test. For balance tests, only a few moderate correlations were seen in the Feet Together position and no significant correlations for the Semi Tandem Stance. This study served as a first step to develop a smartphone self-test application for older adults to assess functional balance at home. Further research is needed to test validity, reliability, and user-experience of this new self-test application.

This co-creation study aimed to develop a smartphone self-test application for balance and leg strength in collaboration between older adults and the research team. The paper describes older participants' preferences for, and their contribution to, the application design. Technology to assess movements is available in smartphones with built-in sensors, and one of the challenges is to develop a valuable self-test for older adults. The participants contributed to the design of the application's instructions and user interface. Multiple data collection methods were used: user-test with Think aloud method, mock-ups, homework assignment as co-researcher, audio and video recordings. Qualitative content analysis with a deductive-inductive approach was used, guided by the Optimized Honeycomb model for user experience (UX) as a categorization matrix. The analysis resulted in 17 subcategories within the seven facets of the UX Honeycomb model (findable, accessible, usable, desirable, credible, useful, and valuable), and describes the older participants' preferences and experiences. The main results were participants' desire to know why, to get clear and appropriate information, and expectations of the self-test to be useful. It was feasible and valuable to develop the self-test application in co-creation with the intended user-group, in order to get direct feedback and suggestions for the development.

Background: Fall prevention exercise programmes are known to be effective, but access to these programmes is not always possible. The use of eHealth solutions might be a way forward to increase access and reach a wider population. In this feasibility study the aim was to explore the choice of programme, adherence, and self-reported experiences comparing two exercise programmes – a digital programme and a paper booklet.

Methods: A participant preference trial of two self-managed fall prevention exercise interventions. Community-dwelling adults aged 70 years and older exercised independently for four months after one introduction meeting. Baseline information was collected at study start, including a short introduction of the exercise programme, a short physical assessment, and completion of questionnaires. During the four months intervention period, participants self-reported their performed exercises in an exercise diary. At a final meeting, questionnaires about their experiences, and post-assessments, were completed. For adherence analyses data from diaries were used and four subgroups for different levels of participation were compared. Exercise maintenance was followed up with a survey 12 months after study start.

Results: Sixty-seven participants, with mean age 77 ± 4 years were included, 72% were women. Forty-three percent chose the digital programme. Attrition rate was 17% in the digital programme group and 37% in the paper booklet group (p = .078). In both groups 50–59% reported exercise at least 75% of the intervention period. The only significant difference for adherence was in the subgroup that completed ≥75% of exercise duration, the digital programme users exercised more minutes per week (p = .001). Participants in both groups were content with their programme but digital programme users reported a significantly higher (p = .026) degree of being content, and feeling supported by the programme (p = .044). At 12 months follow-up 67% of participants using the digital programme continued to exercise regularly compared with 35% for the paper booklet (p = .036).

Conclusions: Exercise interventions based on either a digital programme or a paper booklet can be used as a self-managed, independent fall prevention programme. There is a similar adherence in both programmes during a 4-month intervention, but the digital programme seems to facilitate long-term maintenance in regular exercise.