Discussion

The purpose of this study was first to determine the effects of a community-based implementation of the OEP on physical performance and balance confidence among older adult participants and then to compare the effects among participants who completed two follow-up

visits within 3 versus 6 months of their initial visit. Participants demonstrated statistically and clinically significant improvements on physical performance measures (4SBT, TUG, CRT) from initial visit to F2. Improvement in balance confidence measured by the ABC was not significant. These results are to be expected for an intervention that targets physical performance but not balance confidence. OEP exercises prescribed to participants as part of the CHAMP intervention were intended to improve participants’ strength and balance, and the success of these exercises was reflected in the significant improvement in the 4SBT, TUG, and CRT.

In addition to the fact that CHAMP interventions did not specifically target balance confidence, the lack of improvement in this construct as measured by the ABC may have

reflected participants’ heightened awareness of their risk of falls. CHAMP provided participants with information about their balance that could have lowered confidence levels for some

participants. Participants who had increased risk for falls were informed about this result and received an intervention to reduce their falls risk. Receiving this finding at the initial visit could have decreased participants’ balance confidence, and this reduced confidence may have been captured by the ABC completed at F2. In fact, the ABC test was always administered

immediately upon a participant’s arrival to CHAMP. This timing of the ABC prior to physical performance tests meant that participants did not have knowledge of any improvements that may have occurred in their physical performance until after completing the ABC.

Not only was improvement on the 3 physical performance measures statistically

significant, effect sizes were comparable to those found by Shubert et al27 in a study with a much larger sample size. This finding supports that similar outcomes can be expected with CHAMP participation compared to participation in other OEP interventions. Furthermore, many

Nearly half (45.3%) of the total participants in this study had an improvement on the TUG that exceeded the MCID. More than a quarter (26.9%) of participants initially with increased risk for falls based on TUG score had improvement in TUG sufficient to change to the “not at increased risk” category for this measure. This clinically significant improvement for TUG occurred within a 6-month period and with a total of only 3 CHAMP visits. An important next step is to identify characteristics of those CHAMP participants who made this change in risk category so that we can determine which subgroup(s) to target for this community-based falls prevention program.

Functional lower extremity strength and power are expected to decrease with aging. However, the majority of CHAMP participants included in these analyses improved or

maintained their functional lower extremity strength from initial to F2 visits. Among CHAMP participants whose functional lower extremity strength was measured at the initial and F2 visits using the 5xSTS, 41.4% had improvement that exceeded the MCID of 2.3s, 50.0% maintained their baseline performance, and only 8.6% demonstrated a clinically significant decline in performance. Among participants whose functional lower extremity strength was measured by the 30-s STS test, 16.3% had clinically significant improvement, 72.1% maintained their initial strength, and 11.6% had lower scores at F2. The greater percentage of individuals showing clinically significant improvement in the 5xSTS compared to the 30-s STS is likely a result of the difference in methods between the two tests and their similarities to the chair stand exercise from the OEP. The chair stand exercise is commonly prescribed for home exercise in the

CHAMP intervention, particularly if a participant performs poorly on the initial CRT. As a home exercise, an individual is asked to complete 5-10 repetitions of the exercise in a manner that closely resembles the 5xSTS. Performing the chair stand exercise as prescribed in the CHAMP intervention, therefore, is more likely to result in improvement on the 5xSTS.

Standing within a narrow base of support is often challenging for older adults, and performance of SLS is expected to decline with age.33 CHAMP participants had statistically significant improvement in the 4SBT. It is likely that participants were able to improve their performance of static balance within a narrow base of support because of the use of OEP

exercises in the CHAMP intervention. CHAMP participants were frequently prescribed the SLS and tandem stance OEP exercises, which likely provided the opportunity to practice these challenging stance positions that participants might otherwise have avoided.

We expected the timing of CHAMP participants’ return for F2 to significantly influence change in all 4 key outcome measures. Contrary to our hypothesis, improvement in only one measure, the TUG, had a statistically significant group by visit interaction, with groups formed based on F2 within 3 months as compared to 3-6 months after initial visit. A possible reason for the significant effect of the time to return for F2 on TUG could be simply that individuals who returned sooner for F2 were “getting up and going” to CHAMP visits at a greater frequency and therefore getting more practice in a shorter period of time. Additionally, the TUG, compared to 4SBT or CRT, measures an individual’s performance not only in an activity that could be prescribed for home exercise from the OEP but in a more complex combination of actions requiring functional lower extremity strength and dynamic balance. Improvement in this more comprehensive measure may require more frequent follow-up with less time between visits than is necessary for improvement in static standing balance or repeated chair rises.

Limitations

This study examined a real-world, community-based intervention that necessarily included limitations related to inability to control for selection of participants, timing of return visits, provider fidelity to program protocol for assessments and interventions, and the use of

clinical and self-report measures. Participants were self-selected from two rural communities that have minimal diversity of race, ethnicity, and education, particularly among adults over the age of 60.56 The lack of diversity in the sample for this study limits generalizability to other

populations. Furthermore, this analysis could be performed only for individuals who were identified as having increased risk for falls at an initial visit and then returned for 2 additional follow-up visits, adding an additional layer to self-selection bias inherent in community-based interventions. Insights into why participants did or did not return as well as the degree to which returning participants adhered to program recommendations would be helpful for future projects to assess the CHAMP program.

Though several of these limitations are unavoidable for community-based research, future studies could include outreach to individuals who did not return to CHAMP, evaluating effectiveness of CHAMP offered in different areas with different populations, and including a measurement of actual falls in addition to measures of falls risk. In fact, the finding of

statistically and clinically significant improvement in 3 physical performance measures despite these limitations supports the need for additional research to understand the effects of CHAMP participation on falls and falls-related measures among older adults at risk for falls.