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Changes in Physical Therapy Providers’
Use of Fall Prevention Strategies
Following a Multicomponent
Behavioral Change Intervention
Background and Purpose.
An abundance of evidence suggests that interven-
tions targeting fall risk factors are effective; however, it remains unknown
whether, or to what extent, this body of evidence has affected the clinical
practice of physical therapy providers. The purposes of this study were: (1) to
describe knowledge of, and attitudes toward, fall risk factors and fall reduction
strategies; (2) to assess self-reported use of fall reduction strategies with
patients; and (3) to identify factors associated with increased use of fall
reduction strategies with patients among physical therapy providers exposed
to a behavioral change strategy.
Subjects and Methods.
A cross-sectional survey
of physical therapy providers from hospital-based and freestanding outpatient
physical therapy facilities throughout north-central Connecticut was conducted
between October 2002 and April 2003. The participants were 94 physical therapy
providers who had been exposed to the Connecticut Collaboration for Fall
Prevention (CCFP) behavioral change effort. The CCFP program uses multicom-
ponent professional behavioral change strategies to embed fall risk factor
assessment and management, based on evidence from randomized controlled
trials, into the clinical care of older patients. A telephone questionnaire—
focusing on fall risk factor knowledge and attitudes and self-reported fall risk
factor assessment and management practices before and after exposure to the
CCFP efforts—was administered to consenting physical therapy providers.
Results.
Environmental hazards and gait and balance deficits were named as fall risk
factors by 86 (91%) and 73 (78%) participants, respectively. All of the targeted
risk factors were mentioned by at least 30% of the participants. Sixty-four
participants (68%) reported increased fall reduction practice behaviors. The area
of multiple medications was noted most frequently, with 77 participants (82%)
noting new practices related to medication use. Only knowledge of fall risk factors
and pre-CCFP behaviors were associated with increased fall reduction practices.
Discussion and Conclusion.
Physical therapy providers reported an increase in
practice behaviors in response to the multicomponent behavioral change strat-
egy. Knowledge of fall risk factors was associated with increased fall reduction
practice behaviors, most likely due to the focused nature of the education
strategy. [Brown CJ, Gottschalk M, Van Ness PH, et al. Changes in physical
therapy providers’ use of fall prevention strategies following a multicomponent
behavioral change intervention.
Phys Ther
. 2005;85:394–403.]
Key Words:
Behavioral change, Fall prevention, Physical therapy, Rehabilitation.
Cynthia J Brown, Margaret Gottschalk, Peter H Van Ness, Richard H Fortinsky, Mary E Tinetti
394
Physical Therapy . Volume 85 . Number 5 . May 2005
age 65 years fall each year.
1
People who
experience a fall are at increased risk for
subsequent falls.
2
Major injuries, including
fractures, head trauma, and soft tissue injuries, occur in
about 10% of individual falls.
1
Falls have been associated
with decreased physical and social functioning as well as a
3- to 6-fold increased risk for nursing home placement.
3
affected the clinical practice of outpatient physical ther-
apy providers.
The Connecticut Collaboration for Fall Prevention
(CCFP) program is an ongoing, community-wide effort
in the north-central Connecticut area to translate RCT
evidence into clinical practice. The objective is to embed
multifactorial fall risk factor assessment and manage-
ment throughout the health care system. The focus of
the CCFP effort is on health care providers caring for
ambulatory, community-living older adults, the group
for which evidence of effectiveness of fall prevention
efforts is the strongest. Physicians, nurses, discharge
planners, and physical therapists and occupational ther-
apists working in home health care, ambulatory settings,
and hospitals are involved in the CCFP effort. Out-
patient physical therapy providers, the focus of the
current study, represent one arm of the ongoing CCFP
effort.
Observational studies
2,4,5
have shown falls in community-
dwelling older people to be associated with several risk
factors, including muscle weakness, gait and balance
deficits, polypharmacy, and postural hypotension. Fall-
ing appears to result from the accumulated effect of
these and other multiple risk factors.
2,6
In several ran-
domized controlled trials (RCTs),
1,5,7–11
both single and
multifactorial intervention strategies have proven effec-
tive in both decreasing these risk factors and reducing
falls. In particular, physical therapy interventions,
including gait training, progressive balance exercises,
and home evaluation for environmental hazards, have
proven effective, both as a single intervention and as part
of a multifactorial intervention strategy.
12
Although a
wealth of evidence suggests that interventions targeting
fall risk factors are effective, it remains unknown
whether, or to what extent, this body of evidence has
In a sample of outpatient physical therapy providers
exposed to efforts to increase knowledge and promote
relevant risk factor assessment and management, the
aims of this study were: (1) to describe the physical
therapy providers’ knowledge of, and attitudes toward,
fall risk factors and fall reduction strategies; (2) to assess
CJ Brown, MD, is Investigator, Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center, and Assistant Professor, Department
of Medicine, University of Alabama at Birmingham. Address all correspondence to Dr Brown at University of Alabama at Birmingham, VAMC
GRECC 11-G Room 8225, 1530 3rd Ave S, Birmingham, AL 35294-0001 (USA) (Cbrown@aging.uab.edu).
M Gottschalk, PT, MS, is Staff Physical Therapist, Department of Rehabilitation Services, Yale-New Haven Hospital, New Haven, Conn.
PH Van Ness, PhD, MPH, is Lecturer, Department of Epidemiology and Public Health, and Associate Research Scientist/Senior Biostatistician,
Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn.
RH Fortinsky, PhD, is Professor of Medicine, Center on Aging, University of Connecticut Health Center, Farmington, Conn.
ME Tinetti, MD, is Professor, Department of Epidemiology and Public Health, and Professor, Department of Internal Medicine, Yale University
School of Medicine.
Dr Brown, Ms Gottschalk, Dr Fortinsky, and Dr Tinetti provided concept/idea/research design. Dr Brown and Dr Tinetti provided writing and
project management. Dr Brown provided data collection, and Dr Brown and Dr Tinetti provided data analysis. Ms Gottschalk provided subjects.
Dr Tinetti provided fund procurement and institutional liaisons. Dr Brown, Ms Gottschalk, Dr Van Ness, and Dr Fortinsky provided consultation
(including review of manuscript before submission). The authors thank the physical therapy providers who participated in the study; Paula Clark,
RN, for assistance in data collection; Bridget Mignosa and Virginia Towle for assistance with data management; and Grace Jeng, MD, and Lisa M
Walke, MD, for assistance with coding.
This study was approved by the Institutional Review Board of Yale University School of Medicine.
This project was supported, in part, by a grant from the Donaghue Foundation and by a Yale Pepper Center grant (P60AG10469) from the National
Institute on Aging. Dr Brown was supported by a training grant from the National Institute on Aging (T32AG19134) and is a recipient of a John
A. Hartford Foundation/American Federation for Aging Research Academic Geriatrics Fellowship Program Award (R04191) and a training
support grant from the Hartford Foundation-funded Southeast Center of Excellence in Geriatric Medicine.
An abstract of this research was presented at the Annual Meeting of the American Geriatric Society; May 14–18, 2003; Baltimore, Md.
This article was received December 15, 2003, and was accepted November 4, 2004
.
Physical Therapy . Volume 85 . Number 5 . May 2005
Brown et al . 395
O
ne third of community-dwelling adults over
their self-reported behaviors and practices related to use
of fall reduction strategies for their patients; and (3) to
identify factors associated with an increase in use of fall
reduction strategies for patients in their practices.
Intervention
Based on the available literature that suggests that
multiple approaches are most effective when profes-
sional and organizational behavioral change is the objec-
tive,
14
the CCFP program uses a multifaceted approach
to encourage the adoption of fall risk factor assessment
and management in the care of older patients. The
professional and organizational behavioral change strat-
egies used include outreach visits; procuring support for
the CCFP effort by facility administrators and supervi-
sors; training manuals with instructions for implement-
ing components of fall risk assessment and management;
patient and physical therapy provider risk factor check-
lists and patient handouts; a Web site from which all
materials could be downloaded; working groups of local
physical therapy providers who adapted the fall preven-
tion protocols for practical implementation and who
worked with investigators in encouraging other physical
therapy providers to implement fall prevention prac-
tices; “opinion leaders,” defined as providers whose
opinion was valued by the rest of the group; encourage-
ment of early adopters, or those providers who are first
to adopt new ideas and put into practice new behaviors;
newsletter reminders to the physical therapy providers
about various aspects of the CCFP program; and media
attention to heighten community awareness of falls as an
important clinical problem.
14 –21
All of these strategies
were in place in the north-central Connecticut area
during the study. The CCFP efforts focus on 6 risk
factors based on RCT evidence that interventions target-
ing these risk factors are effective at reducing fall
rates.
1,5,7–11
These risk factors are: gait or balance impair-
ments, multiple medications, postural hypotension, sen-
sory and perceptual deficits, foot and footwear prob-
lems,
22,23
and environmental hazards.
Method
Setting and Participants
North-central Connecticut was the designated interven-
tion area and includes all of Hartford and surrounding
suburbs and rural areas. Of the more than 871,000
people residing in the north-central Connecticut area,
11% are 70 years of age or older.
13
All hospital-based and
freestanding outpatient physical therapy practices in this
area that see patients 70 years of age or older were
identified via 2 methods. First, a physical therapy pro-
vider familiar with the practices in the area compiled a
list, and second, telephone book listings were accessed
through several Web sites via the Internet. Practices were
contacted by letter to inform them of the CCFP effort
and were then individually contacted by telephone and
an outreach visit was scheduled. A total of 129 outpatient
rehabilitation practices were identified, including both
freestanding and hospital-based practices. Of those, 8
practices refused to participate and 2 practices did not
provide data on their physical therapy providers. The
sample of physical therapy providers, therefore, was
derived from 119 practices. Three hundred physical
therapy providers were employed in these practices.
Potential participants for the present study included all
outpatient physical therapy providers, including physical
therapists and physical therapist assistants, who had been
exposed to CCFP efforts, defined as having received one
outreach visit by April 1, 2003. One hundred forty-two
physical therapy providers met this criterion. Ninety-four
providers eventually participated in the study. Figure 1
presents the flow of potential participants and the num-
ber of individual physical therapy providers affiliated
with the targeted 119 outpatient rehabilitation practices.
The outreach visits were the primary strategy and
included a presentation, in the physical therapy provid-
ers’ offices, of the 6 risk factors along with the recom-
mended management and specific strategies for incor-
porating the assessment and management into their
clinical practice. A team that included a physician, a
nurse, and a physical therapist made the outreach visits,
and all physical therapy providers included in the study
were exposed to a visit at least once during the study
period. Sessions usually occurred before or after work or
during lunch and lasted for approximately 1 hour.
Strategies for fall-related assessment included examina-
tion of gait and balance; examination of the feet for
calluses, bunions, and nail problems; review of the
medications for number and types; and examination of
blood pressure in the supine and standing positions.
Fall-related interventions suggested for incorporation
into physical therapist management included progres-
sive balance exercises, gait training, referral to a podia-
trist if foot and footwear problems were noted or to the
The number of physical therapy providers interviewed
from each practice ranged from 1 to 5. Individual
participants were excluded only if they relocated prior to
completion of a questionnaire or if an interview could
not be scheduled.
Baseline characteristics of the cohort are shown in Table
1. Overall, the group was predominantly female (69%),
and the majority were physical therapists (91%). Direct
patient care accounted for the majority of their work
hours (mean hours per week
31.0, SD
396 . Brown et al
Physical Therapy . Volume 85 . Number 5 . May 2005
9.6), with older
patients (70 years of age and older) accounting for one
third of those hours.
Figure 1.
Flow of potential participants. This figure shows the number of individual physical therapy providers affiliated with 119 outpatient rehabilitation
practices that did or did not ultimately receive a Connecticut Collaboration for Fall Prevention (CCFP) outreach visit. Asterisk indicates that of 129
target outpatient rehabilitation practices, 8 practices with 11 physical therapy providers declined participation in the CCFP effort and 2 outpatient
rehabilitation practices declined to provide information on the number of providers who were employed in the practices.
Physical Therapy . Volume 85 . Number 5 . May 2005
Brown et al . 397
Table 1.
Characteristics of Study Sample (N
94)
tive and quantitative information that focused on knowl-
edge, attitudes, and self-reported practice behaviors con-
cerning fall risk assessment and management. Closed-
ended questions were scored using a Likert-type scale,
with responses ranging from 1 to 4. For example,
attitude questions asked how important the physical
therapy providers thought the risk factor was for man-
aging patients in their clinical practice, and responses
for these questions were scored as: 1
N (%) or X
SD
Characteristic
(Range)
Age (y)
37
9.9 (23–60)
Sex
Male
29 (31)
Female
65 (69)
“not very impor-
No. of years since graduation with most
advanced degree, median (range)
9 (1–38)
tant,” 2
“somewhat important,” 3
“moderately impor-
“very important.” Responses varied
depending on the question asked, but all closed-ended
questions had 4 possible answers, with 1 being the lowest
rating and 4 being the highest rating. Demographic data
and practice-related information also were obtained.
The time required to complete the telephone question-
naire ranged from 25 to 40 minutes.
Employed
Full-time
75 (80)
Part-time
19 (20)
Type of provider
Physical therapist 86 (91)
Physical therapist assistant 8 (9)
Hours per week spent in direct patient care 31
9.6 (8–50)
Hours per week spent caring for older adults 12.2
8.5 (1–40)
To assess interrater reliability, the 2 interviewers each
administered the questionnaire to the same 8 physical
therapy providers within a 48-hour period. Interviewers
were masked to each other’s questionnaire results. Test-
retest reliability data were assessed in 9 participants by
repeating the interview 7 days after the initial interview
without knowledge of the original responses. For both
interrater and test-retest reliability data, weighted kappa
statistics were calculated for the 17 four-level data ques-
tions (ie, all questions that asked participants to rate on
a Likert scale from 1 to 4). Weighted summary kappas of
.65 and .64 were obtained for interrater and test-retest
reliability, respectively, suggesting good reliability.
25
Answers that were either 2 points more or less than the
previous score on the ordinal scale were considered to
be outliers, an event that occurred in less than 4% of the
responses.
Physical therapy providers by practice type
Hospital based
39 (41)
Freestanding
55 (59)
primary care provider if the patient was noted to have
orthostatic hypotension or to be taking multiple medi-
cations. The physical therapy intervention was essentially
the same as that described for the Yale FICSIT trial.
24
Potential incentives and barriers also were addressed
during these visits, and easy-to-use materials were pro-
vided in the form of a training manual. The training
manual included the strategies for assessing and manag-
ing each of the risk factors and patient handouts. A
one-page evaluation and management form also was
developed for use in the patient charts. Because the
physical therapy providers practiced in the area where
the CCFP effort was occurring, they were exposed to the
additional behavioral change strategies described ear-
lier. During the outreach visit, names, addresses, and
telephone numbers of physical therapy providers were
obtained for the purpose of constructing a database. The
participants were informed that they would be contacted
at a later date to provide feedback about the CCFP
program.
Outcome Measures
The primary outcome measures were the physical ther-
apy providers’ post-CCFP self-report of use of fall pre-
vention strategies with their patients and a change in use
of fall prevention strategies from before to after expo-
sure to CCFP outreach efforts. Participants were asked to
compare their fall prevention practice behaviors a year
ago (pre-CCFP) with their current behaviors (post-
CCFP). Specifically, they were asked to respond to the
following 2 questions: “Thinking back a year ago, how
often did you consider fall prevention in your routine
care of older adults?” and “In your clinical practice now,
how often do you consider fall prevention in your
routine care of older adults?” A
change in behavior
was
defined as changing one or more levels on the 4-level
ordinal scale, which ranged from “almost never or
never” to “almost always or always.” If changes had been
made, they were asked to give specific examples of the
behaviors that had changed. To examine the open-
ended questions about change in practice, the interview-
Interview
Participants were contacted, by telephone or electronic
mail, at least 6 weeks after the outreach visit, with a range
of 6 to 24 weeks, and invited to complete an in-depth
telephone interview at their convenience. One of the
authors (CJB) or a trained research nurse administered
a telephone questionnaire to all consenting physical
therapy providers according to procedures approved by
the Institutional Review Board of Yale University School
of Medicine. The questionnaire was a mixture of open
and closed-ended questions designed to obtain qualita-
398 . Brown et al
Physical Therapy . Volume 85 . Number 5 . May 2005
tant,” and 4
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