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The aim of this report was to identify and organize evidence and summarize key findings on the clinical effectiveness, cost-effectiveness, patient and provider experiences and preferences, and equity considerations of virtual primary care. It includes 60 relevant reports, of which we summarized 6 systematic reviews (SRs) and organized 54 additional reports into annotated reference lists. This report was not a formal evidence synthesis, and no conclusions were formed about the value of virtual primary care. The literature was not critically appraised, and the quality of the evidence from the included reports is unknown. The evidence about the clinical effectiveness of virtual primary care summarized in this report comes from a limited number of studies identified by 3 SRs and was mainly focused on health care utilization outcomes versus patient health or clinical harms outcomes. The findings were mixed, but overall, in-person visits may be associated with lower rates of health care utilization (e.g., emergency department visits, hospitalizations) compared with virtual visits. Virtual consultations may be associated with improved patient engagement compared with in-person care for certain conditions or settings (e.g., opioid addictions) but not others (e.g., smoking cessation, postnatal care, other general settings). The evidence about the cost-effectiveness of virtual primary care summarized in this report comes from 3 studies identified by 1 SR. Virtual primary care compared with in-person care might be cost-effective for patients with asthma and patients who received cognitive behavioural therapy, but these analyses considered very limited outcomes. The evidence about patient and provider experiences and preferences associated with virtual primary care that is summarized in this report comes from 4 SRs. The SRs identified many perceived benefits and drawbacks of virtual primary care from both patient and provider perspectives, including those around access to care, effectiveness, experience and satisfaction, and financial impact and cost. The evidence about potential equity issues associated with virtual primary care summarized in this report comes from 2 SRs. Equity considerations, such as age, may affect individuals accessing and using primary care health services. For example, telephone consultations tended to be used by older individuals (aged ≥ 85 years), while internet-based consultations tended to be used by younger individuals.

Three evidence-based guidelines were identified about the use of clozapine for patients with psychotic disorders. The included guidelines provide recommendations for testing and assessment of key health parameters for patients who are prescribed clozapine via various means such as laboratory tests and electrocardiogram. The guidelines provide recommendations of co-prescription for patients who have not responded adequately to an optimized dose of clozapine alone. Two guidelines offer specific recommendations on clozapine dosing. The guidelines were generally well developed, clearly reported, and consistent in their recommendations. However, several of the recommendations were derived from sources of evidence that may not be considered of the highest quality, with the strength of recommendation not reported and unclear. The diagnostic accuracy of high-sensitivity troponin I testing versus troponin T testing for detecting myocarditis or cardiomyopathy in patients receiving clozapine for psychotic disorders is unknown as no relevant evidence was identified. Given the limited availability and varying quality of evidence, the diagnostic accuracy of high-sensitivity troponin I testing and how best to monitor for clozapine-induced myocarditis and cardiomyopathy in patients with psychotic disorders remains uncertain.

Background The Centre for Epidemiologic Studies Depression Scale (CES-D) is a commonly used psychometric scale of depression. A four-factor structure (depressed affect, positive affect, somatic symptoms, and interpersonal difficulties) was initially identified in an American sample aged 18 to 65. Despite emerging evidence, a latent structure has not been established in adolescents. This review aimed to investigate the factor structure of the CES-D in adolescents. Methods We searched Web of Science, PsychINFO and Scopus and included peer-reviewed, original studies assessing the factor structure of the 20-item CES-D in adolescents aged ≤18. Two independent researchers screened results and extracted data. Results Thirteen studies met the inclusion criteria and were primarily from school-based samples in the USA or Asia. Studies that conducted confirmatory factor analysis (CFA; n = 9) reported a four-factor structure consistent with the original factor structure; these studies were primarily USA-based. Conversely, studies that conducted exploratory factor analysis (EFA) reported distinct two or three factor structures (n = 4) and were primarily based in Asia. Limitations Studies in a non-English language and those that included individuals aged > 18 years were excluded. Ethnic or cultural differences as well as different analytical methods impacted generalisability of results. The use of CFA as the primary analysis may have biased towards a four-factor structure. Conclusions A four-factor CES-D structure was an appropriate fit for adolescents in Western countries; further research is required to determine the fit in in Asian countries. This has important implications for clinical use of the scale. Future research should consider how cultural differences shape the experience of depression in adolescents.

Background Injurious falls in hospitals and care homes are a life-limiting and costly international issue. Shock-absorbing flooring may offer part of the solution; however, evidence is required to inform decision-making. Objectives The objectives were to assess the clinical effectiveness and cost-effectiveness of shock-absorbing flooring for fall-related injury prevention among older adults in care settings. Review methods A systematic review was conducted of experimental, observational, qualitative and economic studies evaluating flooring in care settings targeting older adults and/or staff. Studies identified by a scoping review (inception to May 2016) were screened, and the search of MEDLINE, AgeLine and Scopus (to September 2019) was updated, alongside other sources. Two independent reviewers assessed risk of bias in duplicate (using Cochrane’s Risk of Bias 2.0 tool, the Risk Of Bias In Non-randomized Studies – of Interventions tool, or the Joanna Briggs Institute’s qualitative tool). Results Of the 22 included studies, 20 assessed the outcomes (three randomised controlled trials; and seven observational, five qualitative and five economic studies) on novel floors (n = 12), sports floors (n = 5), carpet (n = 5) and wooden subfloors (n = 1). Quantitative data related to 11,857 patient/resident falls (nine studies) and 163 staff injuries (one study). Qualitative studies included patients/residents (n = 20), visitors (n = 8) and staff (n = 119). Hospital-based randomised controlled trial data were too imprecise; however, very low-quality evidence indicated that novel/sports flooring reduced injurious falls from three per 1000 patients per day on vinyl with concrete subfloors to two per 1000 patients per day (rate ratio 0.55, 95% confidence interval 0.36 to 0.84; two studies), without increasing falls rates (two studies). One care home-based randomised controlled trial found that a novel underlay produces similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to those of a plywood underlay with vinyl overlays and concrete subfloors. Very low-quality data demonstrated that, compared with rigid floors, novel/sports flooring reduced the number of falls resulting in injury in care homes (26.4% vs. 33.0%; risk ratio 0.80, 95% confidence interval 0.70 to 0.91; three studies) and hospitals (27.1% vs. 42.4%; risk ratio 0.64, 95% confidence interval 0.44 to 0.93; two studies). Fracture and head injury outcomes were imprecise; however, hip fractures reduced from 30 per 1000 falls on concrete to 18 per 1000 falls on wooden subfloors in care homes (odds ratio 0.59, 95% confidence interval 0.45 to 0.78; one study; very low-quality evidence). Four low-quality economic studies concluded that shock-absorbing flooring reduced costs and improved outcomes (three studies), or increased costs and improved outcomes (one study). One, more robust, study estimated that shock-absorbing flooring resulted in fewer quality-adjusted life-years and lower costs, if the number of falls increased on shock-absorbing floors, but that shock-absorbing flooring would be a dominant economic strategy if the number of falls remained the same. Staff found moving wheeled equipment more difficult on shock-absorbing floors, leading to workplace adaptations. Staff injuries were observed; however, very low-quality evidence suggests that these are no less frequent on rigid floors. Limitations Evidence favouring shock-absorbing flooring is of very low quality; thus, much uncertainty remains. Conclusions Robust evidence is lacking in hospitals and indicates that one novel floor may not be effective in care homes. Very low-quality evidence indicates that shock-absorbing floors may be beneficial; however, wider workplace implications need to be addressed. Work is required to establish a core outcome set, and future research needs to more comprehensively deal with confounding and the paucity of hospital-based studies, and better plan for workplace adaptations in the study design. Study registration This study is registered as PROSPERO CRD42019118834. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 5. See the NIHR Journals Library website for further project information.

Oligometastatic cancer (cancer with a limited number of metastases) represents an intermediate state between cancer confined to a single location in the body and cancer that has metastasized — or spread — widely. One treatment option, for which there is growing interest, is stereotactic ablative radiotherapy, also known as SABR. SABR precisely delivers a high dose of radiation to ablate tumours at specific sites while minimizing the radiation dose to surrounding normal tissues. SABR may be used independently or alongside other treatment options in the management of oligometastatic cancer. This CADTH clinical review evaluated the evidence regarding the clinical effectiveness and safety of SABR with or without standard of care (SOC) for people with oligometastatic cancer and found the following: SABR in addition to SOC may offer a benefit in terms of overall survival (OS) and progression-free survival (PFS). The findings for the effectiveness of SABR alone compared with SOC were mixed and deemed inconclusive. There are insufficient data related to adverse events (AEs) at the present time to draw conclusions regarding the safety of SABR relative to SOC alternatives. Note that this is the baseline report of a living systematic review that is being updated every 3 months to ensure the findings remain up to date as new evidence emerges. Please refer to the CADTH project page for the latest version of the report and for the version history.

Objective: The objective of this review is to describe the global evidence of gender inequity among individuals with appointments at academic institutions that conduct health research, and examine how gender intersects with other social identities to influence outcomes. Introduction: The gender demographics of universities have shifted, yet the characteristics of those who lead academic health research institutions have not reflected this change. Synthesized evidence will guide decision-making and policy development to support the progress of gender and other under-represented social identities in academia. Inclusion Criteria: This review will consider any quantitative, qualitative, or mixed methods primary research that reports outcome data related to gender equity and other social identities among individuals affiliated with academic or research institutions that conduct health research, originating from any country. Methods: The JBI Manual for Evidence Synthesis and the Cochrane Collaboration's guidance on living reviews will inform the review methods. Information sources will include electronic databases, unpublished literature sources, reference scanning of relevant systematic reviews, and sources provided by experts on the research team. Searches will be run regularly to monitor the development of new literature and determine when the review will be updated. Study selection and data extraction will be conducted by two reviewers working independently, and all discrepancies will be resolved by discussion or a third reviewer. Data synthesis will summarize information using descriptive frequencies and simple thematic analysis. Results will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension to scoping reviews.

IntroductionFalls in hospitals and care homes are a major issue of international concern. Inpatient falls are the most commonly reported safety incident in the UK’s National Health Service (NHS), costing the NHS £630 million a year. Injurious falls are particularly life-limiting and costly. There is a growing body of evidence on shock-absorbing flooring for fall-related injury prevention; however, no systematic review exists to inform practice.Methods and analysisWe will systematically identify, appraise and summarise studies investigating the clinical and cost-effectiveness, and experiences of shock-absorbing flooring in hospitals and care homes. Our search will build on an extensive search conducted by a scoping review (inception to May 2016). We will search electronic databases (AgeLine, CINAHL, MEDLINE, NHS Economic Evaluation Database, Scopus and Web of Science; May 2016–present), trial registries and grey literature. We will conduct backward and forward citation searches of included studies, and liaise with study researchers. We will evaluate the influence of floors on fall-related injuries, falls and staff work-related injuries through randomised and non-randomised studies, consider economic and qualitative evidence, and implementation factors. We will consider risk of bias, assess heterogeneity and explore potential effect modifiers via subgroup analyses and sensitivity analyses. Where appropriate we will combine studies through meta-analysis. We will use the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach to evaluate the quality of evidence and present the results using summary of findings tables, and adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines.Ethics and disseminationWe will follow the ethical principles of systematic review conduct, by attending to publication ethics, transparency and rigour. Our dissemination plan includes peer-reviewed publication, presentations, press release, stakeholder symposium, patient video and targeted knowledge-to-action reports. This review will inform decision-making around falls management in care settings and identify important directions for future research.PROSPERO registration numberCRD42019118834.

Background Failure to sustain knowledge translation (KT) interventions impacts patients and health systems, diminishing confidence in future implementation. Sustaining KT interventions used to implement chronic disease management (CDM) interventions is of critical importance given the proportion of older adults with chronic diseases and their need for ongoing care. Our objectives are to (1) complete a systematic review and network meta-analysis of the effectiveness and cost-effectiveness of sustainability of KT interventions that target CDM for end-users including older patients, clinicians, public health officials, health services managers and policy-makers on health care outcomes beyond 1 year after implementation or the termination of initial project funding and (2) use the results of this review to complete an economic analysis of the interventions identified to be effective. Methods For objective 1, comprehensive searches of relevant electronic databases (e.g. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials), websites of health care provider organisations and funding agencies will be conducted. We will include randomised controlled trials (RCTs) examining the impact of a KT intervention targeting CDM in adults aged 65 years and older. To examine cost, economic studies (e.g. cost, cost-effectiveness analyses) will be included. Our primary outcome will be the sustainability of the delivery of the KT intervention beyond 1 year after implementation or termination of study funding. Secondary outcomes will include behaviour changes at the level of the patient (e.g. symptom management) and clinician (e.g. physician test ordering) and health system (e.g. cost, hospital admissions). Article screening, data abstraction and risk of bias assessment will be completed independently by two reviewers. Using established methods, if the assumption of transitivity is valid and the evidence forms a connected network, Bayesian random-effects pairwise and network meta-analysis will be conducted. For objective 2, we will build a decision analytic model comparing effective interventions to estimate an incremental cost-effectiveness ratio. Discussion Our results will inform knowledge users (e.g. patients, clinicians, policy-makers) regarding the sustainability of KT interventions for CDM. Dissemination plan of our results will be tailored to end-users and include passive (e.g. publications, website posting) and interactive (e.g. knowledge exchange events with stakeholders) strategies. Systematic review registration PROSPERO CRD42018084810

Background Internet gaming disorder (IGD) was included in the DSM-5 in 2013 as a condition requiring further research, and gaming disorder (GD) was included in the ICD-11 in 2018. Given the importance of including these conditions in diagnostic guidelines, a review was conducted to describe their prevalence. Methods Using guidance from the Joanna Briggs Institute and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we conducted a rapid scoping review. MEDLINE, Embase, PsycINFO, and the Cochrane library were searched for literature published from inception to July 2018. All review stages were pilot-tested to calibrate reviewers. The titles/abstracts and full-text articles were screened by one reviewer to include quantitative primary studies that reported GD or IGD prevalence. Excluded citations were screened by a second reviewer to confirm exclusion. Charting was conducted by one reviewer and verified by another, to capture relevant data. Results were summarized descriptively in tables or text. Results We assessed 5550 potentially relevant citations. No studies on GD were identified. We found 160 studies of various designs that used 35 different methods to diagnose IGD. The prevalence of IGD ranged from 0.21–57.50% in general populations, 3.20–91.00% in clinical populations, and 50.42–79.25% in populations undergoing intervention (severe cases). Most studies were conducted in the Republic of Korea (n = 45), China (n = 29), and the USA (n = 20). Results are also presented for severe IGD and by geographic region, gender/sex, and age groups (child, adolescent, adult). The five most frequently reported health-related variables were depression (67 times), Internet addiction (54 times), anxiety (48 times), impulsiveness (37 times), and attention-deficit hyperactivity disorder (24 times). Conclusions Due to the variability in diagnostic approaches, knowledge users should interpret the wide IGD prevalence ranges with caution. In addition to further research on GD, consensus on the definition of IGD and how it is measured is needed, to better understand the prevalence of these conditions.

This study explored barriers and facilitators to adoption of compliant flooring as a fall injury prevention strategy within long-term care from the perspective of 18 long-term care senior managers....

RÉSUMÉLe revêtement de sol compliant vise à prévenir les blessures causées par les chutes chez les personnes âgées à risque en soins de longue durée, mais l’utilisation de ce type de revêtement dans ces milieux est encore limitée. Nous avons organisé un symposium d’une journée réunissant les parties prenantes afin d’identifier les avantages et les désavantages de l’installation d’un revêtement de sol compliant en soins de longue durée, ainsi que les questions de recherche future les plus pressantes selon les perspectives des parties prenantes clés. Vingt-trois parties prenantes du domaine de la santé, de l’industrie et de la recherche ont assisté au symposium. Les participants considéraient que les avantages les plus importants de ce revêtement étaient la réduction des blessures pour les résidents qui ont chuté auparavant, les avantages potentiels pour le personnel soignant, et la possibilité d’amélioration de la qualité de vie des résidents. Les désavantages perçus comprenaient des considérations financières, le manque de résultats de recherche concernant ce revêtement et les défis associés à l’installation. Les participants ont indiqué que davantage de recherches étaient nécessaires pour montrer le rapport coût-efficacité et l’efficacité clinique du revêtement de sol compliant. Les parties prenantes ont ainsi perçu que ce revêtement procurait une valeur ajoutée en soins de longue durée, mais ont aussi mis en évidence certaines barrières informationnelles et financières significatives liées à son adoption.

Falls in hospitals and care homes are a major issue of international concern. Falls cost the US $34 billion a year, with injurious falls being particularly life-limiting and costly. Shock-absorbing flooring decreases the stiffness of the ground surface to reduce the impact of a fall. There is a growing body of evidence on flooring for fall-related injury prevention, however no systematic review exists to inform practice. We systematically reviewed the evidence on the clinical and cost-effectiveness of shock-absorbing flooring use for fall-related injury prevention in care settings. We searched six databases, clinical trial registries, conference proceedings, theses/dissertations, websites, reference lists, conducted forward citation searches, and liaised with experts in the field. We conducted study selection, data collection, and critical appraisal independently in duplicate. We evaluated the influence of shock-absorbing flooring on fall-related injuries, falls, and staff work-related injuries. We adopted a mixed methods approach considering evidence from randomised, non-randomised, economic, qualitative, and implementation studies. We assessed and reported the quality of outcomes using the GRADE approach and Summary of Findings Tables. This review, conducted over the course of 2019, summarises the certainty of the evidence on whether and which shock-absorbing floors influence injuries from falls, the chance of someone falling over, and work-related injuries in staff (e.g. from manoeuvring equipment across softer floors). Our findings are applicable to health and social care professionals, buildings and facilities managers, carers, older adults, architects, and designers. Funded by National Institute for Health Research, Health Technology Assessment (ref 17/148/11); registered in PROSPERO (CRD42019118834).

Background Systematic reviews have established that exercise reduces falls in older adults, however the most effective types of exercise are not known. This secondary analysis determined the comparative effectiveness of fall prevention exercise approaches. Method All fall prevention exercise interventions for older adults were identified from an existing search from inception until April 2017. Interventions were coded using a framework of 25 exercise types. Two reviewers independently screened studies, extracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis (NMA) were conducted. P-scores were used to rank exercise combinations. Results One hundred and sixty-nine studies were included. NMA was conducted on 73 studies (30,697 participants) for the outcome of number of fallers. The exercise combination ranked with the greatest likelihood of being most effective relative to no exercise was: anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility (p-score = 0.95). This exercise combination also significantly reduced number of fallers compared to 16 other combinations. No exercise combination had a significantly greater effect on reducing number of fallers more than this combination. Conclusion This analysis identified components of effective fall prevention exercise. The results can inform evidence-informed exercise recommendations and be used to design effective programs.

Objective: The aim of this study was to investigate the effects of flooring type and resident weight on external hand forces required to push floor-based lifts in long-term care (LTC). Background: Novel compliant flooring is designed to reduce fall-related injuries among LTC residents but may increase forces required for staff to perform pushing tasks. A motorized lift may offset the effect of flooring on push forces. Method: Fourteen female LTC staff performed straight-line pushes with two floor-based lifts (conventional, motor driven) loaded with passengers of average and 90th-percentile resident weights over four flooring systems (concrete+vinyl, compliant+vinyl, concrete+carpet, compliant+carpet). Initial and sustained push forces were measured by a handlebar-mounted triaxial load cell and compared to participant-specific tolerance limits. Participants rated pushing difficulty. Results: Novel compliant flooring increased initial and sustained push forces and subjective ratings compared to concrete flooring. Compared to the conventional lift, the motor-driven lift substantially reduced initial and sustained push forces and perceived difficulty of pushing for all four floors and both resident weights. Participants exerted forces above published tolerance limits only when using the conventional lift on the carpet conditions (concrete+carpet, compliant+carpet). With the motor-driven lift only, resident weight did not affect push forces. Conclusion: Novel compliant flooring increased linear push forces generated by LTC staff using floor-based lifts, but forces did not exceed tolerance limits when pushing over compliant+vinyl. The motor-driven lift substantially reduced push forces compared to the conventional lift. Application: Results may help to address risk of work-related musculoskeletal injury, especially in locations with novel compliant flooring.

Purpose-designed compliant flooring and carpeting have been promoted as a means for reducing fall-related injuries in high-risk environments, such as long-term care. However, it is not known whether these surfaces influence the forces that long-term care staff exert when pushing residents in wheelchairs. We studied 14 direct-care staff who pushed a loaded wheelchair instrumented with a triaxial load cell to test the effects on hand force of flooring overlay (vinyl versus carpet) and flooring subfloor (concrete versus compliant rubber [brand: SmartCells]). During straight-line pushing, carpet overlay increased initial and sustained hand forces compared to vinyl overlay by 22–49% over a concrete subfloor and by 8–20% over a compliant subfloor. Compliant subflooring increased initial and sustained hand forces compared to concrete subflooring by 18–31% when under a vinyl overlay. In contrast, compliant flooring caused no change in initial or sustained hand forces compared to concrete subflooring when under a carpet overlay.

ObjectiveTo determine (i) the difference in the frequency of serious adverse events (SAEs) reported in trial registrations and their respective primary publications and (ii) the effect of adding SAE data from registries to a network meta-analysis (NMA) in changing the surface under the cumulative ranking (SUCRA) curve values of interventions.DesignSecondary analysis of primary publications from two NMAs.Eligibility criteria for selecting studiesWe included randomised trials published in English after 2005 that were included in two NMAs of pharmacological interventions for Alzheimer’s disease and chronic obstructive pulmonary disease.Data extractionTwo reviewers independently searched multiple international trial registries for registration status and abstracted data from the included study publications and ClinicalTrials.gov.ResultsOf the 203 randomised trials included, 140 (69.0%) were registered with a trial registry and 72 (35.5%) posted results in the registry. The proportion of registered trials increased over time (38.5% in 2005 vs 78.6% in 2014). Of the publications with results posted in a trial registry, 14 (19.4%) had inconsistent reporting of overall SAEs; 7 (10.4%) studies did not report SAEs in the publication but did in the registry. In the 134 randomised trials with a prespecified primary outcome in the registry, 19 studies (9.4%) had a change in the primary outcome in the publication. Adding SAEs reported in registries to the NMAs did not affect the ranking of interventions.ConclusionWe identified inconsistent reporting of SAEs in randomised trials that were included in two NMAs. Findings highlight the importance of including trial registries in the grey literature search and verifying safety data before incorporating it into NMAs.Study registrationosf.io/mk6dr.

Background Fall-related injuries exert an enormous health burden on older adults in long-term care (LTC). Softer landing surfaces, such as those provided by low-stiffness “compliant” flooring, may prevent fall-related injuries by decreasing the forces applied to the body during fall impact. Our primary objective was to assess the clinical effectiveness of compliant flooring at preventing serious fall-related injuries among LTC residents. Methods and findings The Flooring for Injury Prevention (FLIP) Study was a 4-year, randomized superiority trial in 150 single-occupancy resident rooms at a single Canadian LTC site. In April 2013, resident rooms were block randomized (1:1) to installation of intervention compliant flooring (2.54 cm SmartCells) or rigid control flooring (2.54 cm plywood) covered with identical hospital-grade vinyl. The primary outcome was serious fall-related injury over 4 years that required an emergency department visit or hospital admission and a treatment procedure or diagnostic evaluation in hospital. Secondary outcomes included minor fall-related injury, any fall-related injury, falls, and fracture. Outcomes were ascertained by blinded assessors between September 1, 2013 and August 31, 2017 and analyzed by intention to treat. Adverse outcomes were not assessed. During follow-up, 184 residents occupied 74 intervention rooms, and 173 residents occupied 76 control rooms. Residents were 64.3% female with mean (SD) baseline age 81.7 (9.5) years (range 51.1 to 104.6 years), body mass index 25.9 (7.7) kg/m2, and follow-up 1.64 (1.39) years. 1,907 falls were reported; 23 intervention residents experienced 38 serious injuries (from 29 falls in 22 rooms), while 23 control residents experienced 47 serious injuries (from 34 falls in 23 rooms). Compliant flooring did not affect odds of ≥1 serious fall-related injury (12.5% intervention versus 13.3% control, odds ratio [OR]: 0.98, 95% CI: 0.52 to 1.84, p = 0.950) or ≥2 serious fall-related injuries (5.4% versus 7.5%, OR: 0.74, 95% CI: 0.31 to 1.75, p = 0.500). Compliant flooring did not affect rate of serious fall-related injuries (0.362 versus 0.422 per 1,000 bed nights, rate ratio [RR]: 1.04, 95% CI: 0.45 to 2.39, p = 0.925; 0.038 versus 0.053 per fall, RR: 0.81, 95% CI: 0.38 to 1.71, p = 0.560), rate of falls with ≥1 serious fall-related injury (0.276 versus 0.303 per 1,000 bed nights, RR: 0.97, 95% CI: 0.52 to 1.79, p = 0.920), or time to first serious fall-related injury (0.237 versus 0.257, hazard ratio [HR]: 0.92, 95% CI: 0.52 to 1.62, p = 0.760). Compliant flooring did not affect any secondary outcome in this study. Study limitations included the following: findings were specific to 2.54 cm SmartCells compliant flooring installed in LTC resident rooms, standard fall and injury prevention interventions were in use throughout the study and may have influenced the observed effect of compliant flooring, and challenges with concussion detection in LTC residents may have prevented estimation of the effect of compliant flooring on fall-related concussions. Conclusions In contrast to results from previous retrospective and nonrandomized studies, this study found that compliant flooring underneath hospital-grade vinyl was not effective at preventing serious fall-related injuries in LTC. Future studies are needed to identify effective methods for preventing fall-related injuries in LTC. Trial registration ClinicalTrials.gov: NCT01618786, Dawn Mackey and co-workers trial low-stiffness flooring in prevention of fall-related injuries among older adults in long-term care., Author summary Why was this study done? Compliant (low-stiffness) flooring aims to reduce impact forces on the body and thereby prevent injuries from falls. Controlled laboratory studies have shown that specific types of compliant flooring provide meaningful amounts of force attenuation and energy absorption during impact to vulnerable locations, such as the hip and head, without impairing balance or mobility during daily activities, such as standing and walking. Preliminary evidence suggested compliant flooring may be effective at preventing fall-related injuries in long-term care, but past studies were limited by nonrandomized or retrospective designs and insufficient sample sizes; no randomized trial has tested the effectiveness of compliant flooring at preventing serious fall-related injuries in long-term care. What did the researchers do and find? To our knowledge, we conducted the first randomized trial of compliant flooring in long-term care (FLIP Study). We believe it is the largest and most methodologically rigorous study of compliant flooring conducted to date. The compliant flooring we studied (SmartCells 2.54 cm underneath 2 mm hospital-grade vinyl) did not reduce the frequency of serious fall-related injuries, minor fall-related injuries, or falls among long-term care residents over 4 years. What do these findings mean? Toward the design of safer living environments for older adults, our study demonstrates that installation of the compliant flooring we studied would not increase the risk or rate of falls among long-term care residents, but it would also not reduce the risk or rate of fall-related injury. The compliant flooring we investigated is not likely to cause harm to long-term care residents, but we were unable to detect benefits to residents based on the metrics we examined. The results of this study may inform policies, programs, and practices for fall injury prevention in long-term care, but future research is needed to identify effective methods for reducing morbidity from falls.

Background A promising strategy for reducing the incidence and severity of fall-related injuries in long-term care (LTC) is to decrease the ground surface stiffness, and the subsequent forces applied to the body parts at impact, through installation of compliant flooring that does not substantially affect balance or mobility. Definitive evidence of the effects of compliant flooring on fall-related injuries in LTC is lacking. The Flooring for Injury Prevention (FLIP) Study is designed to address this gap. Methods The FLIP Study is a 4-year, parallel-group, 2-arm, randomised controlled superiority trial of flooring in 150 resident rooms at a LTC site. The primary objective is to determine whether compliant flooring reduces serious fall-related injuries relative to control flooring. Intervention (2.54 cm SmartCells compliant; 74 rooms) and control (2.54 cm plywood; 76 rooms) floorings were installed over the top of existing concrete floors and covered with identical 2.00 mm vinyl. The primary outcome is serious fall-related injury, defined as any impact-related injury due to a fall in a study room that results in Emergency Department visit or hospital admission. Secondary outcomes include minor fall-related injury, any fall-related injury, falls, number of fallers, fractures, and healthcare utilisation and costs for serious fall-related injuries. Randomisation of study rooms, and residents in rooms, was stratified by residential unit, and flooring assignments were concealed. Outcome ascertainment began September 2013. Discussion Results from the FLIP Study will provide evidence about the effects of compliant flooring on fall-related injuries in LTC and will guide development of safer environments for vulnerable older adults. Trial registration number NCT01618786.

Normal aging processes result in losses of functional flexibility and muscular strength, which increase seniors’ fall risk and dependence on others. A relatively new intervention to reduce and/or reverse the adverse effects of aging is whole-body vibration (WBV) exercise. The purpose of this article is to review the established effects of WBV exercise exclusively with the aging population. A systematic search utilizing PubMed and Sport Discus databases uncovered journal articles specific to seniors and whole-body vibration. An extensive hand search supplemented the database results to find other relevant articles. Twenty-seven articles were obtained; all articles have been published in the past 8 years, reflecting the recent and growing interest in this area. Researchers have determined that WBV training can reduce fall risk and improve postural control in seniors. It has also been determined that WBV training can be as effective as conventional resistance training to improve seniors’ lower body strength. However, little is known about the effect of WBV exercise on flexibility and upper body strength in the aging population. More research is required to establish how effective WBV training is on these specific components and how it may affect seniors’ quality of life.

Background Compliant flooring, broadly defined as flooring systems or floor coverings with some level of shock absorbency, may reduce the incidence and severity of fall-related injuries in older adults; however, a lack of synthesized evidence may be limiting widespread uptake. Methods Informed by the Arksey and O’Malley framework and guided by a Research Advisory Panel of knowledge users, we conducted a scoping review to answer: what is presented about the biomechanical efficacy, clinical effectiveness, cost-effectiveness, and workplace safety associated with compliant flooring systems that aim to prevent fall-related injuries in healthcare settings? We searched academic and grey literature databases. Any record that discussed a compliant flooring system and at least one of biomechanical efficacy, clinical effectiveness, cost-effectiveness, or workplace safety was eligible for inclusion. Two independent reviewers screened and abstracted records, charted data, and summarized results. Results After screening 3611 titles and abstracts and 166 full-text articles, we included 84 records plus 56 companion (supplementary) reports. Biomechanical efficacy records (n = 50) demonstrate compliant flooring can reduce fall-related impact forces with minimal effects on standing and walking balance. Clinical effectiveness records (n = 20) suggest that compliant flooring may reduce injuries, but may increase risk for falls. Preliminary evidence suggests that compliant flooring may be a cost-effective strategy (n = 12), but may also result in increased physical demands for healthcare workers (n = 17). Conclusions In summary, compliant flooring is a promising strategy for preventing fall-related injuries from a biomechanical perspective. Additional research is warranted to confirm whether compliant flooring (i) prevents fall-related injuries in real-world settings, (ii) is a cost-effective intervention strategy, and (iii) can be installed without negatively impacting workplace safety. Avenues for future research are provided, which will help to determine whether compliant flooring is recommended in healthcare environments.

Preliminary clinical findings suggest that compliant flooring may reduce the incidence and severity of fall- related injuries in long-term care (Knoefel et al., 2013) and acute-care settings (Drahota et al., 2013). However, there is concern that manoeuvring wheeled equipment on compliant flooring could expose care staff to potentially harmful pushing forces (Drahota et al., 2013; Wynn et al., 2011). We measured the external resultant hand forces (initial and sustained) required for female direct care staff to push two floor - based lifts (conventional manual and motor-driven) (n=14) or a wheelchair (n=14), loaded with passengers of average (67 kg) and ninetieth percentile (90 kg) resident weights, over four flooring systems: concrete + vinyl, compliant (1” SmartCells) + vinyl, concrete + carpet, and compliant + carpet. We observed an interaction between lift type and floor system for initial (p < 0.001) and sustained (p < 0.001) forces. Independent of resident weight, mean forces were lower for the motor-driven lift than the conventional lift on all flooring conditions (by 34.8 – 74.4 N for initial forces and by 14.1 – 64.5 N for sustained forces). With the vinyl overlay, initial forces were higher on compliant than concrete subflooring when using the conventional lift (mean difference = 44.7 N, 47.7% increase, p < 0.001) and motor-driven lift (29.8 N, 45.8% increase, p < 0.001). Similarly, with the vinyl overlay, sustained resultant forces were higher on compliant subflooring than concrete subflooring when using the conventional lift (39.0 N, 88.2% increase, p < 0.001) and motor-driven lift (9.7 N, 29.0% increase, p < 0.001). With the carpet overlay, the differences between compliant and concrete subfloors were less pronounced than with the vinyl overlay for the conventional lift (Finitial: 23.0 N higher, 14.9% increase, p < 0.001; Fsustained: 15.6 N higher, 18.7% increase, p < 0.001) and absent when using the motor-driven lift (Finitial: p = 0.975; Fsustained: p = 0.999). We also observed an interaction between resident weight and lift type for initial (p = 0.004) and sustained forces (p < 0.001). Independent of flooring system, Finitial was 18.6 N higher (13.5% increase, p < 0.001) and Fsustained was 11.7 N higher (14.3% increase, p < 0.001) for the ninetieth percentile weight than the average weight for the conventional lift. In contrast, there were no differences in Finitial (p = 0.200) and Fsustained (p = 0.100) between the average and ninetieth percentile weight conditions for the motor-driven lift. Similar trends were observed when participants pushed the wheelchair. In summary, this study found that compliant subflooring increased the external hand forces required for female direct care staff to push floor -based lifts and wheelchairs compared to concrete subflooring, and these increases in force were greater when pushing over vinyl than carpet overlay. This study also demonstrated that a motor-driven lift substantially reduced push forces compared to a conventional manual lift. Thus, motor-driven lifts may help to prevent work- related musculoskeletal injuries in long-term care facilities, especially in facilities with compliant flooring.

In response to high rates of work-related musculoskeletal injury (MSI) in long-term care (LTC), decision makers have implemented minimal-lift policies to reduce strain arising from resident transferring, often advocating the use of lifting devices. Floor-based lifts, in particular, are widely used in LTC, even though users are known to experience potentially injurious forces when pushing overweight or obese residents on carpet (Marras, Knapik & Ferguson, 2009). Motivated by this, a European manufacturer has developed a motor-driven, floor-based lift to assist users with resident transferring (esense Rise, Active4Care, Enschede, NL). Despite the motor-driven lift’s promise as a strategy for improved workplace safety, no research has been published examining its ability to reduce external hand forces, or perceptions of ease among users, during pushing. Therefore, we compared external hand forces and subjective ratings of perceived ease when straight-line pushing a motor-driven versus conventional (manual wheeled) floor-based lift, under conditions of low (vinyl) and high (carpet) rolling resistance, and while transporting passengers of average (67 kg) and ninetieth percentile (90 kg) resident weight. We recruited fourteen female direct care staff from a partner LTC site in British Columbia, Canada. We collected external hand force data using a piezoelectric, triaxial load cell (model 9074C, Kistler, Winterthur, Switzerland), custom mounted between existing lift handholds and a cylindrical handlebar. We also collected information on exposure (frequency, distance) to pushing in LTC by questionnaire, and calculated participant-specific tolerance limits for initial and sustained forces using Snook and Ciriello’s (1991) Hazard Analysis Tool. We observed a significant interaction between lift type and floor surface on initial (p < 0.001) and sustained (p < 0.001) forces. On vinyl, the motor-driven lift required, on average, 35 N (34%) less initial force (p < 0.001) and 14 N (27%) less sustained force (p < 0.001) than the conventional lift, regardless of resident weight. On carpet, we observed larger differences in forces between lifts, with the motor-driven lift requiring, on average, 64 N (36%) less initial force (p < 0.001) and 51 N (52%) less sustained force (p < 0.001) than the conventional lift, regardless of resident weight. Furthermore, there was an interaction between lift type and floor surface on subjective ratings of perceived ease of pushing (p < 0.001). On vinyl, subjective ratings did not differ between lifts (p = 0.32), with the majority of participants rating their ease of pushing as ‘very easy’ when pushing 90 kg passengers in both the conventional lift (n = 8, 57.1%) and the motor- driven lift (n = 12, 85.7%). On carpet, however, ratings were, on average, 1.8-points lower with the motor- driven lift (mean = 1.7; ‘somewhat easy’) than the conventional lift (mean = 3.5; ‘somewhat difficult’), independent of resident weight (p < 0.001). No conditions involving the motor-driven lift imposed forces above tolerable limits, while three of fourteen (21.4%) direct care staff exerted forces above tolerable limits when using the conventional lift on carpet only. Our results did not demonstrate a clear need for a motor-driven lift to mitigate the biomechanical demands of linear pushing on vinyl, as no participants’ force values approached tolerable limits for either lift on vinyl. Subjective ratings were also no different between lifts on vinyl. We did, however, demonstrate that motor-driven lifts reduce the biomechanical demands associated with pushing floor-based lifts on carpet. This insight can be used to inform evidence-based practices to improve worker safety during resident transferring, which could lead to reductions in both the incidence and severity of work-related MSI in LTC.