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      COVID-19 will severely impact older people's lives, and in many more ways than you think!

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          Abstract

          Introduction The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, also known as Coronavirus Disease 2019 (COVID-19) will severely impact older people's lives. COVID-19 can lead to pneumonia, acute respiratory distress syndrome, and other health problems that can lead to poor prognoses, including death, especially in older people.1, 2 Environmental contamination has been identified as a route of transmission of COVID-19, 3 and for this reason, governments worldwide have been initiating quarantine measures that include keeping older people in “social isolation” to slow the transmission of the infection. These measures have a special focus of protecting older people. Is social isolation the best measure to protect older people's lives? There is emerging evidence that suggests that social isolation might be an important measure to protect against COVID-19 infections. 4 However, this may be a “two edge sword”. As we have known well before the pandemic, there are negative consequences of social isolation for older people. Physical activity Both incidental and planned physical activity are likely to decrease in all people with social distancing, but the consequences will be greater for older people due to their compromised cardiorespiratory fitness, and reduced muscle strength and muscle mass. 5 Mental health A recent study by Esain et al. 6 showed that 3 months of detraining (i.e. no physical exercise) led to a decline in not just physical functioning, but also in mental health and quality of life (QoL) in physically active older people. Such adverse consequences may be even greater in older individuals who are sedentary or in poor health. Lack of social connection and neighborhood engagement may also contribute to increased risk of mental disorders due to loneliness, especially in those who live alone. 7 Social isolation has such negative impact, that it remains a strong risk factor for increased mortality in older people after adjusting for demographic and health factors. 8 Being at home is not good medicine Staying at home can lead to additional health problems. For example, a lack of exposure to sunshine can lead to Vitamin D deficiency in older people. 9 Consequently, the immune system can be compromised and infections can occur at a higher frequency, in addition to an increased risk of falling. 9 Confined home environments can also lead individuals with balance and mobility impairments, such as those with Parkinson's disease and dementia, to experience falls. 10 Finally, poor access to physical exercises, when combined with illnesses, fear of falling, and poor motivation can lead to an entrenched sedentary lifestyle, 11 and in consequence declines in both physical and mental health. 5 Therefore, while still unknown, the effects of social isolation during the COVID-19 pandemic lockdown on older people may be substantial. Falls – this is why we are so concerned! Lack of Vitamin D, depression, illness and associated polypharmacy, cognitive decline, loneliness, decline in physical activity levels, increased body mass,5, 7, 9, 12, 13 all negative consequences of social isolation, can increase the risk of falls in older people. A fall at home can lead to serious injuries such as fractures and head trauma, as well as undermine balance confidence and induce excessive fear of falling. For older people who live alone, there is also the risk of a fall-related long lie, i.e. remaining on the floor for 24 h or more following the fall. As could be expected, such a fall-related consequence is a risk factor for significant morbidity and death. Further work to be done Extensive public health research will be required to determine the extent to which social isolation during the current extensive quarantine periods will adversely affect older people as well as what factors mitigate against such adverse effects. Important questions include: (i) how can we provide physical activity during social isolation? (ii) how can we enhance individuals’ quality of life after social isolation is over? and (iii) how can we prepare ourselves in case a new wave of COVID-19 or another pandemic occurs? However, a number of evidence-based initiatives can be implemented without delay. Physicians and allied-health professionals can use telemedicine to provide consultations, assessments, and interventions. 14 As long as the clients have (i) a mobile device or a tablet; (ii) high-speed internet; (iii) and a home area clear of obstacles to exercise; (iv) an assistant or an auxiliary device to help with balance; appropriate exercise interventions and physical assessments can be delivered. There is good evidence that home-based exercise programs can be conducted safely and can enhance quality of life and reduce the risk of falls in older people. 15 Finally, occupational therapy interventions involving removal of environmental hazards along with counseling regarding safe mobility in the home may also help prevent falls in at-risk individuals. Funding Paulo Pelicioni was a recipient of a Coordenação de Aperfeiçoamento de Pessoal do Nivel Superior (CAPES) PhD scholarship [Grant number: BEX 2194/15-5]. Stephen Lord is supported by a NHMRC Research Fellowship. Conflicts of interest The authors declare no conflicts of interest.

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          The problems of vitamin d insufficiency in older people.

          This report reviews evidence on disorders related to inadequate vitamin D repletion in older people. Vitamin D is as essential for bone health in adults as in children, preventing osteomalacia and muscle weakness and protecting against falls and low-impact fractures. Vitamin D is provided by skin synthesis by UVB-irradiation from summer sunshine and to a small extent by absorption from food. However, these processes become less efficient with age. Loss of mobility or residential care restricts solar exposure. Reduced appetite and financial problems often add to these problems. Thus, hypovitaminosis D is common world-wide, but is more common and more severe in older people. Non-classical effects of vitamin D, depending on serum circulating 25-hydroxyvitamin D concentrations, are present in most non-bony tissues; disorders associated with hypovitaminosis D include increased risks of sepsis [bacterial, mycobacterial and viral], cardiovascular and metabolic disorders [e.g. hyperlipidemia, type 2 diabetes mellitus, acute vascular events, dementia, stroke and heart failure]. Many cancer risks are associated with vitamin D inadequacy, though causality is accepted only for colo-rectal cancer. Maintenance of repletion in healthy older people requires intakes of ≥800IU/day [20μg], as advised by the Institute of Medicine [IOM], but achieving such intakes usually requires supplementation. Excessive intakes are dangerous, especially in undiagnosed primary hyperparathyroidism or sarcoidosis, but the IOM finds doses <4000 IU/day are safe. Many experts suggest that ≥1000-2000 IU [25-50μg] of vitamin D daily is necessary for older people, especially when independence is lost, or hypovitaminosis D could add to the clinical problem[s]. Much higher doses than these are needed for treatment of established deficiency or insufficiency.
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            Evaluating the effectiveness of a home-based exercise programme delivered through a tablet computer for preventing falls in older community-dwelling people over 2 years: study protocol for the Standing Tall randomised controlled trial

            Introduction In order to prevent falls, older people should exercise for at least 2 h per week for 6 months, with a strong focus on balance exercises. This article describes the design of a randomised controlled trial to evaluate the effectiveness of a home-based exercise programme delivered through a tablet computer to prevent falls in older people. Methods and analysis Participants aged 70 years or older, living in the community in Sydney will be recruited and randomly allocated to an intervention or control group. The intervention consists of a tailored, home-based balance training delivered through a tablet computer. Intervention participants will be asked to complete 2 h of exercises per week for 2 years. Both groups will receive an education programme focused on health-related information relevant to older adults, delivered through the tablet computer via weekly fact sheets. Primary outcome measures include number of fallers and falls rate recorded in weekly fall diaries at 12 months. A sample size of 500 will be necessary to see an effect on falls rate. Secondary outcome measures include concern about falling, depressive symptoms, health-related quality of life and physical activity levels (in all 500 participants); and physiological fall risk, balance, functional mobility, gait, stepping and cognitive performance (in a subsample of 200 participants). Adherence, acceptability, usability and enjoyment will be recorded in intervention group participants over 2 years. Data will be analysed using the intention-to-treat principle. Secondary analyses are planned in people with greater adherence. Economic analyses will be assessed from a health and community care provider perspective. Ethics and dissemination Ethical approval was obtained from UNSW Ethics Committee in December 2014 (ref number HC#14/266). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conferences. Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN)12615000138583.
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              Digital physical therapy in the COVID-19 pandemic

              On March 11th/2020, the World Health Organization (WHO) declared Coronavirus Disease 2019 (COVID-19), a disease caused by the new coronavirus (severe acute respiratory syndrome coronavirus 2-SARS-COV-2), a pandemic. 1 In this global crisis, physical therapy all over the world, is being challenged to maintain its professional clinical activities in primary and secondary care in private clinics and public health systems.2, 3 Part of the challenge is to continue to provide necessary clinical care in a safe manner, for physical therapists, patients, and the community, by following the general recommendations of the WHO. 1 Social distancing and the interruption of physical therapy activities can have a tremendous negative impact on the health of thousands of patients. Digital physical therapy offers the possibility to continue providing some physical therapy services to patients, but regulations and implementation barriers are extremely heterogeneous around the world. The definition of digital physical therapy Before the COVID-19 crisis, in 2017 the World Confederation for Physical Therapy (WCPT) launched a collaboration to develop initiatives to the global practice and regulations of digital physical therapy practice through a Joint WCPT/INPTRA digital physical therapy Practice Task Force (Task Force). This report published in 2019 defined digital practice as “a term used to describe health care services, support, and information provided remotely via digital communication and devices”. The purpose of this initiative was “to facilitate effective delivery of physical therapy services by improving access to care and information and managing health care resources.” 4 However, for several physical therapists who have never had contact with this terminology, it is important to be aware that different terms are used in this field. There is still no global well-accepted term or definition for digital physical therapy among the literature industry, policymakers, and stakeholder groups. The variety of technologies that encompass this term may include tele-education, telemedicine, telemonitoring, teleassistance, mobile health, among others, and each field has its subset of technologies and specificities. The heterogeneity and barriers of digital physical therapy The worldwide COVID-19 pandemic forced the Brazilian health system to promptly adopt telehealth in different health care areas. The Federal Council of Physiotherapy and Occupational Therapy (COFFITO) allowed the use of telehealth, more specifically teleconsultation, teleconsulting and telemonitoring, for physical therapists (Resolution n° 516/March, 2020). 5 This change was promptly adopted to provide safe treatment delivery according to the WHO recommendations, however, no guidelines are available for physical therapists on how to use these technologies. Some countries currently use specifically designed and secure paid technologies to aid patient rehabilitation and monitoring. However, many physical therapists in Brazil and other similar countries are using free video conferencing software such as Google Hangouts, Zoom, and Skype although these tools were not designed to provide the necessary security in the sharing of health data. Other options include web-based platforms to create customized home-based exercise programs or augmented virtual reality platforms. The implementation of digital physical therapy should be done proactively rather than reactively to generate long term benefits to all parties involved. The COVID-19 crisis has been considered an opportunity for the advancement of telehealth in several countries. Australia, England, and the United States are facing several challenges, however, they included digital practice within the healthcare system a few years ago and recently their associations developed guidelines to assist professionals during the COVID-19 outbreak. The digital practice uptake was only possible because these countries already had the infrastructure needed to support these technologies. Countries like Brazil are just starting to discuss digital practice due to the recent regulation changes. There are several barriers related to digital practice implementation in a country that depend on different factors including infrastructure, legal and social issues, and economic aspects. The most important barriers are related to cost and reimbursement; legal liability, ethical issues such as confidentiality, outdated equipment, patient age and level of education; computer literacy, bandwidth range, and internet speed. 4 Opportunities and perspectives Digital physical therapy offers opportunities for users, service providers, and society, such as the expansion of access to health providers or specialists, encouragement of self-management, increase of flexibility for healthcare delivery, and decrease of sick-leave duration. Treatment efficacy and patient evaluation using digital practice were already investigated for some acute and chronic musculoskeletal conditions, cardiac conditions, neurological problems, post-surgical rehabilitation, pain management, pelvic floor conditions, and respiratory dysfunctions.6, 7, 8, 9, 10, 11, 12, 13, 14 The large-scale implementation of telehealth demands innovation in the technology market to improve capabilities and reduce cost to increase benefits. An important step for digital practice that will need support is data integration. As patients are remotely assessed or treated, professionals will need access to their relevant health data to provide the best care possible. That may be particularly challenging in a country where hospitals and clinics have different electronic health records systems or no electronic record system at all. Brazil as many other countries will need specific laws and guidelines on how to work with telehealth so that obligations and rights for all involved parties are clearly stipulated. Currently in Brazil, in the absence of specific guidelines and legislations, the safety of patients treated with telehealth is supported by resolutions of professional councils and laws about data protection on the internet such as law 13.709/2018 and its amendment 13.853/2019. 15 This law is known as the “General Law on Protection of Personal Data (LGPD)” and it reinforces concepts from the federal constitution in the online environment like free speech, privacy and honor protection, and access to personal information. The LGPD states that clients own their data meaning that individuals must know how their data are used and they can also require the deletion of all stored data from online service providers. The COVID-19 pandemic is stressing the capability of the health care systems across the globe, including the delivery of care for non-pandemic related health conditions. Digital practice will not be the solution for all the challenges that physical therapists will face; however, it is an exponentially growing field, widely adopted within the virus outbreak, and with the potential to reduce costs, increase quality, and overall accessibility of modern health care systems. The question now is whether physical therapists are prepared to implement digital practice to offer rehabilitation services during this undefined period of social distance due to the COVID-19. There is an unmet need to develop specific guidance on the many specific issues involving digital physical therapy practice. This task should involve each country's governmental authorities, physical therapy councils, and corresponding associations. Funding L.O. Dantas is a Ph.D. researcher from the São Paulo Research Foundation ( 10.13039/501100001807 FAPESP , Process number 2015/21422-6). Conflict of interest The author Barreto R.P.G is one of the owners of Vedius, a Brazilian company that has an online platform that enables health professionals to create and share home-exercise programs.
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                Author and article information

                Contributors
                Journal
                Braz J Phys Ther
                Braz J Phys Ther
                Brazilian Journal of Physical Therapy
                Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda.
                1413-3555
                1809-9246
                1 May 2020
                1 May 2020
                Affiliations
                [a ]Neuroscience Research Australia, New South Wales, Australia
                [b ]School of Public Health and Community and Medicine, University of New South Wales, New South Wales, Australia
                Author notes
                [* ]Corresponding author at: Neuroscience Research Australia, Barker Street, Randwick, N.S.W. 2031, Australia. p.pelicioni@ 123456neura.edu.au
                Article
                S1413-3555(20)30353-1
                10.1016/j.bjpt.2020.04.005
                7252007
                32387005
                © 2020 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier Editora Ltda. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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