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Falls prevention exercise for older people in the UK

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Falls prevention exercise for older people in the UK. Dr Dawn Skelton, ... Skelton & Dinan Physiotherapy Theory & Practice J. 1999. DYNAMIC BALANCE TRAINING ... – PowerPoint PPT presentation

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Title: Falls prevention exercise for older people in the UK


1
Falls prevention exercise for older people in the
UK
Dr Dawn Skelton, Reader in Ageing Health,
Glasgow Caledonian University
2
Falls a major problem in the UK
  • 11 million people aged gt 65 yrs
  • 28,000 women aged gt 90 yrs
  • Fractures costs 1.6 billion pa
  • 1 Hip Fracture every 10 mins
  • Cost 12-15 k
  • 1 Wrist Fracture every 9 mins
  • Cost 480
  • 1 Spine Fracture every 3 mins
  • 500 admitted to Hospital every day
  • 33 never go home

Annual European Home and Leisure Accident
Surveillance Survey (EHLASS) Report UK 2000
3
How common are falls?
  • In gt 75s, falls are the leading cause of death
    resulting from injury
  • 75-80 of falls are not reported
  • 1 in 3 gt65s and 1 in 2 gt80s fall each year
  • 10 of all call-outs for UK Ambulance Service
    are for people aged 65 who have fallen but
    nearly half are not taken to Hospital.

4
When do we become fallers instead of trippers?
Fracture site changes with age, wrist fractures
more common in younger people, hip fractures more
common in older people
5
Changing incidence of fractures with increasing
age
  • 50 to 65 yrs - wrist
  • 55 to 85 yrs - spine
  • 75 to 85 yrs - hip
  • (because of poor reaction, coordination and
    reflexes)

6
Incidence of Fractures Compared with Other
Diseases
1
2
2
3
1. National Osteoporosis Foundation, 2002.
Available at http//www.nof.org. 2. American
Heart Association. Heart Stroke Facts 1999
Statistical Supplement. 3. American Cancer
Society. Breast Cancer Facts Figures 1999-2000.
1-14
7
Cost to the Individual
  • Injuries include
  • Cuts and lacerations,
  • Deep bruises,
  • Soft Tissue Injuries,
  • Dislocations,
  • Sprains
  • Increase in joint pain
  • Less than 5 of all falls result in a fracture
  • Long lies complications
  • Depression, fear of falling
  • Avoidance of activities and social isolation

8
Fear and avoiding activity
  • Present in gt50 of fallers up to 40
    non-fallers
  • Predicts
  • decreases in physical and social activity
  • deterioration in physical functioning
  • higher risk of falling
  • Particularly common in people who cannot get up
    from the floor

9
Exercise to Prevent Falls
  • Exercise could help fallers in a number of ways
  • Reducing Falls (or injurious falls)
  • Reducing known Risk Factors for Falls
  • Reducing Fractures (or changing the site of
    fracture)
  • Increasing Quality of Life Social Activities
  • Reducing Fear
  • Reducing Long Lies
  • Reducing Institutionalisation

10
(No Transcript)
11
Rubenstein Josephson 2002
Causes and risks
Individual risk factors 16 controlled studies
Summary of 12 major studies of fall causes
  • Accident /Environment 31
  • Gait /Balance /Weakness 17
  • Dizziness vertigo 13
  • Drop attacks 9
  • Confusion 5
  • Postural hypotension 3
  • Visual disorder 2
  • Syncope 0.3
  • Other 15
  • Unknown 5
  • Weakness 11/11
  • Balance deficit 9/9
  • Mobility limitation 9/9
  • Gait deficit 8/9
  • Visual deficit 5/9
  • Cognitive impairment 4/8
  • Impaired ADL 5/9
  • Postural hypotension 2/7

12
Fracture Prevention Triangle
FRAGILITY
Exercise can increase BMD and alter bone
properties
Exercise can increase muscle strength (padding)
and improve reaction times
Exercise can reduce falls
FRACTURE
FALLS
FORCE
Adapted from National Institute for Health, USA
1999
13
Not all physical activity is safe for fallers!
  • RCT Increasing physical activity in people with
    previous upper arm fracture
  • Intervention Brisk walking
  • Control exercise of upper arm
  • Falls risk ? (Brisk walking gt control)
  • Fracture risk ? (Brisk walking gt control)
  • Beware unsafe pavements!

Ebrahim et al. (1997)
14
Interventions that cannot be recommended
  • Brisk walking. There is no evidence that brisk
    walking reduces the risk of falling. One trial
    showed that an unsupervised brisk walking
    programme increased the risk of falling in
    postmenopausal women with an upper limb fracture
    in the previous year. However, there may be other
    benefits of brisk walking by older people.
  • (NICE 2004, Cochrane Review 2005)

NICE, 2004
15
Unsupported forward flexion may be unsafe for
those with previous spinal fractures.
  • Type of Exercise Reoccurrence of
    Fracture
  • Back extension 16
  • Flexion (abd. curls) 89
  • Combined 53
  • No exercise 67

Sinaki Mickelson 1982
16
Reviews of Exercise Evidence
  • 1995 Province MA et al. - J Am Med Assoc.
    2731341-1347.
  • 1999 Skelton Dinan Physio Theory
    Practice 15105-120
  • 2000 - Gardner M et al. - Br J Sports Med. 34
    7-17
  • Not to fit and Not too frail
  • 2001 - Skelton D - Age Ageing 30S4 33-39
  • 2002 Skelton Beyer Scand J Med Sports Sci
    131-9
  • 2004 - Chang et al. Brit Med J 328 680-687
  • Multifactorial trials reduce risk (RR 0.82)
  • Exercise only trials reduce risk (RR 0.86)
  • 2006 Whitney Sherrington In Press

17
Is Tai Chi the answer?
  • Tai Chi Evidence is Limited (Verhagen 2004
    Review)
  • Reduces trips and falls
  • In older adults with mild deficits of strength
    and balance (Wolf 1996)
  • In older adults who are inactive (Li 2005)
  • Reduces fear
  • In frail fallers (Sattin 2005)
  • Helps gait
  • In patients with vestibular disorders (McGibbon
    2005)
  • Helps stability and balance
  • In patients with vestibular disorders (McGibbon
    2004)
  • In older people aged 80 (Wolfson 1996)
  • Tai Chi practitioners have similar balance under
    challenging somatosensory conditions as younger
    adults (Wong 2001 Tsang 2004)
  • BUT does NOT reduce risk of falls in frail older
    adults (Wolf 2003)

18
Exercise to reduce falls in particular medical
conditions
  • Parkinsons Disease
  • Protas 2005
  • Stroke
  • Marigold 2005
  • Osteoporosis / Kyphosis
  • Sinaki 2005, Liu-Ambrose 2004 Carter 2002
  • Hospital patients
  • Haines 2007

19
Exercise Specificity to reduce falls
Province, 1995 Group individual balance and
strength training gt65s Wolf, 1996 Group Tai Chi
gt65s (NOT gt70s at risk, Wolf 2003) Campbell,
1997 Home-based exercise gt80s Robertson,
2001 Home-based exercise gt65s and gt80s Day,
2002 Group exercise gt70s at risk Barnett,
2003 Group exercise gt65s at risk Lord,
2003 Group exercise gt60s retirement
village Means, 2003 Group exercise gt65s,
psychosocial effects Skelton, 2005 Group exercise
gt65s frequent fallers Liu-Ambrose, 2004 Group
exercise for gt75s with low bone mass
20
Recommendations
  • Exercise works best within a multi-factorial
    intervention programme
  • Exercise should have components of balance, low
    impact aerobic and strengthening components
  • Safely adapted Tai Chi
  • Targeted home exercise with one to one input
  • Also, co-ordination, reaction, power, gait,
    functional and floor work
  • To be effective the exercise must be specific,
    regular (1-2 p/w), progressive, and exceed 3-6
    months duration

21
  • Map of NZ

22
New Zealand RCTs - OTAGO
Individually tailored programme Campbell, BMJ
1997 -80 years, n233, home-based,
physiotherapist
-ankle, leg and hip strength, balance, gait,
transfers -1 year, falls ? 32, injuries ? 39
Nurse delivered programme at home Robertson, BMJ
2001 -75 years, n 240, home, district
nurse -1 year, falls ? 46, ? serious injuries
and hospital costs
Nurse programme at GP centres Robertson, BMJ
2001 -80 years, n450, general practice nurse -1
year, falls ? 30, injuries ? 28
Visually Impaired Older People Campbell, BMJ
2005 -1 year, Only effective with full
compliance, falls? 28
23
OTAGO Exercise Programme
  • Summary
  • Designed to ? falls by ? strength and balance
  • Effective in ? falls in community dwelling OP
  • Effective when delivered by physiotherapist and
    trained, supervised nurses
  • Most cost effective for 80 years with previous
    falls history

24
Programme Essentials
  • Delivered at home or in groups by a trained OEP
    leader
  • Lower limb muscle strength and balance exercises
    individually tailored from a set programme
  • Frequency - 3 x p/w
  • Intensity - Moderate
  • Duration - 30 mins
  • Progressive
  • Walking (30 mins x 2 p/w)

25
OEP Schedule
  • X 4 home visits in first 2 months
  • Booster visit at 6 months
  • 1 hour first visit, 30 mins subsequent visits
  • Telephone call x 1 p/m between visits
  • Exercises (warm up, strength, balance,
    flexibility, cool down)
  • Walking

26
OEP Exercise Components
  • Warm Up 5 exercises
  • Strength training 5 exercises
  • Balance training (dynamic static) 12
    exercises
  • (Cool down)
  • Walking programme

27
Warm Up Exercises
  • 5 exercises

28
Strength Training Exercises
  • 5 exercises

29
Balance Training Exercises
  • 12 exercises

30
Walking Plan
  • Encourage person to include walking for health
    benefits
  • Walk at usual pace with usual walking aid
  • Progress duration before intensity
  • Start with 10 minutes walk-snacks
  • Progress to 30 mins 2 x p/w

31
OEP Equipment
  • For OEP Participant
  • Stable chair / furniture
  • Ankle cuff weights (1, 2, 3 kg)
  • Activity Booklet
  • Calendar / Diary

32
FaME Managing frequent fallers
  • Women aged 65 with a history of 3 or more falls
    in previous year
  • 9 months community based intervention
  • Group exercise individually tailored, once a
    week
  • Home exercise twice a week, based on Otago
  • Trained exercise instructors
  • Falls risk decreased by half RR 0.46
  • Significantly less people in exercise group had
    died, entered a nursing home or were in hospital
    after 3 years

Skelton et al. Age and Ageing, 2005
33
Training Improvements in Risk Factors - STRENGTH
AND POWER






Skelton et al. J.Aging Phys Act 2004 12 (3)
457-458 Age and Ageing, 2005 34 636-639
34
FaME
FUNCTIONAL ABILITY BONE
Functional Reach 20 Up and go 20 Floor
rise 50 Balance 60
  • Fun and social activity
  • Confidence in balance
  • Reduced anxiety and fear
  • tripping not falling
  • Playing with grandchildren
  • Caring skills

35
FaME exercise programme
  • With evidence based activities such as
  • Dynamic balance training
  • Targeted resistance training for leg and ankle
    strength
  • Targeted bone loading
  • Dynamic endurance training for balance
  • Functional movements
  • Mobility and Flexibility
  • Backward chaining
  • Functional floor activities
  • Adapted Tai Chi cool down
  • Aims
  • Increasing balance
  • Increasing functional capacity
  • Increasing bone and muscle mass
  • Increasing confidence (reducing fear of falling)

Following Frequency, Intensity, Duration and
contraindication guidelines (ACSM etc)
Skelton Dinan Physiotherapy Theory Practice
J. 1999
36
DYNAMIC BALANCE TRAINING
37
DYNAMIC BALANCE TRAINING
38
RESISTANCE TRAINING
Weights, bands and body weight including targeted
bone loading -  for leg ankle strength - 
for wrist, spine hips -  open closed chain
39
RESISTANCE TRAINING
40
DYNAMIC ENDURANCE TRAINING
-  for balance -  for cardiovascular fitness
41
FLEXIBILITY TRAINING
-  for leg ankle strength -  for shoulder,
spine hips
42
BACKWARD CHAINING
Teaching transfer skills
43
FUNCTIONAL FLOOR ACTIVITIES
44
ADAPTED TAI CHI TRAINING
Sustained, three dimensional Tai Chi based cool
down
45
PracticalFaME Programme ( OEP)
  • Flexibility
  • Dynamic Endurance
  • Marching
  • Side tap
  • Side step
  • Double side step
  • Sway
  • Resistance Band Exercises
  • Upper Back Strengthener
  • Leg Press
  • Wrist twist and pull
  • Getting down to and up from the floor
  • Backward Chaining Approach
  • Floor work
  • Functional transitional moves
  • Crawl / Bum walk / Roll
  • Box bone load
  • Box balance
  • Strength
  • Back extension
  • Hip extension
  • Tai Chi

46
Hamstring Flexibility
47
Marching
48
Side tap
49
Side step double side step
50
Sway
51
Upper Back Strengthener
52
Leg Press
53
Wrist Twist Pull
54
Backward Chaining Approach to getting up from and
down to the floor




55
Floor Functional Transitional Moves
56
Box Bone Load



57
Box Balance
58
Back Extension
59
Hip Extension
60
Tai Chi


61
A Continuum of Falls Exercise Provision
REFERRAL
REHABILITATION EDUCATION EXERCISE GROUP
FaME STRENGTH BALANCE EXERCISE GROUP
CHAIR BASED EXERCISE GROUP
OTAGO HOME EXERCISE PROGRAMME
SENIORS EXERCISE
TAI CHI
62
  • Much attention has been given to the need for
    better education of older people ... but it is
    the professionals who are probably in greater
    need of education than the older people.

J. A. Muir Gray Public Health Physician
63
Filling the gap in provision
  • Good practice in Hospital Settings
  • Community Provision lacking for frailer older
    patients
  • Physiotherapist

Postural Stability Instructor
  • Seniors Exercise Instructor

64
Trained Provision
  • Physiotherapist

Postural Stability Instructor
Cardiac Rehab. Instructor
  • Seniors Exercise Instructor

Chair Based Exercise Leader
OEP Str. Balance Leader
Walk Leader
Physical Activity Leader
Senior Peer Activity Motivator
Self Led Activity / Exercise
65
Under-used Referral Pathways
  • Physical Activity Specialist - Encourage and
    motivate
  • Local Government based to be more active in
    daily life
  • - Discuss local opportunities for
    appropriate physical activity
  • Trained seniors instructor - Supervised exercise
    classes Extend, Chair, BACR, PSI, KFA to
    improve strength, mobility YMCA, NF
    Seniors and independence
  • - Targeted and tailored (eg. Falls
    prevention, cardiac rehabilitation,
    pulmonary rehabilitation, stroke
    rehabilitation)
  • Peer Activity Motivator - Encourage and
    accompany

66
Peer mentoring
  • Community Healthy Activities Model Programme for
    Seniors (CHAMPS) (Stewart et al, 1997, 1999,
    2002, 2003, 2005)
  • Those enrolled in CHAMPS twice as likely to take
    part in physical activity
  • Effectiveness based on
  • attention from CHAMPS staff (peer mentors)
  • Belonging to a group
  • Written materials
  • Goal setting / self monitoring
  • Range of activities accessible

67
Senior Peer Activity Motivator Course
  • One day training course to health professionals
    wishing to recruit and train peer mentors

68
Chair Based Leadership Course
  • On National Qualifications Framework (NQF)
  • 5 day training course for peer mentors, nurses
    and other allied health professionals without a
    background of exercise delivery
  • 12 prescribed seated exercises
  • Continuing Professional Development

69
Otago Home Exercise Leader
  • 4 day course
  • Peer mentors, nurses, social care workers/CBE
    leaders etc
  • 17 prescribed exercises standing balance and
    strength
  • Leadership Level NVQ units in Health Care, Level
    3 in Maintaining Independence
  • In conjunction with Campbell Robertson

70
Exercise for the Prevention of Falls Injuries
in Frailer Older People (Postural Stability
Instructor)
  • Evidence based (FaME Otago)
  • Aimed at Physiotherapists, Occupational
    Therapists, and Exercise for the Older Person
    Advanced Instructors
  • 6 days incl. assessment
  • Aligned to Register of Exercise Professionals
  • Aligned to NVQ in exercise (Level 4) Learning
    Through Work Credits
  • University of Derby accredited
  • Nearly 800 qualified PSI instructors - reach some
    5,250 older people each week.

71
Recommendations
  • Exercise works best within a multi-factorial
    intervention programme
  • Exercise should have components of balance, low
    impact aerobic and strengthening components
  • Safely adapted Tai Chi
  • Targeted home exercise with one to one input
  • Also, co-ordination, reaction, power, gait,
    functional and floor work
  • To be effective the exercise must be specific,
    regular (1-2 p/w), progressive, and exceed 3-6
    months duration

72
Thank you for your attention
  • Falls prevention information
  • www.profane.eu.org
  • Training Course Information
  • www.laterlifetraining.co.uk
  • Dawn.skelton_at_gcal.ac.uk
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