exercise to reduce falls risk: the research and application
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Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Professor Keith Hill,
School of Physiotherapy
Keith.Hill@Curtin.edu.au
Exercise to reduce falls risk:
the research and application
Gippsland Workshop: September 2014
Overview
How effective is exercise in reducing falls in older people (focus on people without dementia)
Different options for exercise to reduce falls in older people
Factors to consider in exercise prescription
Addressing barriers to exercise participation
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various forms of exercise◦ balance◦ strength◦ cardiovascular fitness◦ flexibility
specificity of training
other health benefits of exercise programs
strong evidence of effectiveness
of training in older people to improve specific
risk factor
Exercise
COCHRANE REVIEW: Gillespie et al, 2012 (159 trials with 79,193 participants)
What works in falls prevention for older people in the community setting
There is good research (at least one randomised trial) evidence that a number of single interventions can reduce falls / injuries:
exercise (home exercise; tai chi, group exercise) cataract extraction / change multifocal glasses to 2 sets of glasses psychotropic medication withdrawal / medication review home visits by Occupational Therapists improved post hospital discharge follow-up approaches to support client uptake in recommended interventions vitamin D and calcium supplementation (in low vit D cases) cardiac pacemaker for carotid sinus hypersensitivity foot exercise, footwear and orthoses
multiple interventions based on a falls risk assessment have also been shown to be effective (including in high falls risk groups, eg older fallers presenting to ED)
Randomly selected sample (>5,000 participants, 61% response rate)
Participation in falls prevention exercise by older Australians
Merom et al, Prev Med, 2012; 55:613-7
Evidence of what works in exercise in falls prevention
Group exercise programs
Home exercise programs (often prescribed by a physiotherapist
Tai Chi- (note: different types of Tai Chi may have different effects)
Foot and ankle exercise as part of podiatric multi-faceted program (Spink et al, 2011)
Cochrane review: Gillespie et al 2012 (159 trials with 79,193 participants)
Exercise and falls prevention: what we know…
7Sherrington et al 2011
54 RCTs (all settings, though most in community)
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Exercise interventions
Sample with disabling foot pain and increased falls risk
Intervention=foot & ankle exercise, footwear subsidy, and orthoses provision
Intervention group had 36% fewer falls, p<0.05
Spink M et al,, .BMJ. 2011 Jun 16;342:
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Exercise interventions
At risk sample – falls or injurious fall in past 12/12
Intervention=Lifestyle Integrated Functional Exercise
Compared LiFE program vs structured exercise program vs control
31% reduction in falls (LiFE vs control, p<0.05)
Clemson L,, et al .BMJ. 2012 Aug 7;345:e4547
Exercise parks for older people
Exercise parks for older people (Finland: Lappset)
recently commenced study at Victoria University
http://www.lappset.com/global/en/Pro_Play/The_Elderly_.iw3
Appropriate exercise prescription - Horses for courses
Very frail/High falls risk
Healthy older people
CONTINUUM OF BALANCE IMPAIRMENT
Tai chi for arthritis – Sun style 24 form Beijing style – Yang style
Otago Exercise Program “Otago Plus” – incl VHI kit
Supervised exercise or home exercise - issues to consider?
Safety concerns
Frail / high falls risk
Limited self - discipline
Impaired memory (potential role of carer)
Balance exercise
cannot include hand support
needs to target balance deficits
safety (boxed in) functional vs non
functional dynamic in
preference to static
for balance exercises to be effective, they need to challenge the balance system safely
Classification from Merom et al, Prev Med, 2012
Framework for modulating task difficulty
Low levelof challenge
High levelof challenge
DYNAMIC TASKS
STATIC TASKS
Single task
Dual / multiple task
Closed environment
Openenvironment
No sensorymanipulation
Sensory manipulation
Lack of visual fixation
Visual fixationWide
BOS
Narrow Base ofSupport (BOS)
Bernhardt & Hill – 2005
Important components of exercise
goal oriented
safety
intermittent reappraisal of performance / feedback
regular practice / repetition
functional context
fun / enjoyable / social
Principles of exercise prescription for older people with increased falls risk
Based on
◦ assessment findings (eg functional tests)
◦ circumstances of falls
◦ patient interests and activities
Observe performance of selected exercise for safety and accurate performance
Written instructions and contact number
Start off with low dosage and intensity relevant to assessment findings
Encourage fitting into daily routine
Intermittent review and modification as required
12 week weight bearing (home based) exercise program (3 times / week) vs seated resistance exercise vs social visit
Loss of up to 50% of balance gains in the subsequent 12 weeks after ceasing exercise
Evidence of detraining when an exercise program is stopped
Vogler et al, 2012, Arch Phys Med Rehabil; 93: 1685-91
Adherence in falls prevention interventions
Reviewed 99 randomised trial in 2009 Cochrane review (falls prevention in the community)
Adherence rates (n = 69) were:◦ ≥80% for vitamin D/calcium supplementation; ◦ ≥70% for walking and class-based exercise; ◦ 52% for individually targeted exercise; ◦ approximately 60-70% for fluid/nutrition therapy and
interventions to increase knowledge; ◦ 58-59% for home modifications; ◦ Adherence to multifactorial interventions was generally
≥75% but ranged 28-95% for individual components. Home-exercises on average 11 times per month
(Nyman and Victor, Age and Ageing, 2012)
CONCLUSIONS: Using median rates for recruitment (70%), attrition (10%) and adherence (80%), we estimate that, at 12 months, on average half of community-dwelling older
people are likely to be adhering to falls prevention interventions in clinical trials.
Barriers to exercise for older people
chronic conditions (eg arthritis)◦ perception that exercise will aggravate pain
access (cost / transport) no-one to exercise with perception that exercise is not
appropriate / beneficial for older people lack of awareness of
◦ benefits◦ available options (locally)
Hill and Murray, 2004. Physical activity & falls prevention (chapter in book edited by Morris and Schoo)
Anne-Marie Hill et al, 2011, The Gerontologist
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Summary
Generally low exercise participation levels in older people - need for approaches to improve participation
Exercise approaches can achieve positive fall related outcomes for older people, across the falls risk / frailty continuum
Strong research evidence that falls can be reduced through exercise interventions, especially those with a balance component those with >50 hours dosage
Most research has excluded people with dementia
Need to consider balance ability, safety and patient preference
Major issue of uptake and longer term adherence
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