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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)

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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:

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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