PPT presentation - Later Life Training

January 5, 2018 | Author: Anonymous | Category: Science, Health Science, Nursing
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The Role of Exercise in Falls Prevention Dr Dawn Skelton PhD Reader in Ageing and Health, HealthQWest, Glasgow Caledonian University Co-ordinator of Prevention of Falls Network Europe, University of Manchester

Falls in the UK  

 

11 million people aged > 65 yrs 28,000 women aged > 90 yrs Fractures costs £1.8 billion 1 Hip Fracture every 10 mins – Cost £12-15K



1 Wrist Fracture every 9 mins – Cost £500



 

Changing site of fracture >age 500 admitted to Hospital every day 33 never go home

Bandolier and Annual European Home and Leisure Accident Surveillance Survey (EHLASS) Report UK 2000

Studies assessing fall risk factors per se: [Rubenstein & Josephson 2002]

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%

Individual risk factors: 16 controlled studies   

    

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

Time – Disease - Disuse EVEN HEALTHY OLDER PEOPLE LOSE...   

   



Strength Power Bone density Balance Stamina Flexibility Cognitive Function Maintenance of temperature control

Sedentary behaviour increases the loss of performance...

International Consensus 

World Health Organisation, 1996

“regular physical activity helps to preserve independent living” and “postpone the age associated declines in balance and co-ordination that are major risk factors for falls” 

Surgeon General, USA, 1997 “Sedentariness is a major public health issue”

We are all trippers….but when do we become fallers? 

Community Dwelling >65 years



Compared to non-fallers, fallers have

– ⇩ quadriceps and hamstring strength (NS) – ⇩ ankle plantarflexion, dorsiflexion, inversion and eversion strength

– ⇩ lower limb explosive power – ⇧ asymmetry between limbs in power and strength Skelton, Kennedy, Rutherford Age Ageing 2002

Fear and avoidance of activity 



Present in >50% 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

Lessons that last a lifetime

Sensory Input  Stability Three main sources of input 

Visual information



Vestibular information



Proprioceptive information

Falls Prevention Approaches 

Individual Approach (high risk patients)

– Multi-factorial (ie. Falls Clinics) Unclear evidence – Uni-factorial (ie. Exercise) Good evidence BUT…



Population based approach (targeting communities)

– Emerging evidence, Relative reduction in fallrelated injuries 6 to 33% – Most include increasing awareness and physical activity, medication and home hazard reviews

Reviews of Exercise Evidence 

1995 – Province MA et al. - J Am Med Assoc. 273:1341-1347.



1999 – Skelton & Dinan – Physio: Theory & Practice 15:105-120



2000 - Gardner M et al. - Br J Sports Med. 34: 7-17



2001 - Skelton D - Age Ageing 30;S4: 33-39



2002 – Skelton & Beyer – Scand J Med Sports Sci 13:1-9



2004 - Chang et al. – Brit Med J 328: 680-687

– Multifactorial interventions reduce risk (RR 0.82) – Exercise only interventions reduce risk (RR 0.86)

Know what to avoid… 

Intervention: Brisk walking



Control: exercise of upper arm



Falls risk (Brisk walking > control)



Beware uneven pavements!

Ebrahim et al. (1997)

Care and encouragement 

   

Type of Exercise

Back extension Flexion (abd. curls) Combined No exercise

Sinaki 1987

Reoccurrence of Vertebral Fracture 16% 89% 53% 67%

‘Pitfalls’ of interventions that don’t work 

Insufficient duration



Insufficient intensity



Insufficient tailoring or specificity of training



Insufficient progression



Not enough time on feet!

Balance Principles 





 

 

Changes of direction, pace and level, head position, weight (transference) Sustained, controlled 3D moves

Progressively challenging tasks to improve gaze stabilisation Obstacle courses Floor work: balances, crawling, rolling, shuffling in seated position Ball games Breakdown all moves into 'steps' or stages

Interventions that work…….. Province, 1995

Group and individual balance and strength training >65’s

Wolf, 1996

Group Tai Chi >65’s (NOT >70’s at risk, Wolf 2003)

Campbell, 1997

Home-based exercise >80’s (OEP)

Robertson, 2001

Home-based exercise >65’s and >80’s (OEP)

Day, 2002

Group exercise >70’s at risk

Barnett, 2003

Group exercise >65’s at risk

Lord, 2003

Group exercise >60’s retirement village

Skelton, 2005, 2008

Group Exercise >65’s frequent fallers (FaME or PSI)

Tai Chi – prevention of

st 1

fall?

- Community Dwelling older people with mild deficits of strength/balance, 2x/week for 15 weeks Wolf et al. (1996) – Cut trip and fall rate by half - Frail older adults aged 70-97, 2 x/week for 48 weeks - no significant reduction in risk of falls Wolf et al. J Am Geriat Soc 2003; 55: 1693-1701

- Community Dwelling older people aged 70+ - 3 x/week for 24 weeks - Increased Falls Self-Efficacy and Decreased Fear of Falling Li et al. J Gerontol B Psychol Sci Soc Sci 2005; 60:P34-40

Campbell et al, BMJ, 1997 Robertson et al, BMJ, 2001

Effective Home Exercise (OEP) Community Dwelling >80 year old women 1 Year duration - Physiotherapist support home-based tailored progressive strength, balance and gait training (3x p/w)

20-30% reduction in risk Campbell J et al., BMJ, 1997

Then - Physiotherapist led nurse training –For over 65’s – cost effective –For over 80’s – saves money Robertson C et al., BMJ, 2001

Then – with Visually Impaired Older People - Not effective unless fully compliant

Campbell J et al., BMJ, 2005

FaME – Group Exercise (PSI) Aims to:

With evidence based activities:

• Increase balance

• Increase functional

capacity • Increase bone / muscle

mass

    

• Increase confidence (reduce fear of falling)

  

Dynamic balance training Targeted resistance training Targeted bone loading Functional movements Dynamic endurance training for balance Backward chaining Functional floor activities Adapted Tai Chi cool down

Following Frequency, Intensity, Duration and contraindication guidelines (ACSM)

DYNAMIC BALANCE TRAINING

DYNAMIC BALANCE TRAINING

Teaching Floor Skills Teaching transfer skills

FaME – managing frequent fallers 

RCT - Women aged 65+ with a history of 3 or more falls in previous year



Exercise-only intervention – 9 months



Group exercise – individually tailored, 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. 2005

STRENGTH / POWER / ASYMMETRY FaME Significant isometric and isokinetic improvements in the exercise group:

• Ankle Plantarflexion

60%

• Ankle Dorsiflexion

40%

• Ankle Inversion

25%

• Ankle Eversion

30%

• Hip Flexion

20%

• Lower Limb Power

25%

• Asymmetry reduced

15%

FaME – Bone improvements

Significant difference with time and group for L2-L4 spine and Wards Triangle (F=3.46, p
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