PPT presentation - Later Life Training
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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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