Exercise to reduce falls Fiona Boddy Highly Specialist Physiotherapist 5th June 2018

Plan Introduction Exercise and physical activity Falls prevention exercises Group activity – exercise and activity in the care home Feedback – 2 actions to take back and implement in your care homes Exercise session

Exercise and physical activity Recommended for people living in the community - 30 minutes moderate level exercise on at least 5 days per week (DoH, 2004). Older people can experience improvements with low intensity activities. Effects of exercise – improve health and wellbeing (NICE, 2008) Physical fitness can be regained in all age groups. Strength has been found to improve with appropriate exercise in 90+ year olds (Fiatarone et al, 1993) and in people with dementia (Thomas & Hageman, 2003) Effects of exercise are greatest in the most frail group of people (Hubbard et al, 2009) Physical activity, particularly resistance exercise, is beneficial in terms of preventing and treating frailty (BGS, 2012) Same for people in care settings but may need to start at low intensity.

Exercise v. physical activity Exercise is physical activity that is planned, structured, and repetitive for the purpose of conditioning any part of the body. Exercise is used to improve health, maintain fitness and is important as a means of physical rehabilitation. Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure. Physical inactivity has been identified as the fourth leading risk factor for global mortality

Effects of exercise

Effects of exercise Increase heart rate Increase heart and lung function Increase circulation Increase flexibility Increase strength Improve posture Improve co-ordination Reduce pain Reduce stiffness Increase bone strength Improve balance Reduce falls Improve reaction time Maintain body weight Improve wellbeing Increase self esteem Improve concentration Improve sleep Reduce stress Reduce depression Increase confidence

Fitness Endurance – ability of the heart and blood vessels to supply oxygen to the muscles for a long period of time Muscular strength – how much force a muscle can exert Muscle endurance – ability of a muscle to work for a period of time Flexibility – how far a joint can move Speed – how quickly a movement occurs Reaction time – how long it takes the body to start to move Balance – ability of the body to maintain an upright position Co-ordination – ability of the body to manage complex movements (arms and legs/left and right side of body moving together)

Improving fitness Improving endurance – 5 x 30 minutes per week Increasing strength – 2 or 3 x 20 minutes per week. Resisted exercise is most effective. Rest days are needed between sessions. Increasing muscle endurance – need strength first, then 5 x 30 mins. per week Improving flexibility – 10 minutes per day

What can different types of exercise do? Weight bearing and resisted exercise can help to maintain bone density Moving joints as far as possible can maintain and improve flexibility and reduce pain Resisted exercise (using weights, Theraband or gravity) can increase muscle strength Exercise that raises the heart rate can improve heart function Standing and walking exercise can improve balance and co-ordination Active games can help balance, reaction times and co-ordination Ask attendees to tell me: Example of a weight bearing exercise etc…..

Ideas for exercises for care home residents Endurance Muscular strength Muscle endurance Flexibility Speed Reaction time Balance Co-ordination

Falls – strength Strength decreases with age: 1% per year after 40 years old Muscles of the lower limbs tend to become weaker than the upper limbs Muscles around the hips and knees contribute to walking and transfers; muscles in the ankles contribute to balance recovery Leg muscle weakness increases the risk of falling fourfold Strength further decreases due to disuse

Falls - balance Balance depends on: sensory information (vision, proprioception/somatosensory, and vestibular), central nervous system and muscles No individual system provides us with all the information we need to balance Balance is affected by ageing: Reduced muscle strength Slower reaction times Reduced endurance Reduced vision Less efficient anticipatory adjustments Reduced dual task performance Reduced vestibular activity vision creates a spatial map of our environment ; helps to detect speed of movement ; the direction of movement ; locating hazards vision becomes progressively worse after the age of 50 years ; of course there will be also underlying pathology as people aged. depth perception; spatial relationship and contrast sensitivity loss Subjects with good vision in both eyes had the lowest rate of falls well those with good vision in only one eye and moderate or poor vision in the other have elevated falling rate. hence asymmetrical vision increases the rate of falls.   vestibular sense  The vestibular system detects position and motion of the head and this information contributes to balance. there are studies that shows that eight of ten adult fallers have vestibular impairment. older people with just vestibular hypofunction often have obvious impairments in posture and gait. The gait is described as broad and staggering on head turns and unsteady turns. with long-term total vestibular loss the gait may appear normal and deficits are only apparent when visual and/or peripheral sensation are impaired or unavailable. this simply suggest that the central nervous system can adapt by using visual and somatosensory input to sensory input to compensate for the absence of the vestibular input. in order to have someone to fall you need 2 sensory balance organs to defect. Somatosensory. sensory information from the receptors in the muscles tendons and joint provide feedback regarding telling position sense and movement and touch the input from the lower limbs is arguably the most important contributors to standing balance. Proprioception has the lower threshold compared to visual and vestibular threshold. foot has 31 joints- has the highest concentration of mechano receptors. the mechano receptors are in low threshold so its easy to stimulate. also there is an evidence that tactile/plantar sensitivity has connection with balance and test performance. age related changes on these somatosensory and proprioceptive structures. peripheral nerve damage occurs in up to 25% of people with diabetes after 10 years being diagnosed with the disease and up to 50% of people after 20 years disease duration. damage of mechanoreceptors on people with arthritis, cervical spondylosis. proprioception is more accurate during weight bearing due to increase in receptor activation. hence mote falls when limb is free or partial weight bearing resulting to trips. also as we age, the threshold to activate in the ankle joint also increases while weight bearing.

Falls prevention exercises Strengthening Lower limb muscles Upper limb muscles Trunk muscles Balance Vision/somatosensory and vestibular challenges Ankle and hip strategy Motor exercises Exercise intervention have been shown to be successful It is the balance training that has shown to impact significantly on fall rates! Specificity- Specific exercise elicits physiological adaptations. For example: walking does improve endurance but not balance. Progressive overload - “little longer or harder than the individual is used to”; to maintain benefit it has to be progressive. The rate of progression depends on individual health and disability status, fitness, response to exercise training, motivation, compliance and age. Graded seated, supported and standing options should be offered. Rest and recovery- adequate r&r enhances the training stimulus, improves performance, long-term commitment and prevents overuse injuries and fatigue related events, such as falls. Individual difference- Consider tailored approach that will assist the individual with adherence, pre-exercise and ongoing assessment, even I n group environemnt The degree of hip strength is an important indicator of physical function in older people and correlates with TUAG and walking speed outcome measures (Woods et al, 2011). Building muscle mass may provide soft-tissue ‘padding’ during falls, but also contributes to pelvic stability during the gait cycle. Hip abductor strength is important for side-stepping when negotiating obstacles or crowds, and for getting out of bed / bath / car. Hamstring strength is necessary for stabilising the hip and knee joints during standing and gait, and acts as a decelerator in the swing-through phase to prepare for the stance phase. For older adults who are chair bound, exercise should be progressive that needs to work towards standing! Low intensity should be encouraged to begin with for most sedentary individuals but needs to work towards moderate intensity as it yields better risk: benefit ratio for older adults.   Otago A tailored exercise programme can reduce the risk as much as 54% Older adults tends to walk with slower velocity, shorter step length, wider step width, and increased double support time it is not clear whether these changes are due to physical limitations or an adaptive strategy for improved safety but what I am sure this are gait patterns are more common in fallers compared to non fallers; ROM – most faller: hamstrings and ankle plantarflexors: risk for tripping

Group activity What physical activity do residents routinely undertake in your care home? Who encourages them? How often? Who gives any assistance that is required? Physical activity Exercise What exercise do residents currently undertake in your care home? Who is it organised by? How often? What is the purpose of the exercise?

Feedback 2 actions you would like to take back to your care home Exercise Falls prevention Physical activity

Falls prevention exercises Strengthening exercises Theraband Weights Body weight Balance exercises Position of reduced stability Standing – feet apart; feet together; one leg Rapid changes of position Reduced sensory input Eyes closed Standing on foam

Any questions?

Let’s exercise!

References Department of Health (2004) At Least Five A Week. National Institute for Health and Clinical Excellence. (2008). Occupational therapy interventions and physical activity interventions to promote the mental wellbeing of older people in primary care and residential care. Fiatarone et al (1993) The Boston FICSIT study: the effects of resistance training and nutritional supplements on physical frailty in the oldest old. Journal of the American Geriatrics Society. 41, 333- 337. Hubbard, Fallah, Searle, Mitnitski & Rockwood (2009) Impact of exercise in community dwelling older adults. PLoS One, 4(7), e6174 Thomas & Hageman (2003) Can neuromuscular strength and function in people with dementia be rehabilitated using resistance- exercise training? Results from a preliminary intervention study. The Journals of Gerontology, 58A (8), 746-751 National Institute for Health and Clinical Excellence. (2013) Falls in older people: assessing risk and prevention