Dr Dawn Skelton Workshop on Strength and Balance Training in Older People to Prevent Falls

New Zealand RCTs - OTAGO Individually tailored programme: Campbell, BMJ 1997 -80+ years, n=233, home-based, physiotherapist -ankle, leg and hip strength, balance, gait, transfers -1 year, falls  32%, injuries  39% Nurse delivered programme at home: Robertson, BMJ 2001 -75+ years, n= 240, home, district nurse -1 year, falls  46%,  serious injuries and hospital costs Physiological studies: Exercise shown to increase muscle strength and improve balance thus provide rational for using it to attempt tp reduce falls. FICSIT metan.(5comm, 2 Nh)-Province 1999,2-4 yrs, dif progs,subjects assigned to an x gp less likely to fall. No x component sig for injurious falls Cochrane review 1997- incons. Data. x alone did not protect against falls Tai Chi: (Atlanta FICSIT): 48% reduction (adjusted for fall risk factors) cf computerised balance training programme(interestingly only controlgp improved balanced showing importance of fall as primary measure (Mcmurdo) Campbell 1997: -cognitively intact, able to move around house - 4 1 hr visits over 2 months- individ 30 min progrm of strengthening exercises using ankle weights and balance training exercises included standing with one foot directlt in front of the other, walking tandem, heel walking, toe walking, knee squats. 3+ times a week and also walk outside home at least 3 times a week. -also relative hazard for injurious falls reduced and balance scores improved Campbell 1999 Age Ageing: rate of falls remained sig lower in the ex group than control gp at 2 years in those who continued the programme. Robertson; Nurse home: serious injuries and hosp admissions reduced. -cost /fall (1988 prices) Pv = NZ$1803 (£523) IRR = Inc rate ratio -cost / fall averted considering hospital costs NZ$155 (£45) Robertson: nurse. GP centres: no diff in serious injuries or hosp. Costs -cost/ fall averted : NZ$1519 (£441) Ebrahims 97, AgeAgeing brisk walking gp: falls up, therefore x is not x is not x. Qualified x practitioners-graded strengthening+ walking program Nurse programme at GP centres: Robertson, BMJ 2001 -80+ years, n=450, general practice nurse -1 year, falls  30%, injuries  28% Visually Impaired Older People: Campbell, BMJ 2005 -1 year, Only effective with full compliance, falls 28%

OTAGO Exercise Programme Summary Designed to ↓ falls by ↑ strength and balance Effective in ↓ falls in community dwelling OP Effective when delivered by physiotherapist and trained, supervised nurses Most effective for 80+ years with previous falls history Only effective with good compliance in OP with visual impairment

Programme Essentials Delivered at home or in groups by a trained OEP leader Lower limb muscle strength and balance exercises individually tailored from a set programme Frequency - 3 x p/w Intensity - Moderate Duration - 30 mins Progressive + Walking (30 mins x 2 p/w)

OEP Schedule X 4 home visits in first 2 months Booster visit at 6 months 1 hour first visit, 30 mins subsequent visits Telephone call x 1 p/m between visits Exercises (warm up, strength, balance, flexibility, cool down) Walking

OEP Schedule 1 2 3 4 5 6 …… 12 8   Month Week Home Exercise Visits Telephone follow up 

OEP Exercise Components Warm Up – 5 exercises Strength training – 5 exercises Balance training (dynamic & static) – 12 exercises (Cool down) Walking programme

Daily walking Plus 3 x per week home exercise programme Exercises do not have to be done in any set order or all at the same time

Head Movements (Repeat 5 times)

Neck Movements (Repeat 5 times)

Back Extension (Repeat 5 times)

Trunk Movements (Repeat 5 times)

Ankle Movements (Sit or stand Repeat 10 times)

Front Knee Strengthening Exercise (Repeat 10 times) Ankle cuffs increase in weight from 0.5 to 5kg over the year

Back Knee Strengthening Exercise (Repeat 10 times) Ankle cuffs increase in weight from 0.5 to 5kg over the year

Side Hip Strengthening Exercise (Repeat 10 times) Ankle cuffs increase in weight from 0.5 to 5kg over the year

Calf (Heel) Raises (with support) (Lift x 20)

Calf Raises (no support) (Lift x 20) PROGRESSION Calf Raises (no support) (Lift x 20)

Toe Raises (with support) (Lift x 20)

Toe Raises (no support) (Lift x 20) PROGRESSION Toe Raises (no support) (Lift x 20)

Knee Bends (with support) (Repeat 10 times)

Knee Bends (no support) (Repeat 10 times) PROGRESSION Knee Bends (no support) (Repeat 10 times)

Backwards Walking (with support) (10 steps x 2) Preparation – Forwards walking with and without support

Backwards Walking (no support) (10 steps x 2) PROGRESSION Backwards Walking (no support) (10 steps x 2)

Walking and Turning Around (figure of 8 x 2) Preparation – with chair support

Sideways walking (10 steps x 2) Preparation – with chair support

Heel Toe Standing (with support) (10 secs)

Heel Toe Standing (no support) (10 secs) PROGRESSION Heel Toe Standing (no support) (10 secs)

Heel Toe Walking (with support) (10 steps x 2)

Heel Toe Walking (no support) (10 steps x 2) PROGRESSION Heel Toe Walking (no support) (10 steps x 2)

One Legged Stand (with support) (10 secs)

One Legged Stand (no support) (10 secs) PROGRESSION One Legged Stand (no support) (10 secs)

Heel walking (with support) (10 steps x 2) Preparation – toe walking

Heel walking (no support) (10 steps x 2) PROGRESSION Heel walking (no support) (10 steps x 2)

Toe walking (with support) (10 steps x 2)

Toe walking (no support) (10 steps x 2) PROGRESSION Toe walking (no support) (10 steps x 2)

Heel Toe Backward Walking (no support) (10 steps x 2) Preparation – heel toe forward walking with and without support and heel toe backward walking with support

Sit to stand (two hands) (Repeat 10 times) PROGRESSION Sit to stand (two hands) (Repeat 10 times)

Sit to stand (one hand) (Repeat 10 times) PROGRESSION Sit to stand (one hand) (Repeat 10 times)

Sit to stand (no hands) (Repeat 10 times) Preparation – hands on knees PROGRESSION Sit to stand (no hands) (Repeat 10 times) Preparation – hands on knees

Stair walking (Up and down steps)