backward chaining approaches to gain skills to get down and up … slide decks... · 2019. 10....
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Backward Chaining Approaches to gain skills to get down and up from floor, avoid long lies, reduce fear, and enjoy a bath again!
October 8, 2019 12:00 PM EST
Dawn Skelton & Bex Townley
THIS WEBINAR IS BEING RECORDED.THE SLIDE DECK AND RECORDING WILL BE
EMAILED AFTER THE WEBINAR.
STAY IN THE LOOP!WWW.FALLSLOOP.COM
WWW.JR.FALLSLOOP.COM
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Backward Chaining Approaches to gain skills to get down and up from floor, avoid long lies, reduce fear, and enjoy a bath again!
October 8, 2019 12:00 PM EST
Dawn Skelton & Bex Townley
THIS WEBINAR IS BEING RECORDED.THE SLIDE DECK AND RECORDING WILL BE
EMAILED AFTER THE WEBINAR.
STAY IN THE LOOP!WWW.FALLSLOOP.COM
WWW.JR.FALLSLOOP.COM
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Backward Training Approaches to gain skills to get down and up from floor
(avoid long lies, reduce fear, & enjoy a bath again!)
Dawn Skelton1,2 & Bex Townley2
1Glasgow Caledonian University 2Later Life Training
United Kingdom
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@LaterLifeTrain
POLL 1 – What is your background?Please choose an option which best fits your experience/expertise
• Physiotherapist
• Occupational Therapist
• Rehabilitation Assistant
• Nurse
• Exercise Instructor
• Clinician/Medic/Doctor
• Other
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@LaterLifeTrain
POLL 2 – What setting do you work in?Please choose an option which best fits your work setting
• Acute Hospital setting
• Rehabilitation/Day Hospital setting
• Care home/Residential Care
• Care at home Service
• Community Setting
• Other
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@LaterLifeTrain
Why is the ability to get up from the floor after a fall so important?• More than an hour on the floor leads to poor outcomes1
• Increased risk of hospitalization
• Poor recovery of physical function
• Increased possibility of admission into residential care facilities
• Death
• Use of ambulance services to ‘pick people up’ but not take them to hospital
• 40% of older people who fall are not transported to Hospital (UK)2
• Cost £75.5 mill in UK in 2012 and projected to rise to £118.9 mill by 20303
• 30% of older recipients of community care services in Australia4
• Increased fear of falling and ‘post fall syndrome’5
1Fleming & Brayne. BMJ 2008;337:a2227; 2Darnell et al. Emerg Med J 2012;29(12):1009-
10.3Burton et al. Disabil Rehab 2018; Dec 4:1-11. doi: 10.1080/09638288.2018; 4Burton & Lewin. JAGS 2016;64:217-218; 5Murphy & Isaacs. Gerontology 1982;28(4):265-70.
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@LaterLifeTrain
History – Backward Chaining
• Simpson & Salkin (1993) - 11% of physiotherapists
taught older adults to rise from the floor
• Simpson & Mandelstam (1995) - 19% of potential
fallers were capable of being taught to rise
• Before Janet Simpson changed practice the method
of teaching was NOT backward chaining! The
method was to lower the person to the ground and
then ask them to rise
• For over 20 years the Backward Chaining approach
has been part of usual physiotherapy practice
(But is it?…)
Simpson & Salkin. Age Ageing 1993 Jul;22(4):294-6;
Simpson & Mandelstram. Clin Rehab 1995;9:65-69
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@LaterLifeTrain
Getting up off the floor?
• Fleming & Brayne (2008) – in over 90s, 80% cannot rise after a fall and 30% lay there for an hour or more (long lie)
• Inability to rise associated with increased age, reported mobility and sever cognitive impairment
• Poor cognition predicted long lies
• Long lies associated with admission to hospital and subsequent moves into residential care
• Call alarms widely available but rarely used
• Schwickert et al. (2016) - slower time to rise (60 yrs+) was associated with
• lower leg extension power
• poor knee and hip flexibility
Fleming & Brayne. BMJ 2008;337:a2227; Schwickert et
al. Aging Clin Exp Res. 2016 Apr;28(2):277-87
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@LaterLifeTrain
Getting up off the floor?
• Tinetti, Liu & Claus (1993) – 47% of non-injured fallers could not get up after a fall (older and with poorer balance)
• Ardali et al. (2018) investigated peoples self reported ability against actual ability (independent or with chair for balance)
• 90% correctly identified their own ability to perform a floor transfer
• Ardali et al. (2019) compared self reported ability (independent, assisted and dependent) with the Floor Transfer (FT) test, the Physical Functioning Scale and the Short Physical Performance Battery (SPPB)
• Predictors of inability to rise included - advanced age, help needed during ADL, frequent faller, needed 2 handed assistive devices for walking, housebound
• Recommended using a backward chaining approach to training
Tinetti et al. JAMA 1993 Jan 6;269(1):65-70; Ardali et al. J Geriatr Phys Ther. 2018 Apr 6 and 2019;42(3):136-147.
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@LaterLifeTrain
Floor rise and future falls
• Bergland & Laake (2005) - ability and timed floor rise is an independent risk factor for serious fall related injury (OR 2.1)
• Those with arthrosis of the hip and difficulty walking indoors most likely unable to rise
• 1 in 3 women unable to rise predicted to have a serious fall related injury in the next 12 months
Bergland & Laake. Aging Clin Exp Res. 2005 Jun;17(3):181-5
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@LaterLifeTrain
UK Context
• Chartered Society of Physiotherapists (UK) (2012)
https://bit.ly/2Qfbv6w
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UK Context
• National Institute of Clinical Excellence (2013): Clinical Guideline CG161
• Information for the Public (Questions to ask your healthcare team)
https://bit.ly/2lXZF68
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@LaterLifeTrain
UK Context
• Chartered Society of Physiotherapists (UK) (2019)
8. Goodwin VA, Briggs, L. Guidelines for the Physiotherapy
management of older people at risk of falling London: AGILE; 2012.
https://bit.ly/2Qfbv6w
9. Burton et al. Disabil Rehabil 2018:1-11. https://bit.ly/2w91u1x
https://bit.ly/2lWaENm
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@LaterLifeTrain
Getting up off the floor
• Skelton et al. (1995/1996) – floor rise ability does not improve with pure strength training but does with functional exercise including backward chaining
• Hofmeyer et al. (2002) - delivered training to improve floor rise ability (6 sessions over 2 weeks)
• Improved floor-rise ability and perceived difficulty and symptoms associated with the rise
• Reece & Simpson (1996) - compared the ‘conventional method’ to the ‘new’
Backward Chaining method
• Patients were very fearful of the conventional approach and Simpsons research showed
many refused to try.
• Experiment had to be discontinued as it was unacceptable to proceed
• Zak (2006) – compared the “conventional” method (rolling on to four point kneel, moving to kneel standing, then standing), or the backwards chaining approach (more effective)
Skelton et al. JAGS 1995 Oct;43(10):1081-7; Skelton & McLaughlin. Physiotherapy
1996;82(3):159-167; Hofmeyer et al. JAGS 2002;50(10):1702-6; Reece & Simpson.
Physiotherapy 1996; 82:227-235; Zak. Adv Rehab. 2006;2:11–17.
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@LaterLifeTrain
Getting up off the floor
• Can interventions improve ability to rise from the floor?
• Mixed methods systematic review – 41 studies
• Meta-analysis sub group including upper and lower limb resistance training showed improvement in ability to rise from the floor
• Other results were also promising for intervention approaches focusing on training the task of getting up from the floor
Burton et al. Disabil Rehab 2018; Dec 4:1-11. doi: 10.1080/09638288.2018.
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@LaterLifeTrain
Rationale for inclusion in falls prevention exercise (FaME)
• Avoid long lies
• Improve confidence and reduce fear
• Improve functional ability around and outside the home
• Key component of physiotherapy guidelines
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FaME – The Evidence Base• RCTs in frequent falling women >60/65yrs1,2,3
• RCT in sedentary >65s from GP practices4
• Feasibility in visual impairment5
• Evaluations in practice6 and Implementation Study >65s self/GP referral7
• Reduces falls rate and falls risk
• Increases habitual physical activity (105-170 mins/wk)
• Improves physical function and confidence
• Reduces fear of falling
• Regains the skill to get up from the floor
• Cost effective if delivered with fidelity8,9
1 Skelton et al. Age Ageing 2005; 2 Skelton et al. JFSF 2019; 3 Yeung et al. PHCR&D 2015; 4 Iliffe et al. HTA
2014; 5 Adams et al. BMC Geriat 2019; 6 Hedley et al. PTP 2010;7 Carpenter et al. Inj Prev 2018; 8 Public Health
England, 2017/8; 9 Gateshead OP Assembly, 2017
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But in practice….
• PhISICAL Study looked at implementation of FaME in practice
• Fidelity in the real world – 72-78% • Including lack of confidence to deliver
floorwork
• Barriers?• No hoists available
• Dirty floors
• No time in session
• Not all in a group are ready for it
• Group too big
• What if they can’t get up?
@LaterLifeTrainhttps://bit.ly/2IctFn3
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@LaterLifeTrain
POLL 3 – Current Practice?
• Do you routinely ASK if older people who have fallen can get back up off the floor?
• Yes
• No
• Not applicable in my job role
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@LaterLifeTrain
Comparison with UK
Physiotherapists only
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@LaterLifeTrain
POLL 4 – Current Practice?
• Do you routinely TEACH older people to get up from the floor if they have fallen?
• Yes
• No
• Sometimes
• Not applicable in my job role
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@LaterLifeTrain
Comparison with UK
Physiotherapists only
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@LaterLifeTrain
So what does backward chaining look like?
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@LaterLifeTrain
Getting down and up from the floor - link by link analysis
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@LaterLifeTrain
Lets get practical
Make a space and join in, it’s helpful to ‘feel’ these body positions and the requirements for mobility, flexibility, power and strength.
In this session we will analyse;
-Full movement sequence of BC approach & floor transitions
-Review each link with skill up considerations
-Examples of some floor coping skills
-(Post your questions as we go)
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@LaterLifeTrain
Backward chaining links of the chain
• We know there are barriers (participant and instructor/therapist related) that prevent this activity e.g painful knees, hands, hips, concerns with not being able to get up ..
• The backward chaining approach assumes mastery of one link before moving onto the next, so technically it can always be a win-win
• What is the start point/where in the chain?
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@LaterLifeTrain
(Video 1: Therapy led, backward chaining approach to teaching getting up from the floor)
We are going to watch this short video twice. - As you watch the first time, consider what each
individual link could be i.e. what is the start and beginning of each link of the chain/movement
- The second time I will talk through the links- Please post any questions you have
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@LaterLifeTrain
Link-by-link analysis in photographs: getting up from the
floor
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@LaterLifeTrain
1. From supported wall sit position
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@LaterLifeTrain
2. Prepare for box position/seated weight
transfer
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3. Prepare for box position/weight shift to hands
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4. Prepare for box position/weight shift over
hands
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5. All 4’s box position
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6. Crawl
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7. Hand to chair/prepare for push up
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9. Weight shift for up8. Hand to chair/prepare
for push up
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8. Prepare for push up8a. Push up
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9. Prepare to stand
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10. Controlled sit
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Link-by-link skill up examples and considerations
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@LaterLifeTrain
1. From supported wall sit position
Skilling up - examples;
• Seated trunk mobility; rotation, lateral flexion/side bends, back extensions
• Hip flexibility
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@LaterLifeTrain
2. Prepare for box position/seated weight transfer
Skilling up - examples;
• Seated trunk mobility; rotation, lateral flexion/side bends, back extensions
• Hip mobility - hip walking in chair or on a bed for weight transfer skills
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@LaterLifeTrain
3. Prepare for box position/weight shift to hands
Skilling up - examples;
• Seated trunk mobility; rotation, lateral flexion/side bends, back extensions
• Hip mobility - hip walking in chair for weight transfer
• Shoulder mobility, strength, wrist strengthener
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@LaterLifeTrain
4. Prepare for box position/weight shift over
hands
Skilling up - examples;
• Seated trunk mobility; rotation, lateral flexion/side bends, back extensions
• Hip mobility - hip walking in chair for weight transfer
• Shoulder mobility, strength, wrist strengthener
• Wall press for trunk/postural muscles and shoulder stability
• Wrist strengthener
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5. All 4’s box positionSkilling up - examples;
• Seated trunk mobility; rotation, lateral flexion/side bends, back extensions
• Hip mobility• Shoulder mobility, strength,
wrist strengthener• Wall press for trunk/postural
muscles and shoulder stability
• Transitions into box positions on plinth/bed
Considerations for painful knees/wrists;• Bum walking instead of
crawling
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6. Crawl Skilling up - examples;
• Seated trunk mobility; rotation, lateral flexion/side bends, back extensions
• Hip mobility• Shoulder mobility, strength,
wrist strengthener• Wall press for trunk/postural
muscles and shoulder stability
• Transitions into box positions on plinth/bed
Considerations for painful knees/wrists;• Bum walking instead of
crawling
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7. Hand to chair/prepare for push up
Skilling up - examples;
• Seated trunk mobility; rotation, lateral flexion/side bends, back extensions
• Hip flexibility• Hip walking in chair for weight
transfer• Shoulder mobility, strength,
wrist strengthener• Wall press for trunk/postural
muscles and shoulder stability • Transitions into box positions
on plinth/bed
Considerations for painful wrists;• Picture shows elbows to chair
NB less reliable grasp for stability
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@LaterLifeTrain
9. Weight shift for up8. Hand to chair/prepare for
push upSkilling up this link - examples;
•Standing lunges to different levels/use platforms to land on•Hip flexor stretch •Shoulder mobility, strength, wrist strengthener•Wall press for trunk/postural muscles and shoulder stability•Ankle mobility – calf stretch
Considerations for painful knees;
Use of cushions under knee or shin to shift load
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@LaterLifeTrain
8. Prepare for push up
8a. Push upSkilling up this link - examples;
•Lunges, different levels, include power, focus on foot placement•Hip flexor stretch •Shoulder mobility, strength, wrist strengthener•Wall press for trunk/postural muscles and shoulder stability•Ankle mobility – calf stretch
Considerations for painful knees;
Use of cushions under knee or shin to shift load
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9. Prepare to stand Skilling up this link -examples;
• Sit to stand• 180 turn
Considerations for fear:
Ensure furniture secure, close to a wall, change support options (height/width etc)
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10. Controlled sit Skilling up this link -examples;
• Sit to stand
Considerations for fear:
Ensure furniture secure, close to a wall, change support options (height/width etc)
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Video 1: floor transitions review
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Floor coping skills and alternatives to therapy led
approach to getting up
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@LaterLifeTrain
Video 2 & 3 bum walking to stairs/sofa
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@LaterLifeTrain
Key messages
• Ascertain floor rise history
• The starting point is the win-win point (it will depend on every individual)
• Skill up for success - mobility, flexibility, strength, power all contribute but…
• Correct body positions, timely instructions, use of levers & centre of mass will make transitions easier
• How far can you go? Even a few links can reduce a long lie
• Plan for success, make a plan, talk about it...
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FINAL POLL – has anything changed for you?
Will you consider teaching more older people (even first few links of) backward chaining approach as a result of this webinar?
• Yes
• No
• Unsure
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@LaterLifeTrain
Further information on LLT
Visit the websitehttps://www.laterlifetraining.co.uk/
Download the backward chaining leaflet for those who can practice at home
https://bit.ly/2mMbKLZ
Become a Member (free and paid options)
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Questions?
Type your questions into the Q&A box.
THIS WEBINAR IS BEING RECORDED.THE SLIDE DECK AND RECORDING WILL BE
EMAILED AFTER THE WEBINAR.
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