Dr Dawn Skelton PhDDr Dawn Skelton PhD

Reader in Ageing and Health, Reader in Ageing and Health, HealthQWest, HealthQWest,

Glasgow Caledonian UniversityGlasgow Caledonian University

Co-ordinator of Prevention of FallsCo-ordinator of Prevention of Falls

Network Europe, University of Network Europe, University of ManchesterManchester

The Role of Exercise in Falls Prevention

Falls in the UKFalls in the UK 11 million people aged > 65 yrs11 million people aged > 65 yrs 28,000 women aged > 90 yrs28,000 women aged > 90 yrs

Fractures costs £1.8 billionFractures costs £1.8 billion 1 Hip Fracture every 10 mins1 Hip Fracture every 10 mins

– Cost £12-15KCost £12-15K 1 Wrist Fracture every 9 mins1 Wrist Fracture every 9 mins

– Cost £500Cost £500 Changing site of fracture >ageChanging site of fracture >age

500 admitted to Hospital every day500 admitted to Hospital every day 3333 never go home never go home

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

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

Accident /Environment 31%Accident /Environment 31% Gait /Balance /Weakness 17%Gait /Balance /Weakness 17% Dizziness vertigo 13%Dizziness vertigo 13% Drop attacks 9%Drop attacks 9% Confusion 5%Confusion 5% Postural hypotension 3%Postural hypotension 3% Visual disorder 2%Visual disorder 2% Syncope 0.3%Syncope 0.3% Other 15%Other 15% Unknown 5%Unknown 5%

Weakness 11/11Weakness 11/11 Balance deficit 9/9 Balance deficit 9/9 Mobility limitation 9/9Mobility limitation 9/9 Gait deficit 8/9Gait deficit 8/9 Visual deficit 5/9Visual deficit 5/9 Cognitive impairment Cognitive impairment

4/84/8 Impaired ADL 5/9Impaired ADL 5/9 Postural hypotension Postural hypotension

2/72/7

Individual risk factors: 16 controlled studies

Summary of 12 major studies of fall causes

Time – Disease - Time – Disease - DisuseDisuse

StrengthStrength Power Power Bone densityBone density BalanceBalance StaminaStamina FlexibilityFlexibility Cognitive FunctionCognitive Function Maintenance of temperatureMaintenance of temperature

controlcontrol

EVEN HEALTHY OLDER PEOPLE LOSE...EVEN HEALTHY OLDER PEOPLE LOSE...

Sedentary behaviour increases the loss of Sedentary behaviour increases the loss of performance...performance...

International ConsensusInternational Consensus

World Health Organisation, World Health Organisation, 19961996

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

Surgeon General, USA, Surgeon General, USA, 19971997 “Sedentariness is a major “Sedentariness is a major public health issue”public health issue”

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

Community Dwelling >65 yearsCommunity Dwelling >65 years

Compared to non-fallers, fallers haveCompared to non-fallers, fallers have

– ⇩⇩ quadriceps and hamstring strength quadriceps and hamstring strength

(NS)(NS)

– ⇩ ⇩ ankle plantarflexion, dorsiflexion, ankle plantarflexion, dorsiflexion,

inversion and eversion strength inversion and eversion strength

– ⇩ ⇩ lower limb explosive power lower limb explosive power

– ⇧ ⇧ asymmetry between limbs in power asymmetry between limbs in power

and strengthand strength

Skelton, Kennedy, Rutherford Age Ageing 2002Skelton, Kennedy, Rutherford Age Ageing 2002

Fear and avoidance of Fear and avoidance of activityactivity

Present in >50% of fallers & up Present in >50% of fallers & up

to 40% non-fallersto 40% non-fallers

Predicts Predicts

– decreases in physical and social decreases in physical and social activityactivity

– deterioration in physical deterioration in physical functioningfunctioning

– higher risk of falling higher risk of falling

Particularly common in people Particularly common in people

who cannot get up from the who cannot get up from the

floorfloor

Lessons that last a Lessons that last a lifetimelifetime

Sensory Input Sensory Input StabilityStability

Three main sources of inputThree main sources of input

Visual informationVisual information

Vestibular informationVestibular information

Proprioceptive informationProprioceptive information

Falls Prevention Falls Prevention ApproachesApproaches Individual Approach (high risk patients)Individual Approach (high risk patients)

– Multi-factorial (ie. Falls Clinics) Multi-factorial (ie. Falls Clinics) Unclear Unclear evidenceevidence

– Uni-factorial (ie. Uni-factorial (ie. ExerciseExercise) ) Good evidence BUT…Good evidence BUT…

Population based approach (targeting Population based approach (targeting communities)communities)– Emerging evidenceEmerging evidence, , Relative reduction in fall-Relative reduction in fall-

related injuries 6 to 33%related injuries 6 to 33%– Most include increasing awareness and Most include increasing awareness and physical physical

activityactivity, medication and home hazard reviews, medication and home hazard reviews

Reviews of Exercise Reviews of Exercise EvidenceEvidence

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

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

2000 - Gardner M et al. 2000 - Gardner M et al. - - Br J Sports Med. Br J Sports Med. 34: 7-1734: 7-17

2001 - Skelton D - 2001 - Skelton D - Age Ageing Age Ageing 30;S4: 33-3930;S4: 33-39

2002 – Skelton & Beyer – 2002 – Skelton & Beyer – Scand J Med Sports Sci Scand J Med Sports Sci 13:1-913:1-9

2004 - Chang et al. – 2004 - Chang et al. – Brit Med J Brit Med J 328: 680-687328: 680-687

– Multifactorial interventions reduce risk (RR 0.82)Multifactorial interventions reduce risk (RR 0.82)

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

Know what to avoid…Know what to avoid…

Intervention: Brisk Intervention: Brisk

walkingwalking

Control: exercise of Control: exercise of

upper armupper arm

Falls risk (Brisk walking Falls risk (Brisk walking

> control)> control)

Beware uneven Beware uneven

pavements!pavements!Ebrahim et al. (1997)Ebrahim et al. (1997)

Care and Care and encouragementencouragement Type of Exercise Type of Exercise

Reoccurrence Reoccurrence of of Vertebral Vertebral Fracture Fracture

Back extensionBack extension 16%16% Flexion (abd. curls)Flexion (abd. curls) 89%89% CombinedCombined 53%53% No exerciseNo exercise 67%67%

Sinaki 1987Sinaki 1987

‘‘Pitfalls’ of Pitfalls’ of interventions that interventions that don’t workdon’t work Insufficient durationInsufficient duration

Insufficient intensityInsufficient intensity

Insufficient tailoring or Insufficient tailoring or

specificity of trainingspecificity of training

Insufficient Insufficient

progressionprogression

Not enough time on Not enough time on

feet!feet!

Balance PrinciplesBalance Principles

Changes of direction, pace and level, head Changes of direction, pace and level, head

position, weight (transference)position, weight (transference)

Sustained, controlled 3D moves Sustained, controlled 3D moves

Progressively challenging tasks Progressively challenging tasks

to improve gaze stabilisationto improve gaze stabilisation Obstacle coursesObstacle courses Floor work: balances, crawling, Floor work: balances, crawling,

rolling, shuffling in seated positionrolling, shuffling in seated position Ball gamesBall games Breakdown all moves into 'steps' or stages Breakdown all moves into 'steps' or stages

Interventions that work…….. 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 Tai Chi – prevention of 11stst fall? fall?

- Community Dwelling older people with mild deficits of Community Dwelling older people with mild deficits of strength/balance, 2x/week for 15 weeksstrength/balance, 2x/week for 15 weeks

– Cut trip and fall rate by Cut trip and fall rate by halfhalf

- 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

Wolf et al. (1996)Wolf et al. (1996)

- 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:P34-40Li et al. J Gerontol B Psychol Sci Soc Sci 2005; 60:P34-40

Campbell et al, BMJ, 1997Campbell et al, BMJ, 1997

Robertson et al, BMJ, 2001Robertson et al, BMJ, 2001

Effective Home Exercise Effective Home Exercise (OEP)(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 FaME – Group Exercise (PSI)(PSI)

With evidence based activities:With evidence based activities:

Dynamic balance training Dynamic balance training Targeted resistance training Targeted resistance training Targeted bone loadingTargeted bone loading Functional movementsFunctional movements Dynamic endurance training for Dynamic endurance training for

balancebalance Backward chainingBackward chaining Functional floor activitiesFunctional floor activities Adapted Tai Chi cool downAdapted Tai Chi cool down

Aims to:

• Increase balance

• Increase functional

capacity

• Increase bone /

muscle mass

• Increase confidence

(reduce fear of falling)

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

DYNAMIC BALANCE TRAINING

DYNAMIC BALANCE TRAINING

Teaching transfer skills

Teaching Floor Skills

FaME – FaME – managing frequent fallersmanaging frequent fallers

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

in previous yearin previous year

Exercise-only intervention – 9 monthsExercise-only intervention – 9 months

Group exercise – individually tailored, trained exercise Group exercise – individually tailored, trained exercise

instructorsinstructors

Falls risk decreased by Falls risk decreased by halfhalf – RR 0.46 – RR 0.46

Significantly less people in exercise group had died, Significantly less people in exercise group had died,

entered a nursing home or were in hospital after 3 yearsentered a nursing home or were in hospital after 3 yearsSkelton et al. 2005

STRENGTH / POWER / ASYMMETRY

FaMESignificant 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%

Significant difference with time and group for L2-L4 spine and Wards Triangle (F=3.46, p<0.05). Exercisers n=32, Controls n=14. Time between visit 1 and visit 2 = mean 10.9 (sd 2.7) months

FaME – Bone improvements

Skelton et al. J.Aging Phys Act 2008, Abstract

Quality of Life Quality of Life – adding life to years– adding life to years

Improvements in ALL domains of SF36 (QoL)Improvements in ALL domains of SF36 (QoL)

Self-reported improvements inSelf-reported improvements in– Caring skillsCaring skills– Playing with grandchildrenPlaying with grandchildren– Bathing instead of showeringBathing instead of showering– Using public transport againUsing public transport again– Reduced fearReduced fear– Increased activity outdoorsIncreased activity outdoors– ConfidenceConfidence

Fallen Angels ClubFallen Angels Club– Meet every two months in Starbucks, Oxford Street, Meet every two months in Starbucks, Oxford Street,

London, UK!London, UK!

Nursing Home Nursing Home ResidentsResidentsIndividually tailored GROUP exercise as part of a multifactorial intervention (staff training, environment modification, drug review etc)

Reduces falls - Becker et al. J Am Geriat Soc 2003; 51:306-313Becker et al. J Am Geriat Soc 2003; 51:306-313

Improves mobility - Jensen et al. Aging Clin Exp Res 2004; 16: Jensen et al. Aging Clin Exp Res 2004; 16: 283-292283-292

Reduces falls risk factors - Reduces falls risk factors - Dyer et al. Age Ageing 2004; 33:596-Dyer et al. Age Ageing 2004; 33:596-602602

Nursing Home Residents

1 to 1 training Whole Body Vibration vs Physical TherapyWhole Body Vibration vs Physical Therapy 42 residents, RCT42 residents, RCT 2 x/week for 6 weeks2 x/week for 6 weeks Reduction in risk factors (Gait, Balance, TUG, QoL) Reduction in risk factors (Gait, Balance, TUG, QoL) Bruyere O et al. Arch Phys Med Rehabil 2005:86: 303-307Bruyere O et al. Arch Phys Med Rehabil 2005:86: 303-307

• 6 months training in post-menopausal 6 months training in post-menopausal

women women • Strength 15%, Hip BMD 1%Strength 15%, Hip BMD 1%

Verschueren SM et al. J Bone Miner Res 2004; Verschueren SM et al. J Bone Miner Res 2004;

19: 352-35919: 352-359

Patients in HospitalPatients in Hospital

Tai Chi + reaching + stepping + transferring Tai Chi + reaching + stepping + transferring

chair to chair chair to chair

1 physiotherapist to max 4 patients, 3 x p/w, 45 1 physiotherapist to max 4 patients, 3 x p/w, 45

mins. mins.

173 patients, 82 yrs, sub-acute ward173 patients, 82 yrs, sub-acute ward

Halved the number of falls (participant days in Halved the number of falls (participant days in

hospital)hospital) Haines et al. Clin Rehab 2007; 21:742-753Haines et al. Clin Rehab 2007; 21:742-753

My residents are too My residents are too frail? frail?

Dose response curveDose response curve The lower the baseline level The lower the baseline level

of physical activity, the of physical activity, the

greater the health benefit greater the health benefit

associated with an increase associated with an increase

in physical activity. in physical activity.

Exercise can be adapted for Exercise can be adapted for

any medical conditionany medical condition

(Haskell 1994)(Haskell 1994) There would be no falls if There would be no falls if

there was no rehabilitation!there was no rehabilitation!

(Oliver, D – 2006)(Oliver, D – 2006)

Confidence in instruction & Confidence in instruction & teaching to increase teaching to increase effectiveness?effectiveness?

Provision of Effective Group Provision of Effective Group ExerciseExercise

Physiotherapist

Seniors Exercise Instructor

Postural Stability Instructor

Otago Exercise Programme Leader

FALLS REHABILITATION

GROUP

‘FaME’ GROUP (PSI)

EXERCISECHAIR BASED

EXERCISE GROUP

REFERRAL

 Community Exercise for the Older Person Sessions (Tai Chi, EXTEND, YFIT etc)

UK’s FOUR EXERCISE GROUPS

OTAGO HOME PROGRAMME

Service Evaluation – PSI classesService Evaluation – PSI classes

Average age 82 years, n=124Average age 82 years, n=124 Average attendance 79%Average attendance 79% Improved functional reach (p<0.01) & Timed up & go Improved functional reach (p<0.01) & Timed up & go

(p<0.05)(p<0.05) Improved quality of life SF36 (p<0.05)Improved quality of life SF36 (p<0.05) Confidence in Balance (p<0.05)Confidence in Balance (p<0.05) Timed Floor Rise (p<0.01) Timed Floor Rise (p<0.01)

Simey, Skelton, Dinan, Land & Irwin (BMJ letter, 2001)Simey, Skelton, Dinan, Land & Irwin (BMJ letter, 2001)

“I can walk upstairs now. I haven’t been able to walk upstairs for four years. I do my exercises every day at home. I know it’s doing me good”

Recommendations for Recommendations for Exercise interventions to Exercise interventions to

reduce the risk of falls and reduce the risk of falls and injuriesinjuries

ExerciseExercise works best works best withinwithin a a multi-factorialmulti-factorial intervention intervention programme programme

– Exercise should have components of balance, low impact aerobic and Exercise should have components of balance, low impact aerobic and

strengthstrength

– To reduce fear, floorwork is recommendedTo reduce fear, floorwork is recommended

To be To be effectiveeffective the exercise must be the exercise must be specific,specific, regular regular (2-3 p/w), (2-3 p/w), progressiveprogressive, and exceed 15 weeks , and exceed 15 weeks durationduration for those at risk of for those at risk of falls and 9 months for those who are already falling regularlyfalls and 9 months for those who are already falling regularly

www.profane.eu.org

www.helptheaged.org.uk/Health/HealthyAgeing/Falls/_practitioners.htm

For information on Books, Videos and other Resources on Falls Prevention including training see

www.laterlifetraining.co.uk

““Man does not cease to play because Man does not cease to play because he grows old. Man grows old because he grows old. Man grows old because

he ceases to playhe ceases to play”” George Bernard ShawGeorge Bernard Shaw