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Professor Keith Hill,

School of Physiotherapy

Keith.Hill@Curtin.edu.au

WA Active Ageing Conference: June 2013

What works in falls prevention – emphasis on exercise

Exercise interventions at both ends of falls risk spectrum: recent research

Factors limiting translation of successful exercise (and other) fall prevention interventions

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COCHRANE REVIEW: Gillespie et al, 2012 (159 trials with 79,193 participants)

There is good research (at least one randomised trial) evidence that a number of single interventions can reduce falls / injuries:

exercise (home exercise; tai chi, group exercise) cataract extraction / change multifocal glasses to 2 sets of

glasses psychotropic medication withdrawal / medication review home visits by Occupational Therapists improved post hospital discharge follow-up approaches to support client uptake in recommended

interventions vitamin D and calcium supplementation (in low vit D cases) cardiac pacemaker for carotid sinus hypersensitivity foot exercise, footwear and orthoses

multiple interventions based on a falls risk assessment have also been shown to be effective (including in high falls risk groups, eg older fallers presenting to ED)

Group exercise programs

Home exercise programs (often prescribed by a physiotherapist

Tai Chi- (note: different types of Tai Chi may have different effects)

Foot and ankle exercise as part of podiatric multi-faceted program (Spink et al, 2011)

Key elements of successful exercise interventions: Moderate balance

component Moderate intensity (Sherrington et al, 2008, 2011)

Cochrane review: Gillespie et al 2012 (159 trials with 79,193 participants)

5 Sherrington et al 2011

54 RCTs (all settings, though most in community)

Randomly selected sample (>5,000 participants, 61% response rate)

Merom et al, Prev Med, 2012; 55:613-7

Anne-Marie Hill et al, 2011, The Gerontologist

Very frail/ High falls risk

Healthy older people

CONTINUUM OF BALANCE IMPAIRMENT

Tai chi for arthritis – Sun style 24 form Beijing style – Yang style

Otago Exercise Program “Otago Plus” – incl VHI kit

Keith Hill1, Plaiwan Suttanon2, Karen Dodd3, Cathy Said4, Sue Williams5, Karin Byrne5, Nicola Lautenschlager5, Dina LoGiudice6

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1 Curtin University, Australia

2 Thammasat University, Thailand

3 LaTrobe University, Australia

4 Austin Health, Australia

5 National Ageing Research Inst, Australia

6 The University of Melbourne, Australia

7 Royal Melbourne Hospital, Australia

COCHRANE REVIEW: Gillespie et al, 2012 (159 trials with 79,193 participants)

There is good research (at least one randomised trial) evidence that a number of single interventions can reduce falls / injuries:

exercise (home exercise; tai chi, group exercise)

cataract extraction / change multifocal glasses to 2 sets of glasses

psychotropic ithdrawal / medication review

home visits by Occupational Therapists

improved post hospital discharge follow-up

approaches to support client uptake in recommended interventions

vitamin D and calcium supplementation (in low vit D cases)

cardiac pacemaker for carotid sinus hypersensitivity

foot exercise, footwear and orthoses

multiple interventions based on a falls risk assessment have also been shown to be effective (including in high falls risk groups, eg older fallers presenting to ED) medication w

Common exclusion criteria:

cognitive impairment

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Time of diagnosis

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to evaluate the feasibility/safety of a home-

based balance exercise program and to

provide preliminary evidence of program

effectiveness in people with mild to moderate

AD

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40 participants* with mild to moderate AD (with carer in most

cases) randomised to 6 month home-based programs:

i) balance exercise (physio), OR

ii) education / support program (OT)

Inclusion criteria:

• community living

• AD diagnosis by GP or specialist

• mild to moderate severity (MMSE>10)

• able to walk outdoors with no more support than a single point stick

• no other major neurological or orthopaedic past history impacting on

balance / mobility

* Apriori power calculation – estimate n=80/group for falls outcome

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Home-based balance exercise program (6 home visits and 5 phone calls in 6

months)

- based on “Otago programme”

- individualised balance and strengthening exercises

- by a physiotherapist (monitor, motivate, modify)

- an exercise booklet

- exercise 5 days/week

Home-based education / support program (6 home visits and 5 phone calls)

- based on study by Graff et al., 2007

- included education/information sessions

- by an occupational therapist

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Balance/mobility performance

Clinical measures (Functional Reach, Step Test, Timed Up and Go –

single and dual task)

Neurocom Balance Master (Limits of Stability, modified CTSIB, Sit to

Stand, Step Quick Turn, Gait step width)

Falls

Falls risk: FROP-com, PPA

Physical activity level (HAP)

Zarit carer burden index

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Characteristic

Exercise

Group

(n = 19)

Control

Group

(n = 21)

Age, mean ± SD 83.42 ± 5.10 80.52 ± 6.01

Gender (M:F), n 6:13 9:12

Mini Mental State Examination score, mean ± SD 20.89 ± 4.74 21.67 ± 4.43

Number of medical conditions†, median (range) 3 (6) 3 (5)

Fallers: non-fallers, n (% fallers) 9:10 (52.6%) 4:17 (19%)*

FROP-Com‡ Falls Risk score, mean ± SD 15.42 ± 4.99 12.57 ± 5.56

PPA§ Falls Risk score, mean ± SD 1.84 ± 1.18 1.39 ± 1.21

Functional Reach (distance_cm), mean ± SD 23.51 ± 5.74 28.48 ± 4.70*

Step Test (number of steps_worse side), mean ± SD 12.33 ± 2.38 13.00 ± 3.23

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Program completion: exercise program (11 of 19, 58%)

control program (18 of 21, 86%)

• No adverse events during exercise program

• 83% adherence for those completing the program

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Generalized linear models, with baseline performance

on the outcome measure as a covariate.

P=0.002

Compared to education group, exercise group achieved significantly better:

Change in falls risk (FROP-Com), p=0.008

Limits of stability (movement velocity), p=0.016

Compared to education group, exercise group achieved trends for better:

Step Test, p=0.082

Modified CTSIB, p=0.086

Timed Up and Go (dual task-manual), p=0.088

Most measures indicated similar direction of change

No significant change between groups for carer burden (Zarit)

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Thanks to Frances Batchelor

for the graphic

Home based balance and strength training appears safe, feasible and preliminary results suggest effectiveness in people with mild to moderate severity Alzheimer’s disease

Consideration needed for carer burden that may limit sustained participation

Loss of confidence

Activity curtailment

Feeling of “balance

not as good as it used

to be”

Effect of age, or

something

else???

Increased falls risk

Balance screening

process

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PhD candidate:

Xiao Jing Yang

Yang et al, Physical Ther 2012

Yang et al, J Clin Geriatr & Gerontol 2012

To determine the proportion of older people expressing concerns about their balance who do have a measurable balance impairment

For those with identified mild balance dysfunction, to determine the effectiveness of a home based exercise program in improving balance and related measures

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Sample and recruitment

Participants were recruited from Melbourne.

Inclusion criteria were:

• aged 65 years or older

• living in the community

• being community ambulant

• used no walking aid or a single point stick;

• had no more than one fall in the past 12 months;

• reported concerns about balance, confidence or near falls.

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Control

6-month

re-assessment

Intervention

Balance within

normal limits

Comprehensive balance

assessment for mild balance

dysfunction (MBD)

Group with

MBD

6-month

re-assessment

randomisation

CLASSIFICATION OF MBD

- >1SD from mean for

older sample on

- Functional Reach (<26cm) OR

- Step Test (<13 steps/15s) OR

- Timed sit to stand (>17.9s)

OR

- > 3 (out of 46 measures)

on the Neurocom Balance

Master outside of normal

limits (normative data

provided by Neurocom

(age and gender matched)

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Yang et al, Physical Ther 2012

Yang et al, J Clin Geriatr & Gerontol 2012

Exercise program based on: Otago Exercise

Programme; and Visual Health Information

(VHI) Exercise Prescription Kits - Balance & Vestibular Rehabilitation Set

Prescribed by a physiotherapist

Customised to individual’s balance performance and fitness level.

Example: toe walking —

no support

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All Participants (n=225)

Age, mean (SD) 79.7 years (6.1)

Gender (%Male) 126 (56%)

Living at home, no carer 208 (92%)

Receiving home help 61 (27%)

Using single point stick 42 (19%)

Walking daily (>30min) 179 (80%)

Fall in last year 81 (36%)

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Following the 6-month exercise program:

•14 out of 59 participants (23.7%) in the intervention group achieved balance performance within the normative range

Participants entered RCT (n=165)

Control group

(n=83)

Intervention group

(n=82)

Randomisation

6-month follow up

62 returned to re-

assessment, 3 (4.8%)

were considered within

normal limits

59 returned to re-

assessment, 14

(23.7%) improved to

within normal limits

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20% intervention vs 29% control group fell (NS)

-10

-5

0

5

10

15

Intervention group

*

* *

* *

Control group

Results: RCT – exercise for mild balance dysfunction (2)

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Mild balance dysfunction:

is common among older people with concerns about

their balance

is measurable with clinical as well as laboratory measures

is responsive to an individualised home exercise program prescribed by a physiotherapist

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12 week weight bearing (home based) exercise program (3 times / week) vs seated resistance exercise vs social visit

Loss of up to 50% of balance gains in the subsequent 12 weeks after ceasing exercise

Vogler et al, 2012, Arch Phys Med Rehabil; 93: 1685-91

1. Inadequate funding 2. Limited engagement of older people

in falls prevention 3. Limited targeting of falls prevention

to key high risk population groups 4. Limited early identification and

prevention approach 5. Limited partnerships of key

stakeholders 6. Limited representativeness of

research samples (eg often no CALD participants, exclude cognitive impairment)

7. Setting of assessment or intervention often not typical of “real life” setting

8. Others …

Key players

The older

person

The health

professional

Reviewed 99 randomised trial in 2009 Cochrane review (falls prevention in the community)

Adherence rates (n = 69) were: ◦ ≥80% for vitamin D/calcium supplementation; ◦ ≥70% for walking and class-based exercise; ◦ 52% for individually targeted exercise; ◦ approximately 60-70% for fluid/nutrition therapy and

interventions to increase knowledge; ◦ 58-59% for home modifications; ◦ Adherence to multifactorial interventions was generally

≥75% but ranged 28-95% for individual components. Home-exercises on average 11 times per month

(Nyman and Victor, Age and Ageing, 2012)

CONCLUSIONS:

Using median rates for recruitment (70%), attrition (10%) and adherence (80%),

we estimate that, at 12 months, on average half of community-dwelling older

people are likely to be adhering to falls prevention interventions in clinical trials.

chronic conditions (eg arthritis) ◦ perception that exercise will aggravate pain

access (cost / transport)

no-one to exercise with

perception that exercise is not appropriate / beneficial for older people

lack of awareness of ◦ benefits

◦ available options (locally)

Hill and Murray, 2004. Physical activity & falls prevention (chapter in

book edited by Morris and Schoo)

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Generally low exercise participation levels in older people - need for approaches to improve participation

Exercise approaches can achieve positive fall related outcomes

for older people, across the falls risk / frailty continuum

Strong research evidence that falls can be reduced through exercise interventions, especially those with a balance component those with >50 hours dosage

Need to consider balance ability, safety and patient preference

Major issue of uptake and longer term adherence