Dr Dawn Skelton PhD

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The Role of Exercise in Falls Prevention
Dr Dawn Skelton PhD Reader in Ageing and Health,
HealthQWest, Glasgow Caledonian
University Co-ordinator of Prevention of
Falls Network Europe, University of Manchester
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Falls in the UK

• 11 million people aged gt 65 yrs
• 28,000 women aged gt 90 yrs
• Fractures costs 1.8 billion
• 1 Hip Fracture every 10 mins
• Cost 12-15K
• 1 Wrist Fracture every 9 mins
• Cost 500
• 500 admitted to Hospital every day
• 33 never go home

Bandolier and Annual European Home and Leisure
Accident Surveillance Survey (EHLASS) Report UK
2000
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Studies assessing fall risk factors per se
Rubenstein Josephson 2002
Individual risk factors 16 controlled studies
Summary of 12 major studies of fall causes

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

• Weakness 11/11
• Balance deficit 9/9
• Mobility limitation 9/9
• Gait deficit 8/9
• Visual deficit 5/9
• Cognitive impairment 4/8
• Impaired ADL 5/9
• Postural hypotension 2/7

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Time Disease - Disuse
EVEN HEALTHY OLDER PEOPLE LOSE...

• Strength
• Power
• Bone density
• Balance
• Stamina
• Flexibility
• Cognitive Function
• Maintenance of temperature control

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

• World Health Organisation, 1996
• regular physical activity helps to preserve
  independent living and postpone the age
  associated declines in balance and co-ordination
  that are major risk factors for falls

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FALLERS vs NON-FALLERS

• Community Dwelling gt65 years
• Reduced isometric and isokinetic quadriceps and
  hamstring strength (NS)
• Significantly lower ankle plantarflexion,
  dorsiflexion, inversion and eversion
• Significantly reduced lower limb explosive power
• Significantly greater asymmetry between limbs in
  leg explosive power and ankle strength
• Skelton, Kennedy, Rutherford Age Ageing 2002

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FEAR

• Present in gt50 of fallers up to 40
  non-fallers
• Predicts
• decreases in physical and social activity
• deterioration in physical functioning
• higher risk of falling
• Particularly common in people who cannot get up
  from the floor

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Falls Prevention Approaches

• Individual Approach (high risk patients)
• Multi-factorial (ie. Falls Clinics Close et al,
  1999)
• Uni-factorial (ie. Exercise Skelton et al, 2005,
  Campbell 1997, Robertson 2001)
• Population based approach (targeting communities)
• Emerging evidence (McClure, 2005)
• Most include increasing awareness and physical
  activity, medication and home hazard reviews

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Cochrane Review Population-based interventions
for the prevention of fall-related injuries in
older people

• McClure et al. 2005 Issue 1. Systematic Review
• www.thecochranelibrary.com
• 23 studies identified, 5 met criteria and
  included
• No RCTs
• Significant decreases or downward trends in
  fall-related injuries reported in all five
  studies
• Relative reduction in fall-related injuries 6 to
  33

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Reviews of Exercise Evidence

• 1995 Province MA et al. - J Am Med Assoc.
  2731341-1347.
• 1999 Skelton Dinan Physio Theory
  Practice 15105-120
• 2000 - Gardner M et al. - Br J Sports Med. 34
  7-17
• Not to fit and Not too frail
• 2001 - Skelton D - Age Ageing 30S4 33-39
• 2002 Skelton Beyer Scand J Med Sports Sci
  131-9
• 2004 - Chang et al. Brit Med J 328 680-687
• Multifactorial trials reduce risk (RR 0.82)
• Exercise only trials reduce risk (RR 0.86)

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Know what to avoid

• Intervention Brisk walking
• Control exercise of upper arm
• Falls risk (Brisk walking gt control)

Ebrahim et al. (1997)
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Balance Principles

• Changes of direction, pace and level, head
  position, weight (transference)
• Sustained, controlled 3D moves
• Progressively challenging tasks to improve
  gaze stabilisation
• Obstacle courses
• Floor work balances, crawling, rolling,
  shuffling in seated position
• Ball games
• Breakdown all moves into 'steps' or stages

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SPECIFICITY TO REDUCE FALLS
Province, 1995 Group and individual balance and
strength training gt65s Wolf, 1996 Group Tai Chi
gt65s (NOT gt70s at risk, Wolf 2003) Campbell,
1997 Home-based exercise gt80s Robertson,
2001 Home-based exercise gt65s and gt80s Day,
2002 Group exercise gt70s at risk Barnett,
2003 Group exercise gt65s at risk Lord,
2003 Group exercise gt60s retirement
village Skelton, 2005, 2008 Group Exercise gt65s
frequent fallers
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Tai Chi secondary prevention in younger years ?

• Community Dwelling older people with mild
  deficits of strength/balance
• 2x/week for 15 weeks
• Cut trip and fall rate by half

Wolf et al. (1996)

• 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

• Community Dwelling older people aged 70
• 3 x/week for 24 weeks
• Increased Falls Self-Efficacy (ABC) and
  Decreased Fear of Falling (SAFFE)

Li et al. J Gerontol B Psychol Sci Soc Sci 2005
60P34-40
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Effective Home Exercise

• Community Dwelling gt80 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 65s cost effective
• For over 80s 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

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FaME Group Exercise

• With evidence based activities
• Dynamic balance training
• Targeted resistance training
• Targeted bone loading
• Functional movements
• Dynamic endurance training for balance
• Backward chaining
• Functional floor activities
• Adapted 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)
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FaME managing frequent fallers

• RCT - Women aged 65 with a history of 3 or more
  falls in previous year
• Exercise-only intervention 9 months
• Group exercise individually tailored, trained
  exercise instructors
• Falls risk decreased by half RR 0.46
• Significantly less people in exercise group had
  died, entered a nursing home or were in hospital
  after 3 years

Skelton et al. J.Aging Phys Act 2004 12 (3)
457-458 Age and Ageing, in Press
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STRENGTH / POWER / ASYMMETRY FaME

• Significant 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

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FaME Bone improvements
Significant difference with time and group for
L2-L4 spine and Wards Triangle (F3.46, plt0.05).
Exercisers n32, Controls n14. Time between
visit 1 and visit 2 mean 10.9 (sd 2.7) months
Skelton et al. J.Aging Phys Act 2008, Abstract
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QUALITY OF LIFE

• Improvements in ALL domains of SF36
• Self-reported improvements in
• Caring skills
• Playing with grandchildren
• Bathing instead of showering
• Using public transport again
• Reduced fear
• Increased activity outdoors
• Confidence
• Fallen Angels Club
• Meet every two months in Starbucks, Oxford
  Street, London, UK!

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Nursing Home Residents
Individually 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 51306-313 Improves mobility - Jensen
et al. Aging Clin Exp Res 2004 16
283-292 Reduces falls risk factors - Dyer et al.
Age Ageing 2004 33596-602
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Nursing Home Residents 1 to 1 training

• Whole Body Vibration vs Physical Therapy
• 42 residents, RCT
• 2 x/week for 6 weeks
• Reduction in risk factors (Gait, Balance, TUG,
  QoL)
• Bruyere O et al. Arch Phys Med Rehabil
  200586 303-307

• 6 months training in post-menopausal women
• Strength 15, Hip BMD 1
• Verschueren SM et al. J Bone Miner Res 2004 19
  352-359

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Patients in Hospital

• 3 rehabilitation and care of the elderly wards,
  626 patients, 80 yrs
• Falls risk card, exercise programme, education
  and hip protectors
• Intervention group had less falls, most
  significant after 45 days
• Haines et al. Brit Med J 2004 328676-680
• Tai Chi reaching stepping transferring
  chair to chair
• 1 physiotherapist to max 4 patients, 3 x p/w, 45
  mins.
• 173 patients, 82 yrs, sub-acute ward
• Halved the number of falls (participant days in
  hospital)
• Haines et al. Clin Rehab 2007 21742-753

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My residents are too frail?

• Dose response curve
• The lower the baseline level of physical
  activity, the greater the health benefit
  associated with an increase in physical activity.
  Exercise can be adapted for any medical condition
• (Haskell 1994)

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Provision of Effective Group Exercise

• Physiotherapist

Postural Stability Instructor
Otago Exercise Programme Leader

• Seniors Exercise Instructor

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UKs FOUR EXERCISE GROUPS
REFERRAL
FALLS REHABILITATION GROUP
FaME PREVENTATIVE EXERCISE
CHAIR BASED EXERCISE GROUP
OTAGO HOME PROGRAMME
  Community Exercise for the Older Person Sessions
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SERVICE EVALUATION

• Average age 82 years, n124
• Average attendance 79
• Improved functional reach (plt0.01) Timed up
  go (plt0.05)
• Improved quality of life SF36 (plt0.05)
• Confidence in Balance (plt0.05)
• Timed Floor Rise (plt0.01)
• Simey, Skelton, Dinan, Land Irwin (BMJ letter,
  2001)

I can walk upstairs now. I havent been able to
walk upstairs for four years. I do my exercises
every day at home. I know its doing me good
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RECOMMENDATIONS

• Exercise works best within a multi-factorial
  intervention programme
• Exercise should have components of balance, low
  impact aerobic and strengthening components
• To be effective the exercise must be specific,
  regular (1-2 p/w), progressive, and exceed 15
  weeks duration for those at risk of falls and 9
  months for those who are already falling regularly