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Exercise for falls prevention: past, present and future
Professor Dawn Skelton
PhD MD h.c. Hon FCSP FRCP Edin
First attempts to change practice
2001 2004 2001
First attempts to raise awareness
1997 2001 2004
EU interest
2003-2007
2013-2016
Definition An unexpected event in which the participant comes to rest on the ground, floor, or lower level
Lay definition
Any fall including a trip or slip in which you lose your balance and land on the floor or ground or lower level
Lamb et al. 2005 JAGS
Repeated attempts to change practice
2012
2013
A lot on assessment and case finding, not a lot on detail of effective interventions!
National Indicators and getting GPs on board…
1996-9: BGS tried to get falls and fractures onto the Quality Outcomes Framework. No luck – too expensive! From 1st July 2017, all GPs to “use an appropriate tool, e.g. Electronic Frailty Index (eFI) to identify patients aged 65 and over who are living with moderate and severe frailty” [GP General Medical Services (GMS) contract, CQUINS] Will ask if the patient has fallen in the last 12 months and provide relevant interventions.
When do we become “fallers”?
When intrinsic (personal) abilities
to remain upright cannot cope
with extrinsic (external) risk
factors
Nervous system, reaction times
and gait speed slows
Balance and strength deteriorates
Frailty - a loss of physiological
reserve
FUNCTIONAL ABILITIES
Independent
Dependent
“Minor illness” eg UTI
Frailty syndromes (and falls) present in crisis
Hyper-acute Frailty syndromes:
• Immobility • Falls • Delirium • Fluctuating
disability • Incontinence
(Clegg, Young, Rockwood Lancet 2013)
3 Dimensions of Human Frailty
TIME
DISEASE DISUSE
HUMAN FRAILTY
Spirduso, 1995
Risk Factors for Falls
All fallers = fell at least once during follow up
Recurrent fallers = fell at least twice during follow up
All fallers (Odds Ratio)
Recurrent Fallers (Odds Ratio)
History of Falls 2.8 3.5
Gait Problems 2.1 2.2
Walking Aids Use 2.2 3.1
Vertigo 1.8 2.3
Parkinson’s Disease 2.7 2.8
Antiepileptic Drug Use 1.9 2.7
Physical Disability 1.6 2.4
Disability in Instrumental Activities in Daily Life 1.5 2.0
Fear of Falling 1.6 2.5
Deandrea S et al. Epidemiology. 2010;21: 658-668.
1-2% in functional ability p.a.
– Strength
– Power
– Bone density
– Flexibility
– Endurance
– Balance and co-ordination
– Mobility and transfer skills
Ageing affects all of us!
Sedentary behaviour accelerates the loss of performance...
Exercise to Prevent Falls
Exercise helps fallers and non-fallers in a number of ways:
• Reducing Falls (or injurious falls)
• Reducing known Risk Factors for falls
• Reducing Fractures ? (or changing the site of fracture)
• Increasing Quality of Life & Social Activities
• Reducing Social Isolation/Loneliness/Fear
• Reducing Institutionalisation
Sherrington et al 2008, 2011, Davis 2010, Campbell 2007, Skelton et al. 2001
Exercise Type ? Exercise Intensity ? Exercise Approach?
How often? How long for?
Wide range of abilities and needs
Secondary falls prevention exercise
• Otago Home Exercise Programme (OEP)
– 1 yr; 3 x p/w; 6 home visits and telephone
support
– 6 mths; 3 x p/w (1 p/w group, 2 p/w home)
exercise instructor
– Effects on strength and balance more pronounced
when run in a group
• Falls Management Exercise Programme
(FaME/PSI)
– 9 mths; 3 x p/w (one group, two home); includes
floorwork;
– Increases habitual physical activity as well
Falls Injuries
Cost effective >80s Cost neutral >65s
Cognitive Function
Falls Quality of Life
Bone Mineral Density Change of residence
Coping strategies Long lies
41% of falls services in the
UK employ a trained OEP
Leader
54% of falls services in the UK employ a trained
PSI (RCP Audit 2012)
(Campbell 1997; Robertson 2001; Campbell 2005; Liu_Ambrose 2008; Kyrdalen 2014; Skelton 2005, 2008)
What makes the difference?
• Greatest effects of exercise on fall rates
(38% reduction) from interventions
including:
– Highly challenging balance training
– High dose (50+ hours)
– Progressive strength training
– No walking program
• These types of exercise also reduce fear of
falling
Sherrington et al., JAGS 2008, NSWPHB 2011 Kendrick Cochrane Review FoF 2014
Effective Falls prevention exercise
• Emerging
– Different programmes for different populations
– Primary prevention VS targetting those at high risk / frequent fallers / frail older people
• Some exercise ineffective
• Some exercise unsafe
Sherrington et al. 2011;
Skelton et al. 2005; Campbell et al., 1997; Wolf et al. 1997; Iliffe et al. 2014; Kendrick et al. 2014
Overall (I-squared = 61.5%, p = 0.000)
Ebrahim, 1997
Barnett, 2003
Woo, Tai Chi, 2007
Luukinen, 2007
Campbell, 2005
Schoenfelder, 2000
Sihvonen, 2004
Lord, 2003
Buchner, 1997
Author,
Nowalk, Tai Chi, 2001
Mulrow, 1994
Day, 2002
Reinsch, 1992
Skelton, 2005
Wolf, Balance, 1996
Woo, Resistance, 2007
Wolf, Tai Chi, 1996
year
McMurdo, 1997
Korpelainen, 2006
Morgan, 2004
Campbell, 1999
Hauer, 2001
Voukelatos, 2007
Faber, Functional walking, 2006
Li, 2005
Lord, 1995
Schnelle, 2003
Steinberg, 2000
Faber, Tai Chi, 2006
Liu-Ambrose, Resistance, 2004
Lin, 2007
Bunout, 2005
Liu-Ambrose, Agility, 2004
Resnick, 2002
Latham, 2003
Madureira, 2007
Carter, 2002
Green, 2002
Toulotte, 2003
Wolf, 2003
Cerny, 1998
Sakamoto, 2006Rubenstein, 2000
Means, 2005
Protas, 2006
Suzuki, 2004
Campbell, 1997
Nowalk, Resist./Endurance, 2001
Robertson, 2001
0.83 (0.75, 0.91)
1.29 (0.90, 1.83)
0.60 (0.36, 0.99)
0.49 (0.24, 0.99)
0.93 (0.80, 1.09)
1.15 (0.82, 1.61)
3.06 (1.61, 5.82)
0.38 (0.17, 0.87)
0.78 (0.62, 0.99)
0.61 (0.40, 0.94)
Effect
0.77 (0.46, 1.28)
1.26 (0.90, 1.76)
0.82 (0.70, 0.97)
1.24 (0.77, 1.98)
0.69 (0.50, 0.96)
0.98 (0.71, 1.34)
0.78 (0.41, 1.48)
0.51 (0.36, 0.72)
size (95% CI)
0.53 (0.28, 0.98)
0.79 (0.59, 1.05)
1.05 (0.66, 1.68)
0.87 (0.36, 2.10)
0.75 (0.46, 1.25)
0.67 (0.46, 0.97)
1.32 (1.03, 1.69)
0.45 (0.33, 0.62)
0.85 (0.57, 1.27)
0.62 (0.38, 1.00)
0.90 (0.79, 1.03)
0.96 (0.76, 1.22)
1.80 (0.67, 4.85)
0.67 (0.32, 1.41)
1.22 (0.70, 2.14)
1.03 (0.36, 2.98)
0.71 (0.04, 11.58)
1.08 (0.87, 1.35)
0.48 (0.25, 0.93)
0.88 (0.32, 2.41)
1.34 (0.87, 2.07)
0.08 (0.00, 1.37)
0.75 (0.52, 1.08)
0.87 (0.17, 4.29)
0.82 (0.64, 1.04)0.90 (0.42, 1.91)
0.41 (0.21, 0.77)
0.62 (0.26, 1.48)
0.35 (0.14, 0.90)
0.68 (0.52, 0.89)
0.96 (0.63, 1.46)
0.54 (0.32, 0.91)
100.00
2.64
1.88
1.22
3.85
2.74
1.40
0.98
3.38
2.21
%
1.88
2.75
3.80
2.04
2.81
2.86
1.41
2.67
Weight
1.48
3.05
2.04
0.88
1.89
2.56
3.31
2.87
2.38
1.98
3.97
3.34
0.72
1.13
1.67
0.65
0.11
3.46
1.34
0.70
2.21
0.10
2.58
0.31
3.341.11
1.40
0.88
0.80
3.13
2.27
1.84
0.83 (0.75, 0.91)
1.29 (0.90, 1.83)
0.60 (0.36, 0.99)
0.49 (0.24, 0.99)
0.93 (0.80, 1.09)
1.15 (0.82, 1.61)
3.06 (1.61, 5.82)
0.38 (0.17, 0.87)
0.78 (0.62, 0.99)
0.61 (0.40, 0.94)
Effect
0.77 (0.46, 1.28)
1.26 (0.90, 1.76)
0.82 (0.70, 0.97)
1.24 (0.77, 1.98)
0.69 (0.50, 0.96)
0.98 (0.71, 1.34)
0.78 (0.41, 1.48)
0.51 (0.36, 0.72)
size (95% CI)
0.53 (0.28, 0.98)
0.79 (0.59, 1.05)
1.05 (0.66, 1.68)
0.87 (0.36, 2.10)
0.75 (0.46, 1.25)
0.67 (0.46, 0.97)
1.32 (1.03, 1.69)
0.45 (0.33, 0.62)
0.85 (0.57, 1.27)
0.62 (0.38, 1.00)
0.90 (0.79, 1.03)
0.96 (0.76, 1.22)
1.80 (0.67, 4.85)
0.67 (0.32, 1.41)
1.22 (0.70, 2.14)
1.03 (0.36, 2.98)
0.71 (0.04, 11.58)
1.08 (0.87, 1.35)
0.48 (0.25, 0.93)
0.88 (0.32, 2.41)
1.34 (0.87, 2.07)
0.08 (0.00, 1.37)
0.75 (0.52, 1.08)
0.87 (0.17, 4.29)
0.82 (0.64, 1.04)0.90 (0.42, 1.91)
0.41 (0.21, 0.77)
0.62 (0.26, 1.48)
0.35 (0.14, 0.90)
0.68 (0.52, 0.89)
0.96 (0.63, 1.46)
0.54 (0.32, 0.91)
100.00
2.64
1.88
1.22
3.85
2.74
1.40
0.98
3.38
2.21
%
1.88
2.75
3.80
2.04
2.81
2.86
1.41
2.67
Weight
1.48
3.05
2.04
0.88
1.89
2.56
3.31
2.87
2.38
1.98
3.97
3.34
0.72
1.13
1.67
0.65
0.11
3.46
1.34
0.70
2.21
0.10
2.58
0.31
3.341.11
1.40
0.88
0.80
3.13
2.27
1.84
Favours exercise Favours control
1.25 .5 1 2 4
Hidden perils
Sherrington et al., JAGS 2008, 2011
Or
Ineffective dose / balance challenge
Safe medical devices / Safe exercise
• Grabrails, stairlifts – all have to have QA/CE marks & safety/effectiveness evaluation
• ‘copies’ and ‘imports’ – safety/effectiveness??
• Exercise for falls prevention ?? Should it have the same stringent QA
– Secondary falls prevention - Physios/L4 Specialist Instructors – UK Exercise Referral Framework (Skills Active/REPs/CIMSPA)
– Primary falls prevention – L3 Ex Referral Instructors or L3 older adult instructors
NOT Brisk walking !!
• Women, previous upper arm fracture
• Excluded
– bisphosphonates, survival < 1yr,
cognitive impairment, too frail
• Intervention: Brisk walking
• Control: exercise of upper arm
• Falls risk (Brisk walking > control)
• Fracture risk (Brisk walking >control)
Ebrahim et al. (1997)
Walking – most common activity and most commonly recommended activity – many benefits but…
Keep on Walking.. Put strength and balance ‘on the map’ with walk leaders
Exercise opportunities in UK Falls Services
0
10
20
30
40
50
60
70
80
90
100
Bone Health Vision Gait & Balance
NICE
Assessment
Intervention
Direct
81% run strength and balance training classes (based on Otago and FaME)
BUT…..
Average once a week for 8 weeks!
Lamb et al, SDO report, 2008
Lack of fidelity….
• More than half the class seated
• Average duration 8 weeks and frequency once per week! = 8 hours!
• Little strength progression
– Ankle weights often not increased
– Max 2 therabands progression
Highly challenging balance?
Ineffective dose ?
Lack of strength
progression ?
No services record falls as outcomes, only strength and balance – all showed improvements BUT…. We have no idea if there were less falls
Transitioning onto other exercise opportunities
• Vital
– to meet effective dose requirements (>50 hours)
• Important
– to encourage an active lifestyle beyond rehabilitation
– to ensure a change in exercise habits and continue to improve social involvement
– to ensure the opportunities continue to improve strength and balance (eg. not seated!)
Fallers Exercise Continuum
CHAIR BASED EXERCISE GROUP
Referral/Assessment
Community Exercise Sessions
(Otago/FaME/Other)
OTAGO HOME EXERCISE
PROGRAMME
FALLS REHABILITATION GROUP
‘FaME’ COMMUNITY FALLS EXERCISE
GROUPS
In-Hospital Ward Out-patients groups
and individual training
Group/individual training
Out-patients Community based
Residential Settings
GP / Exercise
Referral
Tai Chi
Walking
Groups
Dance
….
Age UK Expert Series
• Dissemination: Translating
Research into Best Practice
• Clear easy read
• Reminders of the evidence
base
• Good examples of practice
• Good examples of evaluation
• Good examples of transitions
on after rehabilitiation
Meeting the guidelines?
The forgotten ones!
• Continuing focus on aerobic activity
• 2012–2014 Scottish Health Survey respondents
– 10,488 adults aged 16-64 yrs & 3857 >65s
• 31% percent of men and 24 % of women met the muscle strengthening guideline
– half that of published figures for aerobic physical activity.
• Only 19% percent of older men and 12 % of older women met the balance & co-ordination guidelines.
Strain et al. BMC Public Health (2016) 16:1108
Fear of Falling
• Fear and lack of confidence in balance predict – Deterioration in physical functioning – Decreases in physical activity, indoor and
outdoor – Increase in fractures – Admission to Institutional Care
(Arfken 1994, Vellas 1997, Cumming 2000, Horne 2011)
“It’s the fear that restricts me. In my mind I know that I can’t [walk outside]. The fear of falling and not having the strength to go out, that stops me from going out…” (Female, 60yrs)
Challenges
• Cultural norm is for older people to sit!
• They sit for 8-12 hours of their day
• We encourage them to sit – everywhere!
• If they attend rehabilitation or exercise they are then sedentary the rest of the day and next day! (fatigue, compensation)
• We need to tackle sedentary behaviour!
Sedentary Behaviour (prolonged sitting)
Active bone and strength loss
• No standing activity leads to active loss of bone and muscle
• 1 wk bed rest leg strength by ~ 20%
• 1 wk bed rest spine BMD by ~1%
• Sedentary Behaviour linked to low BMD (independent of physical activity).
• Nursing home residents and those in hospital spend 80-90% of their waking day seated or lying down
(Krolner 1983; Tinetti 1988; Skelton 2001; Dallas Bed Rest Studies 1966-present; Chastin et al. 2011; Beyer 2002)
Sedentary behaviour health risks
In older adults (>60 years old), sedentary behaviour has been found to be significantly associated with:
Sedentary behaviour is also linked to musculoskeletal pain and can affect quality of life, social inclusion and engagement
• Higher plasma glucose • Higher BMI and waist:hip ratio • Higher cholesterol • Reduced muscle strength • Reduced bone density • More falls / frailty
Gennuso et al (2013) Med Sci Sports Exerc.; Skelton (2001) Age Ageing; Chastin et al (2014) Bone.; WHO (2010) Global Recommendations on Physical Activity for Health
• Hospital admission in past 12 months single most
predictive risk for functional decline
• Functional decline after hospital discharge 10% to
50%
• Optimizing physical activity of patients low priority compared to patient safety
• Some felt movement was unsafe without physiotherapy input
• No mobility action plans
Arnaua et al. 2016; Buurman et al. 2011; Helvik et al. 2013); Krumholz, 2013;
Resnick et al. 2015; Brown et al. 2009
Intervening on sitting time
• Two ways of thinking about ‘sitting less’
– Reduce time spent sitting
– Break up periods of sitting (‘sitting bouts’)
SOS Study – over 10 weeks, adding 10-15 sit to stands a day improved timed up and go (-3 sec) and 30s chair rise (+2) in sheltered housing residents
Harvey et al. In press.
Home Based Exercise Resources
• Home exercise booklets translated www.profound.eu.com
• In 14 EU languages
Support and Encouragement
A programme is more than a series of exercises
• Examples from successful falls and exercise programmes • A range of strategies that support participants eg.
– Goal setting and self monitoring
– Overcoming obstacles and difficulties
– Educating the participant
– Highlighting successes
– Providing individual and group support
• Those who have trained in motivational training for older people have better uptake and adherence to their sessions
• Work effectively with those in transition - Frailty and falls
– Safe and effective exercise for those in transition and those who are frail
– Transitions and progressions
– Qualified trainers who understand tailoring/adaptation for multiple conditions, progression and challenge needed, trained to support motivation to adhere and transition on
• Change cultural ‘norms’! – sit less, move more
• Involve older people in engaging other older people
Scaling up to reduce frailty and falls?
Older people as role models and mentors – ‘someone like me’
Scaling up to reduce frailty and falls?
• All ‘contacts’ with older people need to reinforce the move more often message
– Move more often and improve your strength and balance
– Lets stop compounding the problem by not taking every opportunity (eg. Hospital wards and care homes!)
• Raise awareness of physical activity guidelines
– Amongst professionals and older people!
• Increase opportunities for primary prevention
– Effective improvement of strength and balance in all settings
– Map out what’s there and where people can access this
“Life in your years”
- requires more than just stamina and energy, requires strength and balance to feel confident in all other
activities you go on to do.... Its never too late!
