Transcript Specialist PSI Exercise Module

EXERCISE FOR THE
PREVENTION OF FALLS AND
INJURIES IN FRAILER OLDER
PEOPLE
‘PSI’ INSTRUCTOR COURSE
A SPECIALIST NATIONAL TRAINING
INITIATIVE
Specialist PSI Exercise Module
WHY?
• Need for training to:
– Support national accident prevention targets
– Ensure greater consistency of provision
– Ensure best practice
• Need for training that is:
– Specialist
– Evidence-based
– Practical
– Interdisciplinary
– Recognised
Specialist PSI Exercise Module
WHO?
• Department of Health
• Merton, Sutton & Wandsworth Health Authority
• Advisory Group of National Experts
• 1999 first pilot run
• To date over 2000 PSI instructors have qualified 
Specialist PSI Exercise Module
Interested Co-workers
Specialist PSI Exercise Module
WHAT?
• First Recognised National Qualification
• Postural Stability Instructors (PSIs)
• Register of Exercise Professionals (REPS) at
Level 4
– CPD at Level 3
• Chartered Society of Physiotherapy (CSP)
Endorsed training
• Accredited by Queen Margaret University
(QMU)
• Guidelines and Consensus Recommendations
Specialist PSI Exercise Module
HOW?
•
•
•
•
•
Underpinning Knowledge
Application to Practice
Practical
Case Study
Continuing Professional Development
Specialist PSI Exercise Module
AN INTERPROFESSIONAL NETWORK
• Multifactorial Nature of Falls
• Multiprofessional Skills
• District Nurse
• Family/Carers
• General
Practitioner
• Health Visitor
• Chiropodist
•A & E
• Hospital Doctors
• Hospital Therapists
• Ambulance Services
• Social Services
• Community therapy
services
• Pharmacist
• Leisure Services
• Professional Liaison
• Respecting Boundaries/Building Trust
• Patient Centred
Specialist PSI Exercise Module
ACCIDENT &
EMERGENCY
AMBULANCE
SERVICES
PRIMARY CARE
GP
ROUTES INTO
THE FALLS
SECONDARY
CARE
VERY SHELTERED/
RESIDENTIAL HOME/
NURSING HOME
EXERCISE
PATHWAY
SELF REFERRAL
SOCIAL SERVICES
PRE-EXERCISE ASSESSMENT
REHABILITATION
EXERCISE
PSI
CHAIR BASED
EXERCISE
Specialist PSI Exercise Module
THE THREE EXERCISE GROUPS
REFERRAL
FALLS REHABILITATION
GROUP
PSI
CHAIR BASED
EXERCISE GROUP
Exercise for the Older Person Sessions
Specialist PSI Exercise Module
THE EXERCISE
REGISTER UK
High
Risk
Specialist Exercise Instructor
Clinical Exercise
MSc
Patient
Specialist Exercise Instructor
Postural Stability
NVQ4
Physically frail
housebound/outpatient
Independent with
assistance/aids/carer
Populations
Medium Risk
Independent with
assistance/aids
Advanced Exercise Instructor
Exercise Referral
NVQ4
Advanced Exercise Instructor
Exercise for the Older Person
NVQ3
Independently mobile
older people
Special Populations
Low Risk
OTAGO Exercise Leader
Chair-based Exercise Leader
NVQ2/3
General Populations
Dinan, 1999
Exercise Instructor
NVQ2
Specialist PSI Exercise Module
While I have been talking…..
• 4 older people will have been seriously
injured...
• 6 older people will have had a minor injury..
…..as a result of a fall at home
Specialist PSI Exercise Module
While we are here today...
• 900 older people will have had a minor
injury..
• 122 older people will have been seriously
injured..
• 33 older people will never return home…
….as a result of a fall at home
Specialist PSI Exercise Module
FaME into practice
A Four Point Plan to:
Improve Balance and co-ordination
Increase Functional Capacity
Increase Bone and Muscle Mass
Increase Confidence (reduce fear of falling)
Includes:
7 Evidence Based Activities
Specialist PSI Exercise Module
1. Dynamic endurance
training for balance
Specialist PSI Exercise Module
2. Dynamic balance
training
Specialist PSI Exercise Module
Specialist PSI Exercise Module
3. Targeted resistance training (weights, bands and body weight) including
targeted bone loading
for leg and ankle strength
for arm and back
open & closed chain
Specialist PSI Exercise Module
4. Backward chaining
Specialist PSI Exercise Module
5. Functional floor activities
Specialist PSI Exercise Module
6. Flexibility training for leg and ankle, chest, spine
Specialist PSI Exercise Module
7. Sustained, three dimensional
adapted Tai Chi training
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Prevalence and
Consequences of Falls
- Injurious falls
- Non-injurious falls
- Location of falls
- Direct and Indirect costs
- Fear of falling
- Long Lies
Specialist PSI Exercise Module
1 person dies every five
hours as a result of a
fall in the UK
• One in three people aged > 65
years fall each year
• One in two people aged >80
years falls each year
• After the first fall, there is a 60
per cent chance of falling again
• No two fallers are the same!
• 75-80% of falls are not reported
to a health professional
Specialist PSI Exercise Module
What is a fall?
• “an unexpected event in which the participant comes to rest on the ground,
floor, or lower level’” (ProFaNE, 2005)
• With a layman’s definition of:
– ‘. . . have you had any fall including a slip or trip in which you lost your
balance and landed on the floor or ground or lower level?’
 Includes: tumbling down the stairs, falling up stairs, falling onto a
chair, the bed or the floor, sliding out of bed, slipping in the bath
 Does not include: tripping and correcting yourself, banging into the
wall, being knocked or pushed over
Specialist PSI Exercise Module
Saving Lives - Our Healthier
Nation
• National Priority:
– To reduce the rate of accidents - defined as those
requiring a visit to a hospital or consultation with a
doctor - by at least a fifth by 2010, from a baseline at
1996.
Specialist PSI Exercise Module
National Service Framework for
Older People 2001
Standard 6: Falls.
• To reduce the number of falls which result in serious injury and ensure
effective treatment and rehabilitation for those who have fallen
Key Interventions:
• Prevention – including prevention and treatment of osteoporosis
• Improving the diagnosis, care and treatment of those who have fallen
• Rehabilitation and long-term support
Individualise prevention:
• …identifying those most at risk
• …balance, gait and mobility problems
Specialist PSI Exercise Module
NICE CG21 Falls (2004)
•
•
•
•
Case/risk identifications
Multi-factorial falls risk assessment
Multi-factorial interventions
Education and information for patients and
carers
• Healthcare staff training
Specialist PSI Exercise Module
Why?
DoH Prevention Package
2009
• Every five hours in England, an older person dies as a result of a fall.
• For a primary care trust with a population of around 300,000 this
means:
– 15,500 older people will fall each year
– 2,200 of those will attend A & E or minor injuries clinic, and a similar
number will call an ambulance
– 1,100 will sustain a fracture
• 300 of which will be of the hip
Specialist PSI Exercise Module
Dept of Health Prevention
Package (2009)
Hip
fracture
patients
Non-hip fragility
fracture patients
Individuals at high risk
of 1st fragility fracture or
other injurious falls
Older people
Objective 1: Improve outcomes and
improve efficiency of care after hip fractures
– by following the 6 “Blue Book”
standards
Objective 2: Respond to the first fracture,
prevent the second – through Fracture
Liaison Services in acute and
primary care
Objective 3: Early intervention to restore
independence – through falls care
pathway linking acute and urgent
care services to secondary falls
prevention
Objective 4: Prevent frailty, preserve bone
health, reduce accidents – through
preserving physical activity,
healthy lifestyles and reducing
environmental hazards
Specialist PSI Exercise Module
Competing priorities?
Issues
Strokes &
TIAs
Heart Attacks
Fragility
Fractures
Incidence/
year
110,000
275,000
310,000
Current trend
Falling
Falling
Rising
NHS bed days
£1.8 m
£1.15 m
£1.57 m
Annual costs
£2.8 bn
£1.7 bn
£1.8 bn
Specialist PSI Exercise Module
Falls in women over 1 year
25
20
15
%
1 fall
2 falls
3+ falls
10
5
0
65-74
75-85
Age group
85+
Lord 1993
Specialist PSI Exercise Module
Age-specific mortality rates-accidents
among older people
Source: OPCS
Rates per million
1600
65-74
1200
75-84
800
85+
400
0
Men
Women
FALLS
Men
Women
TRAFFIC
Men
Women
FIRE AND
FLAMES
Men
Women
OTHER
Specialist PSI Exercise Module
Deaths from home accidents in older people
Source: Home accident surveillance system, UK, 1987
% deaths from accidents
80
70
65-74
60
75+
50
40
30
20
10
0
Fracture
Concussion
Poisoning/
suspected
poisoning
Foreign Body
Burn/ scald
Other
Specialist PSI Exercise Module
Falls
Rates per million
1600
1400
1200
Falls
Men
1000
800
Falls
Women
600
400
200
0
65-74
75-84
85+
Age (years)
Specialist PSI Exercise Module
How common are falls?
• In those aged over 75, falls are the leading cause of
death resulting from injury
• A third of >65s and a half of >80s fall at least once a
year
• 10% of all call-outs for London Ambulance Service
are for people aged 65+ who have ‘fallen’.
– > 40% are not even taken into Hospital.
Specialist PSI Exercise Module
Reported falling by age and sex
50
40
% fallen 30
in last
month 20
Men
Women
10
0
75-79
80-84
85-89
90-94
95+
Cambridge City Over 75s Cohort Study, Fleming, 2002
Specialist PSI Exercise Module
Reported falling by Residence
50
40
75-84
85+
% fallen 30
in last
month 20
10
0
Institutional
Care
Sheltered
Housing
House/flat
Cambridge City Over 75s Cohort Study, Fleming, 2002
Specialist PSI Exercise Module
Time and Location of Reported
Falls
100
Men
Women
80
% fallen
60
in last
three
40
months
20
0
Day
Night
Indoors
Outdoors
Cambridge City Over 75s Cohort Study, Fleming, 2002
Specialist PSI Exercise Module
Indoor location of falls
35
30
25
% of 20
all falls 15
65-74
75-84
85+
10
5
0
Level Shower / Getting On Stairs Chair /
Surface
Bath
Out of
Ladder
Bed
Lord 1993
Specialist PSI Exercise Module
Reported falling by distance of
walking ability
40
30
%
20
10
0
Around town
1 block
Garden Gate Only indoors
A few steps
Cambridge City >75s Cohort, Fleming, 2002
Specialist PSI Exercise Module
Reported falling by need for
help with walking
50
40
% fallen
in last
month
30
20
10
0
No aid
Stick
Frame
Someone to
help
Wheelchair
Cambridge City Over 75s Cohort Study, Fleming, 2002
Specialist PSI Exercise Module
Types of Injurious falls
• One which results in a visit to or by a health professional.
• 20% of injurious falls result in fractures requiring hospital
treatment.
• Other injuries include:
–
–
–
–
–
–
Cuts and lacerations,
Deep bruises,
Soft Tissue Injuries,
Dislocations,
Sprains
Increase in joint pain
Specialist PSI Exercise Module
Types of ‘fallers’
•
FLOF
Found Lying On the Floor
•
FAOP
Falling All Over the Place
•
FBS
Fall Back Syndrome
•
3F syndrome
Fear of Falling Further
•
3G syndrome
Grabbing Great Grandmother
•
3P syndrome
Patient with Precocious parking
•
FNOF
Fractured Neck Of Femur
Medical
Intrinsic
Intrinsic
Fear
Medical &
Intrinsic
Specialist PSI Exercise Module
Changing incidence of fractures
with increasing age
• 50 to 65 yrs - wrist
• 55 to 85 yrs - spine
• 75 to 85 yrs - hip
(because of poor reaction,
coordination and reflexes)
Specialist PSI Exercise Module
Consequences of Hip
Fracture
• By Year 2031 = 96,000 hip fractures a year.
• Risk of a hip # 10x higher for those in residential settings than in
own home
• 50% of individuals will die, move into a nursing home or be in hospital
within six months of Hip #
• 80% do not regain pre-fracture mobility
• underlying medical conditions, poor strength, balance and muscle
asymmetry all contribute to poor outcome
Specialist PSI Exercise Module
Consequences to the
individual
• Falls and instability contribute to 40% of nursing home
admissions.
• Post-fall syndrome - psychological sequelae
• Reduction in independence and social contact
• Depression
• Frequent fallers (>3 p.a.) have poor outcomes. Nearly a third
admitted to hospital, transferred to nursing home or had died
one year later
(Lord et al., 1992).
Specialist PSI Exercise Module
Long lies with or without injury
• Long lies (> 1-2 hours) lead to an increased risk of:
– dehydration
– hypothermia
– pneumonia
– pressure sores
– kidney failure
– depression
– post fall syndrome
– death
(Tinetti 1993, 1994)
Specialist PSI Exercise Module
DoH Prevention
Package 2009
Counting the cost
• Hip fractures cost the NHS in England £1.8 billion a year.
• The direct cost to commissioners of a hip fracture is estimated to be
£10,000 – plus the cost of local authority social care.
• One-third of people who experience a hip fracture are unable to
continue to live independently afterwards.
• An effective falls and fracture prevention service can make direct
savings of £290,708 over five years for a primary care trust with a
population of 320,000.
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Physical Activity, Older People and
Falls: Research Update
• The effects of ageing on performance
• Exercise to prevent falls
• Holistic benefits of exercise
• Inactivity in the UK
• Exercise as part of a multifactorial intervention
Specialist PSI Exercise Module
AGEING AFFECTS ALL OF US
1-2%
in functional ability p.a.
– Strength
– Power
– Bone density
– Flexibility
– Endurance
– Balance and co-ordination
– Mobility and transfer skills
Sedentary behaviour accelerates the loss of
performance...
Specialist PSI Exercise Module
QUADRICEPS STRENGTH
Men
Women
10
8
6
Threshold
level of
strength for
independence
4
2
70-74
65-69
60-64
Age (years)
55-59
70-74
65-69
60-64
55-59
0
50-54
Strength to be confident of rising
from low chair without using arms
50-54
Knee extension strength (N/kg)
12
Specialist PSI Exercise Module
FUNCTION FOR LIFE
 Wash hair comfortably?
 20% women & 14% of men > 50 do not have sufficient
shoulder flexibility
 Confident of getting out of a chair without using arms ?
 25% women & 7% men aged 70 – 74 do not
have sufficient leg strength
 Ease of stair use?
 47% women aged 70 – 74 do not have
sufficient leg power
 Walk comfortably at a 20 minute a mile pace?
 Nearly 10% men & over 35% women aged 50 – 74 do
not have sufficient aerobic capacity
 35% men and 80% women aged 70 – 74
Specialist PSI Exercise Module
Sedentary vs active lifestyles
• >3 hrs per week targeted exercise
– myocardial infarct - 3 x less likely
– Osteoporosis - 2 x less likely
– Fall-related injuries & Hip fracture - 2 x less likely
• WHO, 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”
– WHO, 2011 “physical activity (for 65+ year olds)
– improves cardiorespiratory and muscular fitness, bone and functional health, and
reduces the risk of NCDs, depression and cognitive decline”
Specialist PSI Exercise Module
Exercise to Prevent Falls
Exercise could help 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 Fear
Reducing Long Lies
Reducing Institutionalisation
Specialist PSI Exercise Module
Fracture Prevention Triangle
Exercise can
increase BMD and
alter bone properties
Exercise can reduce
falls
FALLS
FRAGILITY
FRACTURE
Exercise can
increase muscle
strength (padding)
and improve reaction
times
FORCE
Specialist PSI Exercise Module
Specificity of Exercise to Reduce Falls
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
Robertson, 2001
Home-based exercise >65’s and >80’s
Day, 2002
Group exercise >70’s at risk
Barnett, 2003
Group exercise >65’s at risk
Lord, 2003
Group exercise >60’s retirement village
Means, 2003
Group exercise >65’s, psychosocial effects
Liu-Ambrose, 2004
Group exercise for >75s with low bone mass
Skelton, 2005
Group exercise >65’s frequent fallers
Specialist PSI Exercise Module
Not “ALL” Exercise works to
Prevent Falls
Effective
Ineffective to prevent falls
but effective on falls risk
factors…………
Barnett 2003
Lord 2003
Morgan 2004
Skelton 2005
Buchner 1997
Campbell 1997
Campbell 1999
Cornillon 2002
Day 2002
Robertson 2001
Wolf 1996
Bunout 2005
Campbell 1999, 2005
Carter 2002
Ebrahim 1997
Latham 2003
Lord 1995
McMurdo 1997
Mulrow 1994
Pereria 1998
Reinsch1992
Schnelle 2003
Steinberg 2000
Wolf 2003
• Insufficient tailoring
• Insufficient duration
• Too much time seated
• Not an emphasis on strength
and balance
• Not delivered by trained
personnel
• Not progressive
• Not intensive enough
Specialist PSI Exercise Module
Effective Duration of Exercise
Provision / Benefit
• Strength, Power, Static balance, Gait
8-12 wks
• Dynamic balance, Endurance
12-24 wks
• Bone strength (hip, spine and wrist)
36+ wks
• Dizziness and Postural Hypotension
24+ wks
• Transfer skills
24+ wks
• Mood, Depression, anxiety, self-esteem
12+ wks
• Falls
15-52 wks
Specialist PSI Exercise Module
Interventions in the
community
• Update of 2009 review
•
• 159 trials with 79,193
participants
• most common interventions
tested
Group and home-based exercise
programmes, and home safety
interventions delivered by an occupational
therapist reduce rate of falls and risk of
falling.
• Multi-factorial assessment and
– exercise as a single
intervention programmes reduce rate of
intervention (59 trials)
falls but not risk of falling;
– Multi-factorial programmes • Tai Chi reduces risk of falling.
(40 trials)
Gillespie et al. Interventions for preventing falls in older people living in the community.
Cochrane Library 2012
Specialist PSI Exercise Module
Exercise interventions
• Multiple-component group exercise significantly reduced rate of falls
(RaR 0.71; 16 trials) and risk of falling (RR 0.85; 22 trials)
• Multiple-component home-based exercise (RaR 0.68; 7 trials; and RR
0.78; 6 trials).
• Multiple-component exercise (balance and strength training)
embedded in activities of daily living in people with a history of falls
significantly reduced rate of falls (RaR 0.21; 1 trial) but not risk of falling.
• Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR
0.72; 5 trials) but Tai Chi did significantly reduce risk of falling (RR 0.71; 6 trials).
Gillespie et al. Interventions for preventing falls in older people living in the community.
Cochrane Library 2012
Specialist PSI Exercise Module
New Zealand RCTs - OTAGO
Individually tailored programme: Campbell, BMJ 1997
-80+ years, n=233, home-based, physiotherapist
-1 year, falls  32%, injuries  39%
Nurse delivered programme at home: Robertson, BMJ 2001
-75+ years, n= 240, home-based, district nurse
-1 year, falls  46%,  serious injuries and hospital costs
Nurse programme at GP centres: Robertson, BMJ 2001
-80+ years, n=450, home-based, general practice nurse
-1 year, falls  30%, injuries  28%
Visually Impaired Older People: Campbell, BMJ 2005
-1 year, home-based. Only effective with full compliance, falls 28%
6 month programme: Liu-Ambrose, JAGS 2008
-70+ years, home-based, cognitive function improvements after 6 months and after
1 year falls 47%
Specialist PSI Exercise Module
FaME – Group & Home-based
• Randomised controlled trial – Exercise Only
• Women aged 65+, > 3 falls last year
• Exercise-only intervention – 9 months
• Falls decreased by 60%
• Injurious falls decreased by 75%
• Skelton et al. Age Ageing 2005
Co-workers: O.Rutherford and S.Dinan
Specialist PSI Exercise Module
STRENGTH / POWER / ASYMMETRY
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%
Specialist PSI Exercise Module
BALANCE & MOBILITY
Mean % change (from baseline) post-training
120
Exercise Group
Control Group
80
40
0
-40
Balance-eyes open
(secs)
Balance-eyes
closed (secs)
Functional Reach
(cm)
Timed Up and Go
(sec)
Floor rise (sec)
Specialist PSI Exercise Module
BONE
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
Specialist PSI Exercise Module
FALLS
DURING INTERVENTION
controls (RR 1.19)
•
less likely to have injurious fall (RR 0.51)
DURING FOLLOW UP
•
Exercisers had half the risk of falls
compared to controls (RR 0.53)
•
1.8
1.6
1.4
Exercisers slightly increased risk of falls
Relative Risk
•
compared to
1.2
1
0.8
0.6
0.4
0.2
0
Intervention
Follow-up
++ less likely to have injurious falls (RR 0.39)
THREE YEARS FROM BASELINE
•
10% of exercisers had died, were in Hospital /in a nursing home vs 33% of controls
Specialist PSI Exercise Module
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 anxiety and fear
Confidence
• Fallen Angels Club
– Meet every two months in Starbucks, Oxford Street, London, UK!
Specialist PSI Exercise Module
MORBIDITY AND MORTALITY
80% of over 80’s would rather be dead than suffer the loss of
independence that moving to a nursing home would bring
(Salkeld, 2000).
• It’s NEVER TOO LATE
(Fiatarone, 1990)
Specialist PSI Exercise Module
Can exercise prevent fractures?
• Fractures more common in sedentary
people
• Cochrane Review suggests that
exercise does reduce risk of fractures
(2009 & 2012)
• It is possible to increase BMD in older
people (Welsh 1996; Kohrt 1995; Verschueren
2004)
• It is possible to increase BMD in fallers
(Skelton 2005; Liu Ambrose 2004)
Specialist PSI Exercise Module
Author,
year
Effect
size (95% CI)
Barnett, 2003
Bunout, 2005
Buchner, 1997
Campbell, 1997
Campbell, 1999
Campbell, 2005
Carter, 2002
Cerny, 1998
Day, 2002
Ebrahim, 1997
Faber, Functional walking, 2006
Faber, Tai Chi, 2006
Green, 2002
Hauer, 2001
Korpelainen, 2006
Latham, 2003
Li, 2005
Lin, 2007
Lord, 1995
Lord, 2003
Liu-Ambrose, Resistance, 2004
Liu-Ambrose, Agility, 2004
Luukinen, 2007
McMurdo, 1997
Madureira, 2007
Means, 2005
Morgan, 2004
Mulrow, 1994
Nowalk, Resist./Endurance, 2001
Nowalk, Tai Chi, 2001
Protas, 2006
Reinsch, 1992
Resnick, 2002
Robertson, 2001
Rubenstein, 2000
Sakamoto, 2006
Schoenfelder, 2000
Schnelle, 2003
Sihvonen, 2004
Skelton, 2005
Steinberg, 2000
Suzuki, 2004
Toulotte, 2003
Voukelatos, 2007
Wolf, Tai Chi, 1996
Wolf, Balance, 1996
Wolf, 2003
Woo, Tai Chi, 2007
Woo, Resistance, 2007
Overall (I-squared = 61.5%, p = 0.000)
0.60 (0.36, 0.99) 1.88
1.22 (0.70, 2.14) 1.67
0.61 (0.40, 0.94) 2.21
0.68 (0.52, 0.89) 3.13
0.87 (0.36, 2.10) 0.88
1.15 (0.82, 1.61) 2.74
0.88 (0.32, 2.41) 0.70
0.87 (0.17, 4.29) 0.31
0.82 (0.70, 0.97) 3.80
1.29 (0.90, 1.83) 2.64
1.32 (1.03, 1.69) 3.31
0.96 (0.76, 1.22) 3.34
1.34 (0.87, 2.07) 2.21
0.75 (0.46, 1.25) 1.89
0.79 (0.59, 1.05) 3.05
1.08 (0.87, 1.35) 3.46
0.45 (0.33, 0.62) 2.87
0.67 (0.32, 1.41) 1.13
0.85 (0.57, 1.27) 2.38
0.78 (0.62, 0.99) 3.38
1.80 (0.67, 4.85) 0.72
1.03 (0.36, 2.98) 0.65
0.93 (0.80, 1.09) 3.85
0.53 (0.28, 0.98) 1.48
0.48 (0.25, 0.93) 1.34
0.41 (0.21, 0.77) 1.40
1.05 (0.66, 1.68) 2.04
1.26 (0.90, 1.76) 2.75
0.96 (0.63, 1.46) 2.27
0.77 (0.46, 1.28) 1.88
0.62 (0.26, 1.48) 0.88
1.24 (0.77, 1.98) 2.04
0.71 (0.04, 11.58)0.11
0.54 (0.32, 0.91) 1.84
0.90 (0.42, 1.91) 1.11
0.82 (0.64, 1.04) 3.34
3.06 (1.61, 5.82) 1.40
0.62 (0.38, 1.00) 1.98
0.38 (0.17, 0.87) 0.98
0.69 (0.50, 0.96) 2.81
0.90 (0.79, 1.03) 3.97
0.35 (0.14, 0.90) 0.80
0.08 (0.00, 1.37) 0.10
0.67 (0.46, 0.97) 2.56
0.51 (0.36, 0.72) 2.67
0.98 (0.71, 1.34) 2.86
0.75 (0.52, 1.08) 2.58
0.49 (0.24, 0.99) 1.22
0.78 (0.41, 1.48) 1.41
0.83 (0.75, 0.91) 100.00
.25 .5
Favours exercise
1
2
%
Weight
Systematic
Review of
Exercise and
Falls
But would you
want to be in
these sessions?
17%
reduction
in falls
Sherrington et al., 2008 and
2011
4
Favours control
Specialist PSI Exercise Module
What makes the difference?
• Greatest effects of exercise on fall rates
from interventions including:
– Highly challenging balance training
– High dose (50+ hours)
– No walking programme
Sherrington et al., JAGS 2008, NSWPHB 2011
Specialist PSI Exercise Module
Conclusion of 2011 Systematic Review –
Best Practice Recommendations:
• Exercise must provide a moderate/high challenge to balance
• Sufficient exercise dose (50 hours)
• Ongoing exercise
• Target general community as well as those at high risk
• Brisk Walking should not be prescribed to high risk individuals
• Strength training may be included in addition to balance
Sherrington et al., 2011
Specialist PSI Exercise Module
WHAT’S THE DIFFERENCE?
Gardening
• Physical Activity
– any bodily movement produced by
skeletal muscles that results in energy
expenditure.
DIY
Housework
Bowling
• Exercise
– planned, structured and repetitive
bodily movement undertaken to
improve or maintain one or more
components of physical fitness.
Bouchard 1990
Walking
Cycling
Exercise class
Sports
Specialist PSI Exercise Module
THE BENEFITS OF EXERCISE
Prevention of :
disease
Coronary Heart Disease, Osteoporosis, Obesity,
Stroke, Depression, Type 2 Diabetes,
Hypertension, Some Cancers
disability
Arthritis, Intermittent claudication, Angina,
Sleep, Low back pain
complications of
immobility
Constipation, Deep vein thrombosis,
isolation
Socialisation, Self-efficacy, Confidence
dependence
Functional ability, Falls, Autonomy, Dignity,
Caring skills
Oedema, Pressure sores
Specialist PSI Exercise Module
BENEFITS OF REGULAR PHYSICAL
ACTIVITY
IMPROVES OR MAINTAINS
•
•
•
•
•
Good posture & body image
Intake of nutrients and immunity to infection
Cerebral function, mood, memory
Sleep pattern and duration
Social contacts
INDEPENDENCE
AND QUALITY
OF LIFE
REDUCES OR PREVENTS
•
•
•
•
Falls risk and fear of falling
Breathlessness, fatigue
Incontinence, urinary urgency
Anxiety, Depression, Stress
DEPENDENCE
AND ISOLATION
Specialist PSI Exercise Module
New CMO Guidelines for Older adults
(Start Active, Stay Active 2011)
• Older adults should aim to be active daily. Over a
week, activity should add up to at least 150 minutes
of moderate intensity activity in bouts of 10 minutes
or more.
• Older adults should also undertake physical activity to
improve muscle strength on at least two days a
week.
• Older adults at risk of falls should incorporate physical
activity to improve balance and co-ordination on at
least two days a week.
• All older adults should minimise the amount of time
spent being sedentary (sitting) for extended periods.
82
Specialist PSI Exercise Module
A VISCIOUS CYCLE OF INACTIVITY
Physical deterioration
- Heart disease
- High blood pressure
- Aches and pains
- Osteoporosis
Further decrease
in
physical activity
Social / psychological
ageing
- Feeling ‘old’
- ‘Acting’ one’s age
- Increased stress
- Anxiety, depression
- Low self-esteem
Increasing age
Less exercise
Decreased physical
abilities
- Increased body fat
- Sagging muscles
- Decreased energy
Specialist PSI Exercise Module
UK’S SEDENTARY WAYS
• 40% of people aged 50 or over in the UK are sedentary
• 60-85% are sedentary in ethnic minority groups
 Half of the sedentary over 50’s and 2/3 of
over 70’s believe they take part in enough
physical activity to keep fit.
Specialist PSI Exercise Module
Inactivity related disease?
• Disuse rather than disease?
• 1 wk bed rest  strength by ~ 20%
• 1 wk bed rest  spine BMD by ~1%
• Nursing home residents spend 80-90%
time seated or lying down
to ‘Inactivity related
of their
- leading
disability’
Specialist PSI Exercise Module
Walk with me !
• Walk from Home - Keighley
Mary Moffat - 93
– Referred by physio after a fall
– Loss of confidence and fear of
falling
– Isolated and lonely and dependent
upon others to get out
Specialist PSI Exercise Module
BUT not all physical activity is
safe for fallers!
• RCT Increasing physical activity in people with previous upper arm fracture
(Ebrahim 1997)
• Intervention: Brisk walking
• Control: exercise of upper arm
• Falls risk ↑ (Brisk walking > control)
• Fracture risk ↑ (Brisk walking > control)
NICE 2004 &
Sherrington 2011
do not recommend
brisk walking!
• Beware unsafe pavements!
• PA / Exercise has a complicated relationship with falls – more activity increases
exposure to risk….
Specialist PSI Exercise Module
Physical Activity vs Falls
• Brisk walking correlates with better postural stability in postmenopausal
women (Brooke-Wavell 1998).
– Yet a brisk walking intervention in fallers caused an increased incidence of falls
and fractures (Ebrahim 1997)
• Most falls occur at periods of maximal activity (Luukinen 1994)
– Yet, Hip fractures are less common in active people (Gregg 1998)
• U-shaped relationship in amount of physical activity and number of falls
(Gregg 1998)
• Community dwelling frequent fallers are less habitually active than nonfallers (Skelton 2002)
Specialist PSI Exercise Module
Unsupported forward flexion may be risky for those
with previous spinal fractures…….
Type of Exercise
Reoccurrence
of Fracture
• Back extension
16%
• Flexion (abd. curls)
89%
• Combined
53%
• No exercise
67%
Sinaki & Mickelson 1982
Specialist PSI Exercise Module
Patients in Hospital
• 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
Specialist PSI Exercise Module
Exercise alone? In high risk
7% reduction in fall rate in residential care settings
but this was not statistically significant (p=0.446)
Sherrington et al, 2011
BUT interventions which
provided a challenge to
balance, a high dose of
exercise and no walking
were close to significant
SO….same
recommendations apply
Specialist PSI Exercise Module
Part of a multi-factorial
intervention…care homes
Reduces falls - Becker et al. JAGS 2003
Improves mobility - Jensen et al. Aging Clin Exp Res 2004
Reduces falls risk factors - Dyer et al. Age Ageing 2004
Works better in those with cognitive impairment!!! – Rapp et al. 2008
Specialist PSI Exercise Module
Population Approaches including increasing
physical activity
Do they work?
• Significant decreases or downward trends in fall-related
injuries reported in five large studies
• Relative reduction in fall-related injuries 6 to 33%
• All Interventions included
– Education, advice, medication use, footwear, home hazard reduction,
promotion of physical activity
• Some included
– public lighting, public roadways, housing planning
McClure et al. 2005 Systematic Review
Specialist PSI Exercise Module
Comparison to NICE guidance
100
90
80
70
60
NICE
Assessment
Intervention
Direct
50
40
30
81% run
strength and
balance
training classes
BUT Average
duration 8
weeks and
frequency once
per week!
20
10
0
Bone Health
Vision
Gait & Balance
Lamb et al, SDO
report, 2007
Specialist PSI Exercise Module
Royal College of Physicians Report March 2012
• Audit on NHS exercise provision in falls services across the UK
• First, the good news!
– Over 1,700 older people - 96% felt the exercises were beneficial/quite
beneficial, and 95% were satisfied/very satisfied with their exercise
programme
• Now, the not so good news!
– 86% low frequency (once per week)
– 29% of patients used ankle weights for resistance training
– 52% of patients - exercise programme had been progressed
– 81% of patients - classes had lasted 12 weeks or less
– 73% of patients - home programme lasted for 3 months or less
– Only 54% of sites had PSI trained staff and 41% of sites had Otago
trained staff
Specialist PSI Exercise Module
“Man does not cease to play because he grows old. Man
grows old because he ceases to play”
George Bernard Shaw
If I’d known I was going to live this long, I’d have taken
better care of myself
Dubey Blake
Specialist PSI Exercise Module
Risk Factors for Falls
(and injuries)
- intrinsic
- extrinsic
- modifiable with exercise
Specialist PSI Exercise Module
A Risk continuum ?
• Over 200 risk factors
documented in the literature
D
A
80
70
60
Drugs and alcohol
Age related
physiological changes
M Medical
E Environment
50
%
Falling
(12
months)
40
30
20
10
0
0
1
2
3
4+
Specialist PSI Exercise Module
Intrinsic vs Extrinsic
- we are all ‘trippers’
• Over HALF the falls experienced in the home are due to
environmental hazards - trips, slips, unsafe or unlit stairways
• A decline in a person’s intrinsic risk factors (declining function and
balance) mean that the extrinsic risk factors (loose mats, slippery
floors) no longer just cause a correctable trip - they cause an injurious
fall
Specialist PSI Exercise Module
D - Drugs and Alcohol
• Cumulative effect of medication / time of day
• Prescribed medications / multiple drug regimes
– Analgesics
– Sedatives
– Diuretics
- Antidepressants
- Antipscyhotics
- ANY 4 OR MORE MEDICATIONS
• Heavy drinkers (>7 units per week) (Campbell et al., 1989, O’Loughlin
et al., 1993)
• Mixing medications with alcohol
Specialist PSI Exercise Module
A - Age related physiological
changes
• Deterioration in physical functions and systems (strength, power,
endurance, coordination, reaction, balance, proprioception and neural
control, asymmetry)
• Decrease in functional capacity, mobility and activity
• Deterioration in feet (bunions, corns, circulation, neuropathies)
• Increase in cognitive impairment and depression
Specialist PSI Exercise Module
Psychological risk factors
• Fear of falling
• Avoidance of activity
• Reduced quality of life
• Increased anxiety
Specialist PSI Exercise Module
M - Medical
• Acute Infections
• Cardiovascular control - postural hypotension, drop
attacks, heart disease, stroke, tia’s
• Dementia, Alzheimer’s Disease
• Parkinson’s Disease
• Thyroid dysfunction
 Peripheral Neuropathies or myopathies
 Malignancies
 Impaired hearing or vestibular function (Menieres Disease,
Tinnitus)
 Impaired vision (macular degeneration, glaucoma, cataracts, visual
acuity, contrast sensitivity, adaptation to dark)
Specialist PSI Exercise Module
M - Medical 2
• Foot deformities – pain, bunions, corns, hard skin, arthritis, oedema
 Urinary incontinence or urgency
 Receiving community health or social services
 Recent discharge from hospital
 Use of assistive walking aids - cane, zimmer
• Malnutrition / Anaemia - Nutritional recommendations are 10-20g rda
Vitamin D and 1,000mg rda calcium, Vit B12 deficiency leads to sensory
abnormalities
Specialist PSI Exercise Module
E - Environment
Personal
risk
factors:
• glasses
(bifocals and
varifocals)
• footwear and
clothing
Outdoors:
Indoors:
• Poorly lit pathways
• Loose carpets
• Uneven pavements
• Wires and cables
• Slippery leaves
• Unstable furniture
• Rubbish, building
materials, obstacles
• Change of level
• Bus drivers!
• Cold rooms
• Poor lighting
Sentimentality or “never been a problem before”
Specialist PSI Exercise Module
Not modifiable with tailored
exercise
• vision problems
• gender
• multiple medications
• social class
• chronic medical conditions
• poor housing
• hypothermia
• poor heating
• malnutrition
• poor footwear
• age
exercise may not have a major effect
Specialist PSI Exercise Module
Modifiable with tailored
exercise
•
•
•
•
•
•
low strength
low power
poor gait
poor mobility
poor balance
arthritis
•
•
•
•
•
depression
postural hypotension
cognitive impairment
urinary urgency
fear of falling
exercise is likely to have
a major positive effect
Specialist PSI Exercise Module
How can we identify older people at
high risk of falling?
• AGS/BGS guidelines - “get up and go” test as a filter for a
full assessment by a specialist clinician for people who
have fallen at least once.
J Am Geriatr Soc 2001; 49: 664
– 672.
• Falls Risk Assessment Tool (FRAT) –
5 questions to assess risk.
J Public Health 2004; 26:138-
143.
?? Usefulness in residential/nursing settings
Specialist PSI Exercise Module
FRAT - Assessment of falls
risk in older people
Is there a history of any fall in the previous year?
How assessed? Ask the person.
Is the patient / client on four or more medications per day?
How assessed? Identify number of prescribed medications.
Does the patient / client have a diagnosis of stroke or Parkinson's Disease?
How assessed? Ask the person.
Does the patient / client report any problems with their balance?
How assessed? Ask the person.
Is the patient/client unable to rise from a chair of knee height?
How assessed? Ask the person to stand up from a chair of knee height without
using their arms.
Specialist PSI Exercise Module
PROFET: targeting risk factors
(Close et al. Lancet 1999)
• Medical assessment
•
•
•
•
•
•
General medical
Postural hypotension
Visual acuity
Balance
Cognition and affect
Corotid sinus syndrome
• Occupational Therapy
•
•
•
•
Function
Physical handicap
Psychological handicap
Environmental hazards
• Referral / intervention
–
–
–
–
–
Day hospital
GP
O/P
Optician
Social services
– Supply minor equipment
The rate of falls was reduced by 60%
Specialist PSI Exercise Module
Tinetti (1994) - Multifactorial
Risk factor
Intervention
Postural hypotension (N)
- postural exercise (ankle pump)
- medication review and adjust
Use of sedative-hypnotic
medication (N)
- taper-off and discontinue
- non-pharm. treatment of sleep problems
Use of 4+ medications (N)
- medication review and adjustment
Unsafe bath or toilet transfers
(N)
- transfer training
- environmental adjustment
Gait / balance impairment (P)
- gait, balance and/or strength exercise
- use of aids
Less than full range of motion
against resistance (P)
- resistance exercises
The rate of falls was reduced by 30%
Specialist PSI Exercise Module
Posture & Postural Training
Practical
Specialist PSI Exercise Module
Specialist PSI Exercise Module
Specialist PSI Exercise Module
Ideal
Posture
Specialist PSI Exercise Module
poor habitual posture
•
poor bio-mechanical alignment
•
poor muscle balance
•
adaptive soft tissue shortening
•
compression & stretch of nerves & blood vessels
•
abnormal movement
•
affects balance mechanisms
•
increased risk of injury & disease
•
fear of challenging situations
•
inactivity
•
Isolation, depression
Specialist PSI Exercise Module
Specialist PSI Exercise Module
Specialist PSI Exercise Module
Seated Posture
• Position of head, eyes, chin
• Position of arms, shoulders, elbows,
wrists
• Position of spine - cervical/ thoracic/
lumbar
• Position of pelvis
• Position of legs, hip, knee & foot
• Overall tone
• Forward Flexion
Specialist PSI Exercise Module
Checklist for Standing Posture
Assessment
• Front
–
–
–
–
–
–
–
–
Eyes
Chin
Clavicles
Ribs
Hips
Knees
Ankles
Arch of feet
• Side
• Back
– Angle of
head / jaw /
spine
– Shoulder
– Pelvis
– Hand
– Back of knee
– Angle of
spine / jaw
– Shoulder
– Scapulae /
Sacro-iliacs
– Back of
knees
– Ankles
– Heels and
arch of feet
Specialist PSI Exercise Module
Muscle, Endocrine and Nervous
Systems
A bit on structure and function (but not a
lot!)
Effects of Ageing
Differences in fallers
Effects of Training
Specialist PSI Exercise Module
Main Communication
Systems
• NERVOUS SYSTEM
– rapid communications (seconds)
– Nerve Fibres
• ENDOCRINE SYSTEM
– Slow transmissions (mins to hours)
– Hormones
• CO-ORDINATION
– Nerves stimulate and inhibit hormones
– Hormones can stimulate/inhibit nerve electrical
impulses
• ACTION – Muscles !
Specialist PSI Exercise Module
Function of Nervous
System
Control
Activation
Integration
Modification
Sensory Input
Central Processing
Motor Output
Specialist PSI Exercise Module
Nervous System Structure
• Central
– Spinal Cord
– Brain
• Peripheral
– Spinal (31) and cranial (12) nerves
• Myelinated (faster) and unmyelinated
– Somatic (voluntary)
– Autonomic (involuntary)
• Sympathetic (speeding up)
• Parasympathetic (slowing down)
• Sensory nerves
– ‘Away’ from receptors TO CNS
• Motor nerves
– ‘Exiting’ CNS TO produce response
Specialist PSI Exercise Module
Bridging the gap between
nerve cells and other cells
Synapses - ‘the connectors’
Action Potential crosses synaptic cleft
via chemical neurotransmitter release
Acetylcholine, Noradrenaline,
Dopamine - ‘neurotransmitters’
Specialist PSI Exercise Module
SIMPLE OR REPETITIVE
MOVEMENTS
Spinal reflexes - Reflex Arc
(brain still informed!)
COMPLEX MOVEMENTS
Brain-stem reflexes - complex
reflexes
Balance
Specialist PSI Exercise Module
Cortex
Cerebellum
Basal Ganglia
Brainstem
Spinal Cord
Multi-linked Musculoskeletal
System
Multi-sensory
Information
Vestibular
Visual
Proprioceptive
Cutaneous
Environment
Specialist PSI Exercise Module
Sensory Input  Stability
Three main sources of input
• Visual information
• Vestibular information
• Proprioceptive information
Specialist PSI Exercise Module
Functions of ENDOCRINE
SYSTEM
• Affects bodily activities by releasing hormones into the
bloodstream
–
target organ or system function (metabolism)
– regulates chemical composition and volume
– responds to emergency situations
• Coordinates activities with the nervous system
–
–
–
–
nerves stimulate / inhibit hormones
hormones stimulate/ inhibit nerve impulses
nervous control = seconds
hormones = minutes to hours
• Tightly regulated
Specialist PSI Exercise Module
Endocrine System
• Central nervous control
– hypothalamus produces ‘releasing’/’inhibiting’ chemical secretions
• Endocrine glands (eg. pituitary, thyroid, adrenals)
• Hormones  bloodstream  target organs
• Anabolic (
– Catabolic (
tissue growth)
tissue loss)
Specialist PSI Exercise Module
Anabolic Hormones
• Growth Hormone
• maintenance of muscle and bone in adulthood
• decreased levels - loss of muscle and bone and
increase in fat
• Insulin
• influences blood sugar levels
• allows storage of sugars in muscle and fat cells
• Type I Diabetes Mellitus - insulin replacement
– Short term - ‘hypos’, muscle fatigue, neural control
– Long term - peripheral nerve damage
Specialist PSI Exercise Module
Anabolic Hormones
•
Thyroid Hormones
• affect metabolic rate
• too much - hypersensitivity, weight loss, eventual bone loss
• too little - lethargy, weight gain
•
Oestrogens and Androgens control
– our gender
– the growth of muscle and bone
– the maintenance of muscle and bone in later life
– ‘menopause’
•
Parathyroid hormone (covered in Bone lecture)
Specialist PSI Exercise Module
CALCIUM REGULATING
ANABOLIC HORMONES
• Major controllers
– Parathyroid Hormone (PTH) and active form of Vitamin D
– control serum levels of calcium - excitability
– ‘retrieve’ calcium from bone and
absorption in kidney
• Vit D from diet and sunlight
– produced in kidney
–
absorption of calcium from gut
– mineralisation of bone
•
Vit D = PTH released
– Long term PTH release leads to bone loss
Specialist PSI Exercise Module
Catabolic Hormones
• Cortisol (in excess)
– reduces inflammatory reactions
– increases blood glucose levels
– produced as a response to stress
– causes muscle and bone loss
– causes fat gain
– central effects - depression
Specialist PSI Exercise Module
CALCIUM / VIT D INTAKE
• Essential for
– Muscle contraction
– Bone density
– Teeth and nails
• The course recommendations for participants
– Calcium 1000 mg/day, Vit D 20g/day
• See foods handout
Specialist PSI Exercise Module
Muscular System
• Functions
– Motion
– Maintenance of posture
– Immune Function
– Heat production
• Types
– Skeletal - striated and voluntary
– Cardiac - striated and involuntary
– Smooth - non striated and involuntary
Specialist PSI Exercise Module
– Muscle bundle
– Muscle Fibres
– Connective Tissue
– Sarcomeres
– Sarcoplasmic reticulum
(Calcium)
– Cross-bridges
– Protein filaments
Structure
• actin (thin)
• myosin (thick)
– Mitochondria
– Rich blood and nerve
supply
Specialist PSI Exercise Module
Type 1
Type 2
Slow
Fast
Non-fatiguable
Fatiguable
Oxidative
Non-oxidative
Specialist PSI Exercise Module
Power
• Product of strength (Type 2 fibres) and
speed
• Functionally relevant
• Affected by temperature changes
• Asymmetry in lower limbs of fallers
Specialist PSI Exercise Module
Sedentary behaviour
• Immobilisation reduces muscle mass, muscle
strength and power (Appell 1990)
• Lower limb muscles and faster Type 2 muscles
fibres are particularly vulnerable (Broomfield 1997)
• 27 days of bed rest has lead to the loss of 0.9% of
bone mineral density per week (Frost, 1990).
Specialist PSI Exercise Module
active, strength-trained
The same size difference is
seen between 30 yr old and 80
yr old
70 yr old
females
sedentary
(Adapted from Sipilä & Suominen
Muscle Nerve 1993;16:294)
Specialist PSI Exercise Module
Ageing, falling…what are the effects ?
• Effects of ageing
• Differences in fallers
Specialist PSI Exercise Module
Effects of Ageing on the Nervous System
•  Neurones (somatosensory, vestibular and visual)
•  Spinal Cord Axons
•  Speed of transmission
•  Speed of central processing
• Changes in sensory input
–  Mass and strength in eye muscles,  Elasticity in lens,  Hydration of
the eye,  Eye Infections
–  Viscosity of fluid in inner ear,  medications that affect vestibular
system
–  number and efficiency of Proprioceptors,  medications that reduce
efficiency of proprioceptors,  oedema
Specialist PSI Exercise Module
Functional Consequences of
an ageing nervous system
• Poorer short term memory
• Slower learning and performance
• Poorer kinesthetic awareness
• Poorer reaction / coordination integration
• Poorer complex task performance
• Difficulty comprehending floor patterns/textures
• Simple movement tasks, repetition and rehearsal
• Longer transition times
• Effective verbal and visual cueing
• Functional moves
Specialist PSI Exercise Module
EFFECTS OF AGEING on
the ENDOCRINE SYSTEM
•
Hormones
– less well regulated
– Some glands produce less hormone
•
Target tissues and organs
– less responsive, poor circulation
•
System becomes more catabolic
– Calcium intake reduced and sunlight exposure reduced
↓ anabolic
hormone
production
↑ Cortisol
– Cortisol release
– Less anabolic hormone production
•
Metabolism and hormone diseases more prevalent
•
Side effects of medication (eg. Secondary
osteoporosis)
Specialist PSI Exercise Module
FUNCTIONAL CONSEQUENCES of
an AGEING ENDOCRINE SYSTEM
• Musculo-skeletal injuries
• Fatigue
• Dizziness / Fainting
• Arrythmias
• ‘Hypos’
• Dehydration
• Longer warm up and warm-down
• Fartlek training approach
• Observation
Specialist PSI Exercise Module
Effects of Ageing on MUSCLE
•  No. & size of muscle fibres
– Preferentially type 2 fibres
•  Muscle mass
•  No. motor units &  size of remaining motor units (therefore loss
of fine control)
•  Turnover of contractile proteins
•  No. and size of mitochondria
•  Proprioception in muscle and tendon
•  Connective tissue and fat
•  heat production
•  Susceptibility to injury and damage
Specialist PSI Exercise Module
Functional Consequences of
Ageing of the Muscle System
• Weaker muscles
• Slower muscles
• Fatigue
• Poorer temperature maintenance
• Poorer immune function
• Poorer functional reserve
• Target major functional muscle groups
• Time for rest
• Fartlek training approach
• Effective warm-up, warm-down and stretches
Specialist PSI Exercise Module
Differences in Fallers
NERVOUS SYSTEM / SENSORY INPUTS
• Visual impairment a risk factor
–
–
–
–
Contrast sensitivity
Depth Perception
Visual Field
Visual acuity
• Cognition a major risk factor
– Dementia
– Alzheimers
– Dehydration
Fallers have:
Worse balance
Larger sway
Worse gait
Difficulty in dual
tasking
• Nervous System control of movement
– Parkinsons Disease
– Stroke
• Vestibular impairment = more falls
• Peripheral neuropathy (eg. Lack of proprioceptive feedback) = more falls
Specialist PSI Exercise Module
Differences in Fallers
ENDOCRINE SYSTEM / DISEASE
• Those with metabolic / endocrine diseases are more likely to
fall
– Diabetes
– Hypothyroid
• Those with secondary bone loss due to endocrine disease
more likely to fracture if they do fall
Specialist PSI Exercise Module
Differences in Fallers
MUSCULAR SYSTEM – STRENGTH
• Community dwelling frequent fallers have weaker ankle
dorsiflexion strength than non-fallers (Skelton 2002)
• Community dwelling fallers have reduced hip extensor and
adductor strength, they tend to weigh more and have
increased medio-lateral sway standing on foam (Quinn 2003)
• Nursing home fallers are weaker in quadriceps and hamstring
strength than non-fallers (Whipple 1987)
Specialist PSI Exercise Module
Differences in Fallers
MUSCULAR SYSTEM - POWER
• Explosive muscle power declines faster with
increasing age than isometric quadriceps strength
• Community dwelling frequent fallers are less
powerful in their lower limbs than non-fallers (Skelton
2002)
– Fallers more asymmetrical in lower limb power than non fallers
– Average fallers power/kg is below the threshold level to step
confidently onto a 30cm step
– Power more predictive of risk of falls than strength
Specialist PSI Exercise Module
But…the good news is…
• Training can help reduce the ravages of age
and sedentary behaviour…..
Specialist PSI Exercise Module
Effects of Training on balance
and sensory inputs
• Practice of specific functional movements and complex tasks =
–  dynamic balance
–  static balance
–  righting reflexes
–  proprioception
–  vestibular function
–  simple and complex reaction and movement times
–  visual function ?
–  body awareness
–  posture and gait
Specialist PSI Exercise Module
Effects of Training on the
Endocrine System
• Improves
– circulation
– intake of nutrients (calcium, vitamins and proteins)
– cerebral function
• Releases growth hormone
– stimulates muscle and bone growth
• Improves insulin sensitivity
• Alters medication doses over time (insulin / thyroxine)
• Decreased cortisol production in response to stress
– strength-training
Specialist PSI Exercise Module
Effects of Training on Muscle
•
At any age
– Neural improvements in first 12 weeks then
muscle growth (Hypertrophy) so training has to
be of >12 weeks duration to improve muscle
size
–  strength (size of fibres, activation, increase
in protein turnover, speed of contraction,
relaxation time, agonist and antagonist coactivation etc)
–  power
–  posture and gait
–  blood supply
–  insulin sensitivity
0
3
6
9
12
15
Weeks
Muscle strength
Muscle size
–  neural control of movement
Specialist PSI Exercise Module
• In over 75’s three months of strength training
rejuvenates up to 20 years worth of lost
strength. (Skelton, 1994)
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
CARDIOVASCULAR SYSTEM
• Main transport system
–
–
–
–
–
–
Gases
Food
Waste
Hormones
Minerals
Medications
• Heart rate - controlled by autonomic
nervous system
Specialist PSI Exercise Module
• Circulation
–Pulmonary (to lungs)
–Systemic (to body)
–Coronary (to heart muscle)
• Blood vessels “tubes”
–Arteries - from heart to
body
–Veins - from the body to
the heart
–Capillaries - interchange of
gases, food and waste
Specialist PSI Exercise Module
CONTRACTION OF HEART
MUSCLE
• Heart muscle contracts automatically – spontaneous
discharge of pacemaker cells
• Sino-atrial node - heart’s pacemaker located in right
atrium. Impulses travel through atria to ventricles via A-V
node.
• Heart muscle cells are connected
Specialist PSI Exercise Module
CONTRACTION OF HEART
•
Parasympathetic activity slows the heart
• vagus nerve releases Acetylcholine
•
Sympathetic activity quickens the heart
• release of Adrenaline and neurotransmitters
•
Blood Pressure
• cardiac output flowing into vascular system influences systolic pressure
• resistance of blood vessels influences diastolic blood pressure
Specialist PSI Exercise Module
VOLUMES
•
Stroke Volume
• Blood per beat
•
Cardiac Output
• Blood per minute
•
Maximal O2 Uptake
• Amount of oxygen that can be used in one
minute – ml/kg/min
Specialist PSI Exercise Module
40
Men
% VO2 max
100
Maximal Oxygen Uptake (ml/kg.min)
75
Stair Climbing (slowly)
Walking (3mph)
20
50
25
% VO2 max
100
Making the bed
75
Dressing
50
25
0
0
30
Age 
80
Specialist PSI Exercise Module
EFFECTS OF AGEING
At rest no major changes to heart rate, stroke volume or
cardiac output due to age alone BUT when the system is
challenged then there are age-related deficits –
compounded by sedentary behaviour
•  stiffness of heart wall (collagen)
•  Maximal H.R.
•  Maximal stroke volume
•  Maximal cardiac output
•  Maximal aerobic power – 10% per decade
•  systolic blood pressure
•  incidence of postural hypotension (failure of venous return)
Specialist PSI Exercise Module
Fallers vs Non-fallers
• Cardiac symptoms can affect falls
–
–
–
–
Syncope
Arrythmias
TIAs
Postural Hypotension
• Cardiac medications not a major risk
except in combination with other
medications (>4)
Specialist PSI Exercise Module
FUNCTIONAL CONSEQUENCES
• Tasks will require  % of maximum in older person
• Unable to sustain submaximal activities
• Postural hypotension can lead to blackout / drop attack /
injury
• Fartlek training approach
• Circulation re-booster on major postural transitions
Specialist PSI Exercise Module
EFFECTS OF TRAINING
• Increased time in Diastole ( heart health)
• Maximal aerobic power can be  by 
– Muscle oxidative enzymes
– Muscle capillarisation
– Stroke volume and cardiac output
• Relative increases similar to young people
• Everyday tasks require  % of VO2 max
• Everyday tasks can be performed for longer with greater ease
•  Hypertension and  Postural Hypotension in some
Specialist PSI Exercise Module
PULMONARY SYSTEM
• Main transport system for gases
– Oxygen
– Carbon Dioxide
• Ventilation controlled by Nervous
System
– normally automatic (respiratory centres in
brain stem)
– some voluntary control (cortex overides
respiratory centres)
Specialist PSI Exercise Module
Structure
•
•
•
•
•
Nasal passages
Larynx
Trachea
Bronchi
Bronchioles
• Terminal Bronchioles
• Alveolar Ducts
• Alveoli
•
Gas exchange takes place
rapidly in alveoli - large
surface area surrounded by
dense capillaries
Specialist PSI Exercise Module
VENTILATION
Inspiration is active
volume of thoracic
cavity  by
contraction of intercostal
muscles and diaphragm
Expiration (at rest)
is passive
volume returned to
resting values
Specialist PSI Exercise Module
LUNG VOLUMES
Specialist PSI Exercise Module
EFFECTS OF AGING
•  Stiffness of chest wall
•  Strength of respiratory muscles
•  Elastic recoil in lung
•  Residual dead space
•  Functional area of lung
•  Cartilaginous support
•  Thickening of mucosal lining
•  Sensitivity of respiratory centres
Specialist PSI Exercise Module
FUNCTIONAL
CONSEQUENCES
System still adequate for sub-maximal activity
•  Respiratory work
•  Oxygen costs of many activities
•  Breathlessness may reduce tolerance of
exercise
•  maximal voluntary ventilation
•  mechanical efficiency of movement
•  posture
Specialist PSI Exercise Module
EFFECTS OF TRAINING
•  maximal voluntary ventilation
•  mechanical efficiency of movement
•  posture
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Joints
Effects of Ageing - 1
•  Dehydration (62% @ 25 yrs, 53% @ 75 yrs, synovial fluid less runny and
fewer, larger villi)
•  Joint changes (85%, only 50% OA)
•  Number of cross links between collagen fibres
•  Length of life of collagen molecules
•  Visco-elastic properties (25-60 yrs  50%)
•  Disc compression ( length spine 3-4% @ 70 yrs)
•  Flexibility ( 25-30% @ spine, 50% @ hip)
Specialist PSI Exercise Module
Effects of Ageing - 2
•  Calcification (cartilage tougher, more fibrous and brittle)
•  Hairline fractures
•  ROM (change in rebound energy exchanges during walking,  tendon 
calcium in stretch phase)
•  Stride length
•  Single leg support
•  Cautious gait
•  Sway - wider stance, trunk and knee flexion
•  Efficiency of response to balance problems
•   Changes with physical inactivity
Specialist PSI Exercise Module
Joints in Osteoarthritis
Specialist PSI Exercise Module
Functional Consequences
•  Stiffness
•  Stability
•  Comfort
•  Ease of movement
•  Energy cost
•  Proprioception
Specialist PSI Exercise Module
Effects of Training
•  Length of life of collagen molecules
•  Viscoelastic properties
• Regular/Lifetime maintain length in spine
•  Stride Length
•  Rhythm
•  Sway
•  Correction efficiency
•  Confidence in movement
Specialist PSI Exercise Module
BONE BASICS
•
Function
•
Structure
•
Architecture
•
Production
•
Maintenance
•
Ageing
•
Training
Specialist PSI Exercise Module
Trabecular or spongy bone
Cortical or compact bone
4 Components
Tough resilient collagen
fibres
More brittle mineral material
Bone Marrow
Bone cells
+ Blood vessels
Specialist PSI Exercise Module
BONE: ARCHITECTURE
•
Cylinders of compact bone - long bones
•
Varied symmetrical, contoured trabecular bone vertebrae and ends of long bones
Comparison of fragile osteoporotic bone with strong, dense bone
•
Skeleton 1/10th
body weight
•
Bone in constant
turnover
Strong, dense bone
Fragile, osteoporotic bone
Figure 3
Specialist PSI Exercise Module
BONE: PRODUCTION
•
10% renewed per annum
•
osteoclasts - resorption
•
osteoblasts - formation
•
osteocytes - bone monitors
and signallers
•
peak bone mass 20-40
years
•
40-45+  0.5-1% per year
•
post menopause 1 > 6% per
year
Specialist PSI Exercise Module
Main fracture
sites:
Spine
Wrist
Hip
Change of fracture
site with
increasing age
Specialist PSI Exercise Module
BONE: RISK FACTORS
• Genetics
• Hormone levels
•Anorexia
•Overtraining
•Endocrine disease
• Bone loading activity
• Calcium and Vitamin D
Specialist PSI Exercise Module
Risk Factors for Fracture
•
•
•
•
•
•
•
•
•
•
Female
Tall height
Previous fracture or family history of fractures
History of falling
Poor self rated health
Lack of weight gain since age 25
Early menopause
Spending less than 4 hours a day on their feet
Smoking, high caffeine intake, low calcium intake
Nil childbearing
Specialist PSI Exercise Module
EFFECTS OF AGEING
•  oestrogen/progesterone/
testosterone
Effect of age on bone mass
•  mineralisation
•  resilience of collagen 
density
•  renewal
Bone
Mass
•  bone density and bone
mass
•  growth hormone
0
10
200
30
40
50
60
70
Age (years)
•  muscle mass
Figure 4
•  physical activity
Specialist PSI Exercise Module
Young healthy spine
Osteoporotic spine
Specialist PSI Exercise Module
Specialist PSI Exercise Module
Functional Consequences
•  Fracture risk
•  Pain
•  Disability and Discomfort
•  Exercise Cost
•  Postural Instability
 Fear, anxiety,
loneliness
•  Physical Activity

Confidence
•  Field of Vision
•  Integrity of the Spine
Specialist PSI Exercise Module
EFFECTS OF TRAINING
Exercise can slow or reverse age related bone loss provided it is:
•Weight resisted
- weight training
- impact
- loading
•Site specific - wrist, hip, spine
•Peak Strain
- hold the movement
•Fast Strain
- effective and brief
•Error Rich
- tennis, squash, fitness class
Strategy = short periods of site specific, high strain rate in unusual
relationships
Specialist PSI Exercise Module
High intensity strength
training.
3
p=0.02
p=0.04
% Change in BMD
2
1
0
Exercise
Control
-1
-2
-3
Femur
Spine
-4
Nelson et al, 1994
Specialist PSI Exercise Module
% Change
Aerobic class with step and site
specific impact in over 50s
2.5
2
1.5
1
0.5
0
-0.5
-1
-1.5
-2
o
k
c
Ne
f
Exercise
Control
ur
m
Fe
T
r
e
t
an
h
roc
Welsh & Rutherford, 1996
Specialist PSI Exercise Module
EFFECTS OF TRAINING
ALSO
• Bone strengthening + bone protection + fall prevention
• Exercise + HRT = more beneficial
• Exercise + calcium = more beneficial
• Exercise + Vit D = more beneficial
Specialist PSI Exercise Module
Get Practical
Bone Loading Workshop
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Fear of Falling and Motivation to
Exercise
Fear of Falling
Stages of Behaviour Change
Listening and Talking about exercise
Specialist PSI Exercise Module
Fear of Falling
• Prevalance (Tinetti 1994)
– 30-60% in people over age of 65
– 50-65% in previous fallers
• Fear and lack of confidence in balance predict
– Deterioration in physical functioning (Arfken 1994, Vellas 1997)
– Decreases in physical activity, indoor and outdoor (Arfken
1994, Finch 1997)
– Increase in fractures (Arfken 1994)
– Admission to Institutional Care (Cumming 2000, Vellas 1997)
Specialist PSI Exercise Module
Adherence to exercise regimens
• Fear of activity – avoidance of activity that might lead to a fall
• High refusal to uptake exercise interventions to prevent falls
– >50% common
– Lord study (2002)
• Invited 11,000 responded 1,967 (18%)
• Low adherence once started
– Lord study (2002)
• Randomised 1107, 74% started, 60% attended >50% of sessions
• But FaME (Skelton 2004) in frequent fallers
• Randomised 50
• 100% started, 10% dropped out of classes
• 79% Attended >75% of sessions
Specialist PSI Exercise Module
Increasing Motivation and
Adherence – how ?
1. Assessing motivation towards
physical activity
2. Helping to overcoming the barriers
3. Support strategies
Specialist PSI Exercise Module
Pre-exercise assessment
• Health
• Function
• Readiness to exercise
(Later Life Training Manual)
How do we assess readiness to exercise
among participants in PSI classes ?
Specialist PSI Exercise Module
Lifetime model
of physical
activity
Specialist PSI Exercise Module
Key questions to ask
(exploring thoughts)
• Importance question - I wonder how important
being active is for you ?
• General questions - What kinds of physical activity
do you do at the moment ?
• Benefits question - Imagine if you did more, what
benefits would you expect to see ?
• Barriers question - What things prevent you from
being more active ?
• Concerns question - What things worry you about
being more active ?
Specialist PSI Exercise Module
Change is more likely when ….
• Perceived benefits (of physical activity) outweigh the costs
(decisional balance)
• Leads to social approval (significant others) not disapproval
• Consistent with highly valued, broader life goals (values and
motives)
• Outcomes are within one’s personal control (self efficacy)
• There are few obstacles in the way (barriers)
• Opportunities and access (to physical activity) are high
(Sport England 2005)
Specialist PSI Exercise Module
Evidence about strength and balance
classes - the barriers
• Health problems (actual and perceived interference)
• No observed positive effects when tried programme
• Not liking social contacts in classes (peers or leader!)
• Unpleasant experiences (fatigue, pain etc.) or not enjoyable
• Low motivation or perceived relevance
• Other priorities (caring for dependents, holidays, other
appointments, housework)
(Yardley et al 2005a)
Specialist PSI Exercise Module
Perceived positive factors and benefits
• Noticeable benefit/improvement (restoring/maintaining fitness
and functioning, better health –blood pressure, dizziness,
diabetes)
• Feel and look good (less stiff, less pain, more mobile, strong,
energetic, better balance, mood, weight loss)
• Able to do more things (walk, do without stick, climb stairs,
travel, go out alone, go shopping, ADLs)
• Maintaining and increasing independence
• Social contact (bond formed through prolonged contact with
group)
• Confidence/pride in achievement (general increase in self-
Specialist PSI Exercise Module
motives for older people to take up strength
and balance training
• thinking you are the kind of person who should do these
activities (self-efficacy)
• thinking other people think you should do these exercises
(peers, family, partners)
• believing that these activities would be enjoyable
• concern about the risk of a future fall
• (NOT having recent falls, or risk factors for falls)
(Yardley et al 2005a)
Specialist PSI Exercise Module
Don’t mention the F-word!
Understanding older people’s views
of falls prevention advice
(Yardley et al. 2005,2006)
Communication / Motivation important in encouraging
uptake and adherence to falls prevention interventions
and the pre-exercise assessment is an ideal place to
discuss their attitudes / barriers / motivators
Specialist PSI Exercise Module
Increasing engagement with exercise ?
60 people attending A & E as a result of a fall. When offered choice on
an intervention to prevent a future fall
• 72% reluctant to take up exercise programme
• 28% reluctant to take osteoporosis medication
But when asked if likely to take up an intervention to prevent a
worsening health state
• 63% said they would take up exercise!
• 93% would take osteoporosis medication
(Whitehead 2006)
Specialist PSI Exercise Module
During assessment and
intervention..
To encourage people to exercise:
• Emphasise immediate benefits for them (rather than
reduction of risk)
• Promote positive social image (rather than simply rational
advantages)
• Ensure patients have positive but realistic expectations
• Use psychological techniques to encourage adherence
(monitoring and reinforcement, modelling, explicit
commitment etc.)
• Ensure early experiences of sessions
arerecommendations,
positive
ProFaNE
Yardley
(through graded goal setting, social reinforcement etc.) 2007
Specialist PSI Exercise Module
Engaging older people in preventative
health care
• Raise awareness in the general population that
undertaking specific physical activities has the potential to
improve balance and prevent falls.
• When offering or publicising interventions, promote
benefits which fit with a positive self-identity.
• Utilise a variety of forms of social encouragement to
engage older people in interventions.
• Ensure the intervention is designed to meet the needs,
preferences and capabilities of the individual
• Encourage self-management rather than dependence on
professionals by giving older people an active role
• Draw on validated methods for promoting and assessing
the processes that maintain adherence, especially in the
longer-term.
Yardley et al (2005)
Specialist PSI Exercise Module
Support strategies
• All literature provides strong evidence that they are
effective (NICE, HDA, CDC, Campbell, FAME)
• Communication strategies - follow up using
technologies, phone, diaries, email
• Social support activities (events and buddies)
• Educational programmes
Which are the “best buys” and why ?
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Detection and Assessment:
Theory and Guidelines
- Finding fallers…in different settings:
- Pre-exercise assessment
- Health, Function and Motivation
- Ongoing assessment
- Triggers for referral to medical setting
- Triggers for referral between exercise
settings
Specialist PSI Exercise Module
Targeting Intervention
Identify high risk from a general population
Identify what more in depth assessment is required
Identify modifiable risk factors for each individual
Target Intervention
Specialist PSI Exercise Module
NICE Falls CG: “Safety net” service
model
Specialist PSI Exercise Module
NICE Falls CG: specialist integrated service
model
Specialist PSI Exercise Module
What tool or test ?
It needs to be:
 Reliable
same result in same person
over short intervals of time
 Consistent
same result whoever
assesses
 Valid
for the age and functional
capacity of the individual
• Plus functional and understandable to the
older person
Specialist PSI Exercise Module
The role of pre-exercise assessment
• Assessment
– is the cornerstone of rehabilitation
– identifies health status (safety and warning
signs)
– identifies areas of limitation
(pre-exercise)
– influences subsequent
treatment/intervention (tailoring)
– gauges efficacy of treatment (ongoing)
Specialist PSI Exercise Module
Pre-exercise Assessment
• Assessment should be:
– what they can do and build upon …..NOT. ….
what they cannot do
– an education tool (fitness vs health symptoms)
– relevant (age, medical condition and functional
capacity of the participant)
Specialist PSI Exercise Module
TRIGGERS
Referral back to Rehab Exercise Setting
• Onto therapy setting (or stay within chair-based setting)
–
–
–
–
–
cannot stand for more than 30 seconds without excessive sway
cannot transfer weight from one leg to another without concern
cannot take a step backwards unassisted
chronic or acute pain on walking
marked deformities, severe asymmetry, marked weakness
Functional Grid
• ticks mainly 6’s
Specialist PSI Exercise Module
Ongoing Assessment
• ? Every 3 / 6 / 9 months or if participants health or
functional condition deteriorates
• Essential for
– updating health or functional status information
– assessing effectiveness of programming
– comparing goals with actual gains
– improving motivation
• Continually assess
– environment and safety
– ‘appearance’ of participants
– correct intensity (Borg)
Specialist PSI Exercise Module
TRIGGERS
Ongoing assessment - 1
• Sudden onset of symptoms of illness
– Dizziness, inner ear infections, excessive tiredness, weight loss, loss of
appetite or shortness of breath, anxiety, unidentified or uncontrolled pain
• Worsening of existing medical condition
– Frequency of transient ischaemic attacks increases, swelling of an OA
knee following the session or a longer than usual walk
• Onset of dizziness with current or new medications or concerns about
whether correct pills are being taken at the correct time or dose
• Sudden onset of pain in joints
– Osteoarthritis of the knee, swollen joints, limping
Specialist PSI Exercise Module
TRIGGERS
Ongoing assessment - 2
• Deterioration of functional capacity or balance
– Now needs walking aid, progressive difficulty with walking on the flat,
fatigues more quickly, transfers becoming difficult
• Increase in frequency of falls or increase in injury due to falls
– Starts to fall at home in repeat areas of the house or doing certain tasks,
can no longer rise from the floor, injuries not healing properly, arrives with
a black eye and has not been to see the GP after the last fall yet
• Distinct changes in vision
– Depth perception, missing steps, light-headedness on walking downstairs
with bifocals
• Distinct changes in hearing
– Wax removal, inner ear infection
Specialist PSI Exercise Module
The value of assessment
• You get to know your participants
• Good time to discuss exercise history, likes, dislikes and
perceptions of exercise and of falling
• You’re safe and so are they
• You know where to start and where to adapt
• You know if you are getting it right
• Funder’s know you are getting it right
• Participants feel informed
Specialist PSI Exercise Module
Case Study Guidelines
• Find a person at risk of falls or with a falls history that
would be able to join a PSI led class
• Perform functional assessments and do the health / QoL /
fear of falling questionnaires with them
• Write up – 1500 words
• Include tailor / adapt the FaME phases of training for that
individual
• Present the written case study on Day 6/7
• See Case Study Guidelines in your pack
Specialist PSI Exercise Module
Practical / Case Study Guidelines
• Pre-exercise Assessment
–
–
–
–
–
–
–
–
Readiness to exercise
Health
Falls Risk (FRAT)
Fracture Risk (Black)
Fear of Falling (FES-I )
Confidence in Maintaining Balance (ConFBal)
Health outcome (EQ-5D)
Functional Assessments - GRID
Specialist PSI Exercise Module
Selection Criteria
-Is your participant at risk of falls?
Each individual should have one or
more of the following:
• Fear of falling
• Feeling unstable (balance problems)
• History of falls (injury or not)
• Low bone density (and/or family
history of osteoporotic fracture)
Specialist PSI Exercise Module
Readiness to Exercise
• Stage of Health Behaviour Change
–
–
–
–
–
–
Considering
Preparing
Currently Active <6 Months
Regularly Active >6 Months
Relapse
Unknown
• Gauge from a conversation with them about
exercise history and current participation
Specialist PSI Exercise Module
Health Assessment
Referred or self-referred
•
Health status must be checked with / acknowledged by
participants GP
•
Complete a health questionnaire with them that will identify their
medical conditions and medications
•
Use to ensure your know if someone has any conditions which are
contraindicated and need specific feedback from GP before they
can continue in the class
•
A health questionnaire is in your case study pack but when you
qualify you may use one that has been developed by your service.
Specialist PSI Exercise Module
Contraindications to the ‘Prehab’ Class
People with the following:
•
Uncontrolled angina
•
Uncontrolled resting BP >
180/100 mmHg
Significant drop in BP during
exercise
Uncontrolled tachycardia
> 100 bpm
Unstable or acute heart failure
Uncontrolled acute systemic
illness
•
•
•
•
•
•
•
•
•
Uncontrolled visual or
vestibular problems
Unable to maintain seated
upright position
Recent injurious fall
without attention
Impaired cognition
Place others and
themselves at risk
should not take part until their GP advises that their condition
permits safe participation
Specialist PSI Exercise Module
History of Fall
• Number in last 6 months
• Last one
–
–
–
–
–
–
–
–
Location
Time
Doing what?
Reason?
Loss of consciousness? Or dizziness prior?
Any injury?
Could they get up again?
Did they see GP or go to Hospital?
Specialist PSI Exercise Module
FRAT – Falls Risk Assessment Tool
Multi - professional guidance for use by the primary health care
team, hospital staff, and social care workers
Is there a history of any fall in the previous year?
How assessed? Ask the person.
Is the patient / client on four or more medications per day?
How assessed? Identify number of prescribed medications.
Does the patient / client have a diagnosis of stroke or Parkinson's Disease?
How assessed? Ask the person.
Does the patient / client report any problems with their balance?
How assessed? Ask the person.
Is the patient/client unable to rise from a chair of knee height?
How assessed? Ask the person to stand up from a chair of knee height without using their
arms.
Specialist PSI Exercise Module
Risk of Fracture Tool
• Black 2001
– High risk Score 7-10
– Moderate risk Score 5-6
– To use in your case study
Specialist PSI Exercise Module
Fear of Falling Scale – FES-I
• Long Version – 16 Qs
– Yardley et al. 2006
• Short Version – 7 Qs
– Kempen et al. 2008
– To be used for your case
study
– Scoring
• 7 (no concern about falling)
to
• 28 (severe concern about
falling).
ProFaNE recommended
Specialist PSI Exercise Module
Confidence in Maintaining Balance
• Simpson et al. 2004
• 10 Qs
• Scoring
– 10 confident
– 30 unconfident
• Use for your case
study
Specialist PSI Exercise Module
EQ-5D – heath outcome measure
• Page 1
So this
would score
as:
1,2,3,4,5
Specialist PSI Exercise Module
EQ-5D
• Page 2
Specialist PSI Exercise Module
Functional
assessment
Seated shoulder external
rotation flexibility
Denote L and R arm in box(es)
Seated shoulder internal
rotation flexibility
Denote L and R arm in box(es)
Seated hamstring flexibility
Denote L and R arm in box(es)
180 degree turn
Number of steps: ______
Functional Reach
Use of walking aid? Cm:____
Timed Up and Go
Use of walking aid?
Time (seconds):_____
No Limitation
Can reach over their
shoulder to between
their shoulder blades
1
Can reach to behind
the back to touch
their shoulder blades
1
Able to reach to midcalf of the extended
leg
1
Able to turn safely in
4 steps or less
1
Reaches greater
than 35 cm
1
Able to rise from the
chair easily, walk
unaided, turn without
dizziness or
stumbling. Faster
than 8 seconds
1
Severe Limitation
Can reach to the
back of the neck
2
Can reach to
behind the back to
touch just below
the shoulder
blades
2
Able to reach just
past knee of the
extended leg
2
Able to turn safely
in 6 steps or less
2
Reaches between
25 and 34 cm
2
Able to rise from
the chair without
arms, walk
unaided, turn
without stumbling.
Between 9 and 15
seconds
2
Can reach behind the
head to level of ears
3
L
Can reach behind to
mid-back level
3
L
Able to reach to knee
of the extended leg
3
Able to turn safely in
8 steps or less
3
Reaches between 16
and 24 cm
3
Difficulty on rising
from chair, walks
aided or unaided but
takes between 16 and
24 seconds
3
Can reach the top
of their head
4
R
Can reach behind
to waist level
4
R
Able to reach to
mid thigh of the
extended leg
4
Needs close
supervision and
verbal cueing for
safety. Takes 912 steps
4
Reaches between
10 and 15 cm
4
Difficulty on rising
from chair, walks
aided or unaided
but takes between
25 and 40 seconds
4
Can reach above
shoulder level but
not touch the top of
their head
Unable
Unable to reach above
shoulder level without
pain or movement
limitation
5
6
Can reach behind
to buttock level
Unable to reach behind
their back, pain or
movement limitation
5
6
Able to reach to
knee but unable to
complete with
correct technique
5
LR
Needs assistance
from one person or
furniture to turn
5
Reaches less than
10 cm
5
Difficulty on rising
from chair, needs
walking aid,
unconfident or
dizzy on turning - or
takes over 40
seconds
5
Unable to reach
forward because of
pain, deformity or fear
of falling
6
Needs assistance from
two people to turn
6
Unable or afraid to
reach forward
6
Unable to rise from the
chair, walk or turn
without help
6
Specialist PSI Exercise Module
FLOW DIAGRAM FOR PROSPECTIVE PARTICIPANTS IN EXERCISE SESSIONS TO IMPROVE POSTURAL
STABILITY AND REDUCE FALLS AND INJURIES
Referrer
Selection
Criteria
Functional Assessment Grid
Exercise
Groups
Mostly ticks
SELF – REFERRED
1
2
DYNAMIC
‘PREHAB’
PSI
3
4
GP – PRIMARY
CARE
Those
meeting
inclusion
criteria
and
having
no
exclusion
criteria
5
6
PHYSIOTHERAPY REHABILITATION
SETTING
CHAIR –
BASED
(maybe PSI
led or chair
adaptations)
P
R
O
G
E
S
S
W
I
T
H
T
I
M
E
‘REHAB’ –
THERAPY
(one to one or
small group)
Specialist PSI Exercise Module
Final thoughts on case study
• You need to tailor the phases of the FaME programme to your
participants abilities
–
–
–
–
Any limitations (adaptations)
Any confidence issues (buddying)
Are they particularly good at anything (so can progress faster)
Asymmetry (homework)
• In your judgement would they progress through any of the phases
faster/slower?
• Consider the main points of this individual you would want a cover
teacher to know?
– Medications
– Limitations
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
DAYS 3 & 4 – OVERVIEW
•
Programming, Theory and Practice I and II
•
Teaching Practice Workshop
•
Assessment Briefing
•
Medical Conditions, Medications and Exercise Management
•
Health and Safety
•
Progression and Adaptation Workshop
•
Implementation in Community Programmes
Specialist PSI Exercise Module
PROGRAMMING THEORY & PRACTICE
• AIMS
- Making the case for PSIs
- Types of exercise sessions in falls exercise provision
- FaME
- Exercise programming theory
- Applying theory to practice
- Practical
Manual 2 Section 3
Specialist PSI Exercise Module
Making the case for PSIs
4 Types of Opportunities, Phase IV:
•
PSI
•
Exercise for the Older Person
•
1 to 1 Personal Training / Physiotherapist
•
Active Lifestyle
4
Advantages
4
Drawbacks
Specialist PSI Exercise Module
Types of exercise sessions in falls exercise
provision: 3 Settings, 3 Session Structures
• Rehab
PSI Approaches Phase 3
• Prehab
PSI
Phase IV
• Chair
“Holding Group”
Functional Strength
3 Common
3 Distinct
Activities
Activities (one per session)
Manual 2 Section 3
Specialist PSI Exercise Module
FaME
PHASES 1. 2. 3.
Phase names and corresponding weeks
Content of each phase
Manual 2 Section 3
Your practical assessment is week 15 – 20 (training gains / phase 2) – See
Manual 2 Section 3 for session planner
Specialist PSI Exercise Module
SAFETY FIRST
PSI Session Structure + Content
Warm Up
CIRCULATION BOOST; JOINT MOBILITY; STRETCH
Workout
5 (of 7) EVIDENCE-BASED ACTIVITIES
Cool Down
CIRCULATION LOWERER; FLEXIBILITY; TAI CHI
Tea + Chat and re-energise
Manual 2 Section 3
Specialist PSI Exercise Module
EXERCISE PROGRAMMING THEORY
•
Principles
Specificity
Progressive Overload
Rest & Recovery
Individual Difference
•
Variables (recap)
FITTA
Manual 2 Section 3
Specialist PSI Exercise Module
PSI =
EXERCISE for OLDER PEOPLE –
Best Practice Guidelines
+
SPECIAL CONSIDERATIONS for
Older People with HIGH RISK OF FALLS –
Best Practice Guidelines
Manual 2 Section 3
Specialist PSI Exercise Module
EXERCISE GUIDELINES
COMPONENTS OF FITNESS WORKSHOP
BALANCE: STRENGTH: FLEXIBILITY: ENDURANCE
What
is it ?
Older Person
Guidelines
Special Considerations
For Fallers
Examples of
exercises
F
Definition
I
Only 3 please!
T
T
A
Specialist PSI Exercise Module
STRENGTH
Older Person
Guidelines
What
is it ?
Working
F
Resistance
I
12 –15 reps to begin
1 – 3 sets
progress up to 70-80% 1RM
6-8 reps
Postural and bone-load for
back extensors
T
20 mins –1hr
6-9 secs per Isotonic Rep
5 Secs Isometric
Specific
Targeted
Muscles: Hip, Knee, Ankle
T
Body weight / Weights
Open/closed chain
Isometric / isotonic
To Gain
Stronger
Muscles
And Bones
To Make
Everyday
Activities
Examples
of
Exercises
2 – 3 Times / week
Functional abdominal work
Muscle + Bones
Against
Special
Considerations for
fallers
FaME: seated
leg press,
seated upper
back
strengthener,
prone back
extension
Otago:
standing knee
flexion,
standing hip
abduction
Easier
Fun / Relaxed
A
Variety
Safe
Warm
Social
Manual 2
Specialist PSI Exercise Module
The Borg Scale
Rate of perceived exertion
0
0.5
NOTHING AT ALL
VERY VERY LIGHT
NB.
1
VERY LIGHT
2
FAIRLY LIGHT
3
MODERATE
4
FAIRLY HARD
Evaluation 0 – 10 scale in
Dynamic Endurance
Component
5
HARD
 Research 6 – 20 scale
6
7
VERY HARD
8
VERY TIRING
 Community Session
Endurance Component
before mid point + post
9
10
VERY VERY HARD
Manual 2 Section 3
EXHAUSTING
Specialist PSI Exercise Module
Resistance Training Continuum
Endurance
15
Strength
12
10
8
6
30%
50%
>60%
>70%
of IRM
of IRM
of IRM
of IRM
Low weight
High Reps
>80%
of IRM
Heavy weight
Low Reps
Manual 2 Section 3
Specialist PSI Exercise Module
ENDURANCE
Older Person Guidelines
What
is it ?
Stamina:
Work muscles harder &
longer
(in order to increase the
pulse rate, breathing rate)
F
I
Special Considerations for
fallers
Marching
3 – 5 days per wk
- Focus on coordination and
balance
Moderate,
30-75 % VO2 Max
Examples of
Exercises
- Chair based initially then
chair support
Side-stepping
Gait training
Toe taps
- Simple / repetitive / stable
T
30 – 60 mins.
T
Aerobic
Fartlek
A
Longer build up and
build down
Avoid steps that
could cause a trip
Manual 2 Section 3
Specialist PSI Exercise Module
BALANCE
What
is it ?
Maintaining upright
posture during position
change
(eg. Standing up and to
prevent falls)
Older Person
Guidelines
F
3 x per week
Special
Considerations for
fallers
Start with ‘win win’ tasks
(eg – seated ball games)
Examples of
Exercises
Functional reach while
sitting
Toe & heel walking
I
T
T
Increase slowly –
graded to group
10 mins – building up to 1
hour.
Ensure appropriate ratio of
supervision for each task
Explain benefits
Method of using support
Tandem walks
calf raises
Flamingo swings
Picking objects off the
floor
Dynamic balance
i.e weight transference
Backward walking
.
A
Varying activities &
weaning off support
slowly – vary positions
Manual 2 Section 3
Specialist PSI Exercise Module
FLEXIBILITY
What
is it ?
Best optimal range of
movement available at a
joint or joints
Older Person
Guidelines
F
I
Special
Considerations for
fallers
Examples of
exercises
2 – 7 days a week
Mild muscular tension
No Pain
T
Maintenance:
1 x 8 – 10 secs
Developmental:
2-3 x 11-40 secs
T
Static and active
Developmental +
Maintenance
A
“Reward”
Relaxing
Remain seated 2 – 3 mins
following work (stretches)
in lying
Targeted stretches
Alignment is paramount
Tai Chi
Precise instructions – step
by step
Functional Activities
Yoga
Manual 2 Section 3
Specialist PSI Exercise Module
BACKWARD CHAINING
FLOOR WORK
• Strength
• Balance / Co – ordination
• Flexibility
• Coping strategies
TAI CHI
Manual 3
Specialist PSI Exercise Module
EDUCATION and PREPARATION OF PARTICIPANTS
INDUCTION SESSION
WHEN EXERCISE SHOULD
Manual 2
- NOT HAPPEN
Manual 2
- BE DISCONTINUED
- BE CONTINUED
FALLS SPECIFIC EDUCATION / COPING STRATEGY
MONITORING
Manual 2
BORG, TALK TEST, observing co-ordination & technique
= comfortably challenged
Manual 2
Specialist PSI Exercise Module
How To Avoid Spending A Long Time On The Floor After A Fall
FALL OVER
Remain still. Avoid panic and wasting
energy on ineffective struggling.
NO
Have any serious injury?
Any movements limited?
Any pain?
Will help arrive soon and this person will
summon help or use a lifting cushion
Can you get up
without help?
NO
OK
YES
NO
YES
YES
OK
Plan how to summon help
OK
YES
If you are wearing an alarm button or
you can reach one – then do so!
NO
Simpson J. 1998
Manual 2
Carry out your previously worked out plan to summon help by alternative methods and while waiting for help to
arrive carry out your plan to avoid any consequences of being on the floor for a long time.
Specialist PSI Exercise Module
PROGRESSION + ADAPTATION
• Seated Adaptations for:
– Trunk rotation, calf stretch, upward side stretch
– Double side step, wide-based sway, march
– Heel raise and toe walk, toe raise and heel walk, flamingo
swing, tandem stand
– Backward chaining
– Prone back extension, side lying leg raise, prone hip
extension
– Working the oar
Specialist PSI Exercise Module
Exercise Management of Patients with Chronic
Illness / Conditions
STEP 1
The Individual Difference Principle
• Liaison with Health Professionals
• Liaison with Patient
• Liaison with Leisure Professionals
Manual 1
Specialist PSI Exercise Module
Exercise Management of Patients with Chronic Illness
/ Conditions
STEP 2
•
•
•
•
•
•
•
•
•
•
•
Type of condition
Site of condition
Stage of condition
Functional Limitations
Disease Specific Effects
Disease Specific Effects to the individual
Medication Effects
Exercise performance limitations
Risk stratification
Prognosis
SMART goals – Specific; Measurable; Agreed; Realistic; Timed
N.B. SMART - Not in manual / not assessed but an important tool.
Specialist PSI Exercise Module
DISEASE
Do’s
Don’ts
Adapts
Benefits
FREQUENCY
(How Often)
INTENSITY
(How Hard)
TIME
(How Long)
TYPE
(+ Activities)
‘Which type’ eg Strength /
Endurance Isometric / Isotonic
Continuous/Interval
APPROACH/ ADHERENCE
(Variety, Individual interests etc)
Specialist PSI Exercise Module
HEALTH & SAFETY
1. The Environment / Facility
2. The Equipment
3. The People
Specialist PSI Exercise Module
ASSESSMENT INSTRUCTIONS
Formative Assessment of Tai Chi:
On Day 5 (afternoon) you will have your teaching skills for delivering the
Tai Chi section of a class formatively assessed.
1. THEORY PAPER
• ON DAY 5
• 2 Hours
• 5 short answer questions and 30 multiple choice
• 70% pass mark
• 5 mins reading time
• Let us know before if special needs requiring additional support
Specialist PSI Exercise Module
TIPS for Theory Paper
• LEARN YOUR PPTs!
• In the Manual
• If its in bold its important
• If its in a box its VERY IMPORTANT
• If its in a box + bold its VERY IMPORTANT
Specialist PSI Exercise Module
ASSESSMENT INSTRUCTIONS
2. PRACTICAL
• On Day 6 or 7 (whichever you signed up for)
• Plan 1 hour week 15-20 PSI Session – bring 2 copies of plan - ie.
assessed on planning
Refer to Manual 2 Session Planner;
Use sesson plan proformas provided;
Only teaching points necessary ie. not instructions
• Approx 30 mins teaching to your peers – ie. assessed on teaching
Equipment provided = therabands, chairs, mats;
Moved on by assessor – plenty of time / prompts;
Assessment checklist will be used by assessor;
Consider lifting technique e.g. for mats. Chair alternatives but Not Chair focus;
Notes can be used if necessary – or assessor prompt
Specialist PSI Exercise Module
ASSESSMENT INSTRUCTIONS
2. PRACTICAL cont’d
• No Pass Mark for Practical delivery, only Pass/Refer and
action points given
• Receive peer evaluation
• Write up self- evaluation – ie. assessed on evaluation
Practice with people - not just in front room!
Specialist PSI Exercise Module
ASSESSMENT INSTRUCTIONS
3. CASE STUDY
Ensure meets Criteria for PSI intervention and is at risk of falls
•
Complete all paperwork - (questionnaires + functional grid) in
assessment pack
•
Complete 1500 word ‘write up’ – see case study guidelines in
Summative Assessment Pack
•
Submit on day 6/7
•
Pass mark 70%
All results (case study, practical and theory paper) in post
(8-10 weeks later)
Specialist PSI Exercise Module
PSI Workshop
Warm Up
1. Circulation Exercise
2. Mobility
3. Stretch
Workout
5. Dynamic Endurance
6. Dynamic Balance
7. Resistance Bands
8. Backward Chaining
9. Floorwork
Cool Down
10. Circulation Lowerer
11. Flexibility
12. Tai Chi
Specialist PSI Exercise Module
Teaching Workshop Feedback Guidelines
pace
Appropriate to
component and
evidence-based
transitions
1. Content
2. Teaching
What
Where
When
- Position
- T. Instruction
- T. Points
How
- 1 - 1 observing
analysing,
solution,
communicating
3. Personal Performance
- Attire, Organised, Technique, Voice,
Communication
Specialist PSI Exercise Module
Medical Conditions and Medications
Impacting on Falls, Injury and Capacity to
Exercise
With thanks to Dr Rob Morris
(contributions also by
Drs J Close, J Treml, A Carr and S Shah)
Specialist PSI Exercise Module
Introduction
Why bother with this?
Medical conditions (diseases and disorders), and the medications
used to treat them, both have potential influence on postural stability
and the capacity to exercise effectively
Older People:
More diseases/conditions – accumulated deficits
More susceptible to drug toxicity (side effects)
More disease = More drugs + More types of drugs
= Greater potential for falling
Specialist PSI Exercise Module
Question
• Identify any condition common among older
people
Consider:
– Does it increase risk of falls and why
– Does it limit exercise capacity
– Risks and Benefits of Exercise
Specialist PSI Exercise Module
Contents
Part 1 – Medical Conditions
Cardiovascular disease
Ischaemic heart disease
Peripheral vascular disease
Cerebrovascular disease - Stroke
Hypertension
Arrhythmias
Heart Failure
Respiratory disease
Asthma
Chronic Obstructive Pulmonary Disease
Brain disease
Parkinsonism and Parkinson’s disease
Depression
Dementia
Specialist PSI Exercise Module
Musculoskeletal Disorders
Osteoarthritis
Rheumatoid arthritis
Endocrine and Metabolic Disorders
Diabetes
Osteoporosis
Sensory system abnormalities & Nervous System Integration
Cataracts
Glaucoma
Age-related macular degeneration
Ménières disease
Specialist PSI Exercise Module
Part 2 – Medications (drugs)
•
Drugs for high blood pressure (Antihypertensives)
•
Drugs used in angina
•
Drugs used to reduce clots (Antiplatelet drugs & anticoagulants)
•
Drugs for abnormal heart rhythms (Antiarrhythmic drugs)
•
Drugs used in respiratory disease
•
Drugs for Parkinson’s disease
•
Drugs acting on the brain (Psychotropic drugs)
•
Drugs for arthritis and connective tissue disorders
•
Drugs for diabetes
•
Drugs for osteoporosis
Specialist PSI Exercise Module
Cardiovascular Disease
Specialist PSI Exercise Module
Ischaemic Heart Disease
Definition
Impairment of blood flow to heart muscle caused by narrowing of coronary
arteries
Symptoms
Chest pain/tightness on exertion and relieved by rest – angina (pectoris)
Concern
Can ultimately lead to heart attack – myocardial infarction
Management
Medication or invasive procedures, including angioplasty (balloon dilatation),
stent & coronary artery bypass grafting (CABG)
Relevance for exercise
Should always consult with GP prior to exercise program
Specialist PSI Exercise Module
Angioplasty
Specialist PSI Exercise Module
Coronary Artery Bypass Surgery
Specialist PSI Exercise Module
Peripheral Vascular Disease
Definition
Impairment of blood flow to the peripheries (legs mainly) caused by narrowing
of blood vessels
Symptoms
Cramp like pain in legs on exertion, relieved by rest
Concern
May deter people from exercising. Often co-existent with ischaemic heart
disease (which may be silent)
Management
Angioplasty (balloon dilatation) or stent, if narrowing is in larger blood
vessels, or bypass surgery
Relevance for exercise
Will limit exercise capacity.
Need to encourage to work into, but not through, pain (which may lead to
opening of collateral vessels)
Specialist PSI Exercise Module
Stroke
Definition
Damage to part of the brain from either blockage to a blood vessel or bleeding
from a blood vessel (15%)
Symptoms
Depends on area damaged in brain - Face, Arm, Leg, Speech, Vision
Concern
Increased risk of falls: may also affect comprehension or speech
Management
Thrombolysis, rehabilitation, and address risk factors for recurrent stroke.
Occasionally carotid artery angioplasty
Relevance for exercise
Increased risk of falls due to weakness, impaired co-ordination of movement,
loss of visual field, sensory neglect or confusion.
Nonetheless have potential to benefit from exercise.
Need to be aware of language, memory or sensory problems.
Specialist PSI Exercise Module
Stroke – CT Scan
Specialist PSI Exercise Module
Carotid Artery Angioplasty
Before
After
Specialist
PSI Exercise Module
Hypertension
Definition
High blood pressure
Systolic pressure > 140 and/or Diastolic pressure > 80mmHg
Symptoms
Usually no symptoms
Concern
Increased risk of stroke or heart attack
Management
Usually controlled on medication long term, also diet and exercise
Relevance for exercise
Not an exclusion for exercise.
Some studies have shown that exercise lowers BP (Tai Chi).
Client responsibility to ensure BP is checked regularly and liaise with GP
Specialist PSI Exercise Module
Arrhythmias
Definition
Abnormalities of the heart rhythm
Symptoms
Palpitations, dizzy spells (rare), collapse. May be asymptomatic.
Determined by site in heart where disturbance originates.
Concern
Risk of exercise inducing abnormal rhythm
Management
Once type of rhythm disturbance is identified, then medication is usual treatment
Relevance for exercise
Be aware of any precipitating factors
Client responsibility to liaise with GP
Specialist PSI Exercise Module
Heart Failure
Definition
A complex syndrome that can result from any structural or functional cardiac
disorder that impairs the ability of the heart to function as a pump to support a
physiological circulation
Symptoms
Severe tiredness, breathlessness or swelling of the ankles and feet
Concern
Development of heart failure is associated with poor prognosis but careful
exercise can improve heart function and symptoms
Management
Dependent upon cause. Drugs form the mainstay of management in most
cases.
Relevance for exercise
Depending on severity may limit exercise capacity significantly
Specialist PSI Exercise Module
Pacemakers and Defibrillators
Definition
Pacemakers are electrical implants used to treat certain disorders of cardiac rhythm,
usually where the heart goes too slowly.
Defibrillators are implanted to treat more serious rhythm disorders, particularly
paroxysmal ventricular tachycardia or fibrillation.
Symptoms
Usually the presence of a pacemaker or defibrillator is asymptomatic
Concern
Patients with exercise-induced arrhythmias may find that their defibrillator is triggered.
Pacemakers should not be a concern.
Relevance for exercise
Pacemakers should not preclude exercise, though clients should check with their GP or
pacing clinic. Should not exercise within 6 weeks of a new pacemaker.
Clients with defibrillators must check with their specialist clinic and should avoid
exercising to maximum heart rate. More sustained, lower intensity exercise is
preferable.
Specialist PSI Exercise Module
Respiratory Diseases
Specialist PSI Exercise Module
Asthma
Definition
Reversible airflow limitation due to constriction of airways
Symptoms
Shortness of breath, wheeze, cough
Concern
Can be induced by exercise or limit exercise capacity
Management
Inhaled medication for the majority
Some will take oral medications
Relevance for exercise
Not a contra-indication to exercise but may limit exercise capacity.
Clients should bring inhalers with them and use at beginning of session
Specialist PSI Exercise Module
Airways in Asthma
Specialist PSI Exercise Module
COPD/Emphysema
Definition
Irreversible airflow limitation usually caused by smoking
Symptoms
Shortness of breath on exertion
Concern
Reduced exercise capacity
Management
Similar to that of asthma although less responsive
Relevance for exercise
Can limit exercise capacity, but exercise may improve this.
Specialist PSI Exercise Module
Case Study 1
• 74 year old male with history of COPD
and a myocardial infarction 6 months
ago
– What is the likely causal link between the
two conditions?
– What are the benefits of physical activity for
this patient?
– What may limit his activity?
Specialist PSI Exercise Module
Brain Diseases
Specialist PSI Exercise Module
Parkinson’s Disease
Definition
Deficiency of neurotransmitter dopamine in the brain
Symptoms
Resting tremor, bradykinesia (slowness of movement), rigidity, postural
instability, shuffling gait and reduced facial expression
Concern
Increased risk of falls
Management
Managed with drugs. Rarely surgery
Relevance for exercise
Likely to be slow to initiate movement and exhibit postural instability
May be embarrassed
No specific exercise programme has proven benefit
Specialist PSI Exercise Module
Definition
Low mood
Depression
Symptoms
Sad, low self-esteem, loss of appetite, weight loss, concentration and memory
problems, sleep problems, anxiety, somatic symptoms etc.
Concern
Increased risk of falls, may be increased fear of falling
Management
Medication or psychology
Relevance for exercise
Postural instability, due to deconditioning or drugs
Participation may be poor and will need encouragement etc.
Specialist PSI Exercise Module
Dementia
Definition
Progressive decline in cognitive ability and other brain functions. Alzheimer’s
disease is commonest cause, followed by vascular disease
Symptoms
Impairment in short term memory, alteration in ability to sequence tasks,
disorientation, reduced risk-awareness, ?impaired balance
Concern
Increased risk of falls
Management
Depends on cause but largely supportive, drugs of limited benefit
Relevance for exercise
May have difficulty following commands
May get agitated or disorientated
Some can benefit from supervised exercise
May be better to have carer present
Specialist PSI Exercise Module
Osteoarthritis
Definition
Degeneration of joints with loss of cartilage. Affects most commonly used joints knees, hips, lower back, shoulders and hands
Symptoms
Pain, stiffness and swelling of joints. Instability of knees. Reduced mobility.
Concern
Pain in joints may be worsened by exercise. Unstable knees can give way.
Management
Analgesia is mainstay of management. Consideration of joint replacement.
Strength training has proven benefit - may protect joint from excess wear.
Relevance for exercise
Will limit exercise tolerance through affected joint. This may be helped by taking
analgesia prior to exercising.
Specialist PSI Exercise Module
Rheumatoid Arthritis
Definition
Inflammatory disorder of joint lining and tendon sheath lining
Symptoms
May be similar to OA, but different joints affected - hands, wrists, neck
Inflammatory changes and swelling more common, especially in the morning
Concern
As with OA. Joints need protection when acutely inflamed
Management
Usually controlled with variety of analgesic agents and disease modifying drugs.
Sometimes joint replacement.
Relevance for exercise
Ensure adequate analgesia, may be less stiff in afternoon
Specialist PSI Exercise Module
Joints in Rheumatoid Arthritis
Specialist PSI Exercise Module
Diabetes
Definition
Impaired production of, or reduced sensitivity to, insulin causing high blood sugar.
Associated with abnormal lipids, high BP, obesity.
Symptoms
Weight loss, thirst, passing a lot of urine, blurred vision
Concern
Hypoglycaemia if prolonged fast or excessive exercise (only if treated with tablets or
insulin)
Management
Can be managed with diet, oral tablets and/or insulin
Relevance for exercise
Peripheral neuropathy causes impaired foot sensation, altering balance
Should carry dextrose tablets for classes
Exercise training has proven benefit in reducing blood sugar
Specialist PSI Exercise Module
Osteoporosis
Definition
Progressive loss of bone (all bones) and disruption of bone architecture leading to a
weak & fragile skeleton that is prone to fractures - particularly spine, hip & wrist.
Symptoms
Low trauma fractures
Concern
Risk of injury from fall. Pain
Management
Usually treated with drugs, including calcium and vitamin D
Relevance for exercise
Increased risk of fracture in the event of a fall
Weight-bearing exercise may increase bone density
Might be a group to consider for hip protectors???
Specialist PSI Exercise Module
Nervous System Integration
Specialist PSI Exercise Module
Nervous System Integration
Vestibular system
Balance
Brain stem
Basal Ganglia
Movement control
Spinal cord
Relay of signals
Cerebrum
Cerebellum
Coordination
Autonomic
Nervous System
Pulse, BP control
Peripheral nerves
Motor - muscles
Sensory - skin sensation
- proprioception
Specialist PSI Exercise Module
Nervous System Integration
Vision
Vestibular
Pain/Temperature
Proprioception/Vibration
Pressure
Light touch
Motor
Autonomic
Blood pressure
Heart rate
Specialist PSI Exercise Module
Nervous System Integration
Diseases affecting sensory input
Vision
Age-related refractive error (long sight)
Age-related macular degeneration
Glaucoma
Cataracts
Stroke causing visual field defect
Proprioception
Diabetic neuropathy
Vitamin B12 deficiency (uncommon)
Syphilis (very rare)
Degenerative joint disease, especially of neck and ankles
Vestibular
Age-related middle and inner ear changes
Chronic ear infections
Perforated ear drum?
Labyrinthitis
Benign paroxysmal positional vertigo
Specialist PSI Exercise Module
Nervous System Integration
Diseases affecting central processing
Cerebrum
Cerebrovascular disease (stroke, small vessel disease)
Dementia
Brain tumour (benign & malignant)
Cerebellum
Cerebrovascular disease (stroke)
Long term alcohol misuse
Basal ganglia
Cerebrovascular disease (stroke)
Parkinson’s disease and related conditions
Brain stem
Cerebrovascular disease (stroke)
Atherosclerosis (narrowing of blood vessels supplying the brain)
Postural hypotension
Specialist PSI Exercise Module
Nervous System Integration
Diseases affecting Effector response
Spinal cord and
nerves
Any condition causing narrowing of spinal cord
Neuropathy
Motor neurone disease
Multiple sclerosis
Foot drop (common peroneal nerve palsy)
Muscles
Cerebrovascular disease (stroke)
Motor neurone disease
Muscular dystrophy (unlikely in older adults)
Multiple sclerosis
Polymyalgia rheumatica
Polymyositis
Hypothyroidism
Vitamin D deficiency (osteomalacia)
Diabetes (diabetic amyotrophy)
Muscle disuse following fracture, injury or prolonged immobility
Joints
Osteoarthritis
Rheumatoid arthritis
Other
Foot deformities
Poor fitting shoes
Specialist PSI Exercise Module
Case Study 2
•
•
•
•
•
•
75 year old woman
20 year history of diabetes poorly controlled by diet.
High blood pressure and angina.
Hip osteoarthritis
Smokes 20/day
What are the potential medical problems which may
limit exercise ability/capacity?
Specialist PSI Exercise Module
Medications
• 4/5 aged 75 or over prescribed at least one
medication
• Over one third on four or more
• One drug may have a number of indications
• Potential Impact on
– Risk of falls
– Exercise Capacity
Specialist PSI Exercise Module
For all Medication
• Consider
–
–
–
–
–
–
–
Indications
Main effects
Side-effects including falls and exercise ability/capacity
Idiosyncratic adverse effects
Contra-indications
Interactions with other drugs
Compliance
– Eg Atenolol
Specialist PSI Exercise Module
Common Indications
•
Cardiovascular Drugs
•High blood pressure (Antihypertensives)
•Angina
•Abnormal Heart rhythms (Antiarrhythmic drugs
•Drugs used to reduce clots (Antiplatelet/Anticoagulant drugs)
•
Drugs for diabetes
•
Drugs used in respiratory disease
•
Drugs for Parkinson’s Disease
•
Drugs acting on the brain (Psychotropic drugs)
•
Drugs for arthritis and connective tissue disorders
•
Drugs for osteoporosis
Specialist PSI Exercise Module
Drugs for high blood pressure
•
β – Blockers (atenolol, metoprolol etc)
•
Diuretics (Thiazide)
•
Calcium Channel Blockers (Nifedipine, Verapamil etc)
•
ACE Inhibitors (& Angiotensin receptor blockers)
(Captopri, Enalarpril etc)
•
Often in combination
•
Not contraindicated for exercise
Specialist PSI Exercise Module
Drugs used in angina
•
β – Blockers
•
Nitrates (GTN and long acting)
•
Calcium Channel Blockers
•
Potassium Channel Openers (Nicorandil)
•
Often used in combination and statins (cholesterol
lowering) also prescribed
•
•
If patient has GTN, they should keep it with them when exercising
and may consider using it prior to exercise.
If patient forgets their GTN, recommend gentle exercise only
Specialist PSI Exercise Module
Drugs used in heart failure
•
Diuretics
•
ACE-Inhibitors
•
β – Blockers
•
Vasodilators
•
•
Patients may have reduced exercise tolerance
Patients may omit diuretics if going out, which may further reduce
their exercise capacity - they should be advised to continue all
medications
Specialist PSI Exercise Module
Antiplatelet drugs
•
After heart attacks, strokes, or when risk of clots
•
Antiplatelet
-Aspirin (Acetyl Salicylic Acid – ASA)
-Dipyridamole (Persantin)
-Clopidogrel (Plavix)
•
Anticoagulant
-Warfarin
•
Not a contraindication to exercise, but may increase risk
of bleeding in the event of a fall, particularly if on both
Aspirin and Clopidogrel
Specialist PSI Exercise Module
Anticoagulants
•
Warfarin
•
(Phenindione - rare)
•
Not a contraindication for exercise, but will increase risk of
bleeding if patient falls
Specialist PSI Exercise Module
Antiarrhythmic drugs
•
•
β – Blockers
•Atenolol, Bisoprolol, Sotalol
Calcium Antagonists
•Verapamil, Diltiazem
Digoxin
•
Amiodarone
•
Drugs for ventricular arrhythmias
•Quinidine, Flecainide, Mexiletine, Disopyramide
•
•
Patients on Digoxin or Amiodarone should be able to exercise
Patients treated for Ventricular arrhythmias should only exercise with
medical advice
•
Specialist PSI Exercise Module
Drugs used in respiratory disease
Inhaled therapy
β2 Agonists Salbutamol (Ventolin), Terbutaline (Bricanyl)
Long acting Salmeterol (Serevent, Seretide), Formoterol
Anticholinergics
Ipratropium Bromide (Atrovent), Tiotropium (Spiriva)
Steroids
Beclometasone (Becotide, Becloforte)
Budesonide (Pulmicort), Fluticasone (Flixotide)
Patients should have short-acting β2 Agonists with them when exercising
Oral Therapy
β2 Agonists Salbutamol (Ventolin) - rarely used
Theophyllines
Uniphyllin, Phyllocontin
Steroids
Immunomodulator
Prednisolone
Monteleukast, Zafirlukast - rarely used in older adults
If on a course of steroids for acute exacerbation, not advisable to exercise
Specialist PSI Exercise Module
Drugs used in Parkinson’s disease
L-Dopa
Co-careldopa - Sinemet
Co-beneldopa - Madopar
Dopamine agonists
Ergot-based - Pergolide, Cabergoline
Bromocriptine - rarely used
Non-Ergot - Pramipexole, Ropinirole
COMT inhibitors
Entacapone
Other drugs
MAO(B)-inhibitor - Selegiline
Amantadine
Anticholinergics - Trihexyphenidyl, Procyclidine
Apomorphine injection - used in late disease
Ability to exercise will depend on stage of disease and time of day
Drug regimes can be complex - should not miss doses
Specialist PSI Exercise Module
Psychotropic drugs
Anti-depressants Tricyclic - Amitriptyline, Dosulepin, Lofepramine
SSRI’s - Citalopram, Sertraline, Fluoxetine
SNRI - Venlafaxine
Sedatives
Benzodiazepines - Temazepam, Nitrazepam, Diazepam
‘Z drugs’ - Zopiclone, Zolpidem
Phenothiazines
Nausea - Prochlorperazine, Metoclopramide
Agitation (usually acute) - Haloperidol
New agents - Risperidone, Quetiapine
All can cause sedation or confusion and increase falls risk
Anti-dementia
Donepezil (Aricept), Rivastigmine, Galantamine
Despite modestly improving cognitive function, do not reduce falls risk
Specialist PSI Exercise Module
Drugs for arthritis and connective tissue disorders
Analgesics
Combination analgesics
Paracetamol, Codeine, Tramadol
Co-codamol, Co-dydramol
Co-proxamol has been withdrawn
Anti-inflammatory drugs
Aspirin (only over the counter)
NSAID’s - ibuprofen, diclofenac
Disease-modifying drugs
Immunosuppressants
Steroids (e.g. Prednisolone)
Azathioprine, Methotrexate, etc.
Ensure patient has taken pain relief, or has it with them for after exercise
Avoid exercise during acute flare-ups
Specialist PSI Exercise Module
Drugs for diabetes
Oral hypoglycaemic agents
Biguanides - Metformin
Sulphonylureas - Gliclazide, Tolbutamide
Glitazones - Pioglitazone, Rosiglitazone
Insulin
Human (recombinant, analogue)
Beef or Pork (rarely used now)
Long-acting - Insulatard, Glargine, Detamir
Intermediate Acting - Mixtard, Novomix
Short-acting - Actrapid, Humalog
Glucose
Dextrose tablets
Glucogel (Hypostop)
Specialist PSI Exercise Module
Drugs for osteoporosis
Calcium + Vitamin D
Adcal D3, Calcichew D3 Forte, Cacit D3
Vitamin D insufficiency is common in older people
Causes reduced bone and muscle strength
Treatment reduces fractures by about one third in housebound or
institutionalised older women, may also reduce falls
Bisphosphonates
Alendronic acid (Fosamax), Risedronate
Build bones by slowing resorption.
Robust evidence of fracture reduction (approx 50%)
Other drugs
Strontium ranelate, Teriparatide, Raloxifene
HRT no longer recommended for osteoporosis due to adverse effects. Slows postmenopausal bone loss. Effect lost once withdrawn. Some concerns over
increased risk of breast cancer.
Specialist PSI Exercise Module
Case Study 1 - Mrs A (age 75 years)
History:
Two falls
Hypertension
Type 2 diabetes
Angina
Sleep problems
Glaucoma
Medications:
Zopiclone
GTN spray
Gliclazide
Aspirin
Atenolol
Adcal D3
Questions:
•
•
•
Why is she on each medication?
Which medications may be contributing to her falls?
Are there any exercise considerations with these medications?
Specialist PSI Exercise Module
Case Study 2 - Mr. B (age 80years)
Medications:
Aricept
Becotide
Captopril
Citalopram
Co-dydramol
Furosemide
Salbutamol
Questions:
•
•
•
What medical conditions might he have?
Could any of these medications be contributing to his falls?
Are there any exercise considerations of the medications?
Specialist PSI Exercise Module
If someone is prescribed the following drug(s),
what conditions are they likely to have?
a) Alendronic acid
b) Diltiazem
c) Pergolide and Co-careldopa (Sinemet)
d) Mixtard
Specialist PSI Exercise Module
Useful Information Sources
• www.prodigy.nhs.uk (patient and
professional)
• www.bnf.org.uk (need to register)
• www.merck.com/mmpe (professional)
• www.merck.com/mmhe (patient)
• www.besttreatments.co.uk (patient)
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module
Implementation
Making it work
and making it sustainable
Different models, but similar
principles
Specialist PSI Exercise Module
IDEALLY - An Integrated
Falls and Fracture Prevention Service
• multi-professional
Medical and Nursing staff, Therapists, Social Workers, Exercise Professionals
• multi- agency
Local health authority, Social services. Local authority , Leisure Services,
Sports Development Service, Voluntary sector
• co-ordinated
Working to agreed protocols, Working to agreed pathways, Utilising agreed
communication pathways
• and integrated service
Using a regular mechanism of meeting to agree strategy and review progress
towards objectives
Specialist PSI Exercise Module
What should a service consider?
•
•
•
•
Aims of Service
To provide a seamless service across all agencies
To promote personal responsibility for healthy active
ageing
To pro actively identify those at risk of falls and
osteoporosis
To ensure appropriate assessment and interventions for
those at risk
Specialist PSI Exercise Module
3-tiered inter agency assessment process:-
3. Specialist falls assessment
2. Determine risk factors
1. To identify a falls problem
Specialist PSI Exercise Module
Getting falls and fractures on the
map
• ? Trigger questions on falls and fractures in
– A&E
– GPs
– Single Assessment process?
• Educating others
– Pharmacy, Opticians, Chiropodists, Day Centres
– etc
Specialist PSI Exercise Module
Exercise Continuum
3 components:1. Community exercise opportunities that offer varied and
progressive programme
2. Specific falls prevention (and injuries from falls) rehab
class and
3. home based exercise programme
Specialist PSI Exercise Module
How?
• Clinical Exercise Specialists creating links between
health and leisure
• Nationally validated courses:- CBE, OEP, PSI available
to all professional groups
• Additional ‘top up’ training to develop skills and
standards of practice across all areas
• ‘Code of practice’ – agreed minimum standards for all
instructors in both health and leisure
• List of approved classes (monitored and evaluated on
a regular basis)
Specialist PSI Exercise Module
Community Exercise Programme
Aim: to ensure that all older adults have
easy access to a regular, safe and
effective local exercise class
• community
• sheltered housing complex
• day centre
• residential home
Specialist PSI Exercise Module
Cambridgeshire Falls Prevention EXERCISE PATHWAY
Falls Assessment
Identification of a falls problem and screening to determine risk factors
Motivation Screening Pathway
Home based exercise
programme
OTAGO
OTAGO
exercise classes
(Community based)
Chair Based Exercise
Class
(Community based)
PSI/Rehab based
exercise group
12 weeks
Exercise Referral Scheme
12 weeks
Community based
classes for older people
Specialist PSI Exercise Module
Transport issues……Funding issues
• Link in with other services
–
–
–
–
Exercise Referral
Mental Health priorities
Social Care funding
Leisure Services
• Consider self funding after initial period?
– Often more valued and attendance better!
• Consider ‘buddying’ shemes to aid travel
– Going with people on the bus
– Providing a lift
– Bring along family (and their car!)
Specialist PSI Exercise Module
Challenges for future
• Keeping falls and osteoporosis on agenda
(different priorities across primary and secondary
care and community)
• financial constraints - demonstrating cost
effectiveness
• ongoing organisational changes
• staff - rapid turnover
- low morale
Specialist PSI Exercise Module
Conclusions
• Falls and Fracture Prevention Services have come a long way in
past 6 years.
• In order to ensure ongoing funding locally, we must convince
commissioners of cost effectiveness in terms of:- preventing falls related injuries.
- maintaining independence and improved QOL for those at risk
of falls and fractures (eg. Evaluation!)
Be clear about the specific needs of this group of people (Not all
exercise is the same!)
Specialist PSI Exercise Module
Assignments – Day One
MANUAL 2
• Remind yourself of
– the Selection and Exclusion Criteria for entry into the ‘prehab’ class
(Manual 2 – Section 2)
– the triggers for referral onto medical or other exercise settings
(Manual 2 – Section 2)
• Look at the Functional Assessments grid
– read the protocols for the six functional tests
(Manual 2 – Section 2)
Specialist PSI Exercise Module
Assignments – Day Two
Underpinning Knowledge
• Read over content covered in first two days of module
• Read medical conditions and medications (Manual 1 Section
4) and exercise programming, theory and practice (Manual 2
Section 3)
Specialist PSI Exercise Module
Assignments – Day Two
Case Study and Practical
• Visit a Rehab AND a Prehab postural stability group – if
possible!
• Identify an individual appropriate for a Case Study and
secure their agreement.
– Discuss choice and method of approaching individual with
therapist/instructor
– Schedule start of your Case Study after days 2/3
Specialist PSI Exercise Module
Assignments – Day Two
Practical Workshop
Prepare approximately ten minutes of one of the following:
• Warm-up (circulation and mobility or stretch)
• Resistance / bone loading (seated)
• Dynamic Balance / Endurance
• Backward Chaining + floor exercise
• Floor work (considering transitions)
• Flexibility
• Tai Chi
to teach as part of a teaching workshop on day 3/4
Specialist PSI Exercise Module
Assignments – Day Four
PSI Theory Paper
• Revision
– Do the Mock Theory Paper on the Website (Student Page)
– Have a go at the Quiz on the Website (Student Page)
– Remember that the PPT handouts cover most but you need to know
your exercises and your delivery skills (theoretically)
Tai Chi
• Revise your Tai Chi skills as these will be assessed on Day 5
formatively
Specialist PSI Exercise Module
Notes
Specialist PSI Exercise Module