Bradford Teaching Hospitals Trust

1. Bradford Teaching Hospitals Trust The Importance of Exercise in the prevention of falls in older people– Strength & Balance Phil Wright – Clinical Coordinator Physiotherapy Services for Older People

2. Exercise – the Evidence Risk factors for falls – muscle weakness x4 risk - gait deficit x3 risk - fall history x3 risk Exercise is effective as a single intervention as it addresses weakness, balance + gait Most falls prevention programmes utilise a multi-intervention approach, identifying and modifying risk factorsMost falls prevention programmes utilise a multi-intervention approach, identifying and modifying risk factors

3. Importance of exercise Evidence Based Maintenance of bone density Falls prevention Postural stability Muscle strength - resistance training Balance Weight bearing exercise is best There is plenty of evidence to support exercise as being effective in preventing falls. I was very pleased to see the emphasis on exercised in the newly published NICE guidelinesThere is plenty of evidence to support exercise as being effective in preventing falls. I was very pleased to see the emphasis on exercised in the newly published NICE guidelines

4. NICE Guidelines Recommends strength & balance training Most likely to benefit community dwelling people with history of falls or gait/balance deficit Individually prescribed and monitored by appropriately trained professional No evidence to support untargeted group exercise or walking

5. Exercise &Fall PreventionWhich type of exercise is effective? Exercise must be highly specific to be effective in reducing falls Individually tailored,professionally advised strength & balance training has the best evidence to support it (Campbell et al, BMJ, 1997) Most appropriate target group are 80+ yrs with fall in past yr or other major risk factor Two recent trials give more support for group therapy (Lord et al, JAGS, 2003 & Barnett et al Age & Ageing 2003) Evidence is specific to population and setting Most evidence relates to community dwelling population Campbell trial- 4x 1 hour visits over 2 months ( therapist or nurse trained by therapist) Individualised programme of progressive strengthening using ankle weights aimed at strengthening around the hip and ankle (not the knee?) Balance re-training / gait training Fewer falls even at 2 year follow up Lord et al Mean age =80 12 months of 1 hour 2x week Weight bearing strength and balance and co-ordination 22% reduction in falls Barnett - mean age = 75 37 classes over 12 months Strength, balance, flexibility, endurance, co-ordinationEvidence is specific to population and setting Most evidence relates to community dwelling population Campbell trial- 4x 1 hour visits over 2 months ( therapist or nurse trained by therapist) Individualised programme of progressive strengthening using ankle weights aimed at strengthening around the hip and ankle (not the knee?) Balance re-training / gait training Fewer falls even at 2 year follow up Lord et al Mean age =80 12 months of 1 hour 2x week Weight bearing strength and balance and co-ordination 22% reduction in falls Barnett - mean age = 75 37 classes over 12 months Strength, balance, flexibility, endurance, co-ordination

6. Specific Exercises Strengthening against resistance using weighted cuffs, theraband, body weight, for all major lower limb muscle groups, emphasising hip abductors and extensors, knee extensors, foot dorsi-flexors Dynamic balance exercises, stepping in different directions, turning, coping with distraction, uneven surfaces

7. Exercise & Fall Prevention Tai Chi? Only one study (Wolf, JAGS,1996) has reported a reduction in falls Many different forms, lack of teachers Far more evidence to support S&B exercise than Tai Chi NHS physiotherapists are trained in exercise, not Tai Chi The NICE Guidelines make no mention of Tai Chi.The NICE Guidelines make no mention of Tai Chi.

8. What can physiotherapists offer? Assessment of gait, balance, muscle strength, joint flexibility,functional mobility Specific exercise to address any problems identified above Provision of appropriate walking aids Teach coping strategies in the event of a fall Restore confidence

9. What Services are available locally Community- based P.T :- domiciliary. Fast response. Rehab centres. Social Services rehab units Residential & nursing. Day Hospital (Shipley & Westwood) Walking and Balance Groups – Basic, Advanced, Asian. Hospital – based services ;- In-patients ( Acute & Community Hospitals) Rapid Access Clinic – multi-disciplinary assessment

10. Balance &Walking Groups

11. Current Structure Groups running in three centres, one in each P.C.T. 10 groups running from May 2004 Therapist lead to assess, evaluate and develop (evidence based ) Assistants deliver – two per group 16 sessions, 2x week for 8 weeks Basic, Advanced, Asian ladies groups in Bradford City P.C.T. Numbers attending – 6-8 basic,10 advanced (max)

12. Content - practical Warm up Group exercise Individual circuits Posture Muscle strengthening, joint range of movement Balance – dynamic ! Games = Fun! Getting up from the floor – backward chaining Home exercise programme

13. Content - educational External speaker’s sessions ; OT, Podiatrist Falls prevention Coping strategies in the event of falling ; getting up from floor, summoning help , staying warm etc Information – hip protectors, pendant alarms, handy person scheme, BEEP, access bus, fire safety check, D.T.I. leaflets

14. Evaluation Improved scores on outcome measures at six week follow up MFES up by 18 points 6m walk down by 4 seconds Functional reach up by 1.3 inches TUSS up by 5 seconds 65% patients complete the programme

15. Constraints Transport Staffing Space

16. Criteria for Referral to Physiotherapy Medical screen Risk factors Muscle Weakness ? Balance problem? Loss of confidence – fear of falling? Motivation to take part? Potential to improve with physiotherapy – recent change in function?

17. Who can refer to these services? G.P.’s Consultants District Nurses Falls Nurses Other healthcare professionals Social Services

18. Where to Refer North PCT GP – Shipley Hospital 322070 or Eccleshill Hospital on 323121 City PCT GP – Horton Park Centre 228844 South & West GP – Westwood Park Hospital - 425925

19. Response times Referrals are screened on receipt and put into one of 4 categories according to urgency Most urgent ( category 1) seen within 1 working day Longest wait ( category 4) = no more than 20 working days Waiting lists for Exercise groups vary ( average = 4 weeks) but pts can be seen as individuals whilst waiting for a place in the group to become available

20. Maintaining an exercise Programme Use it or lose it! Home Exercises Exercise Groups in the Community Walk from Home Scheme (North , S&W only)

21. Questions?

22. Bradford Teaching Hospitals Trust The Importance of Exercise – Strength & Balance Phil Wright – Clinical Coordinator Physiotherapy Services for Older People