The Great Exercise The Great Exercise Jigsaw PuzzleJigsaw Puzzle

Applying the Research Relating to Applying the Research Relating to Exercise and Falls Injury ReductionExercise and Falls Injury Reduction

Sally CastellSally Castell

““Health is created and lived by people within Health is created and lived by people within the settings of everyday life; where they the settings of everyday life; where they

learn, work, play and love. Health is created learn, work, play and love. Health is created by caring for oneself and others, by being by caring for oneself and others, by being able to take decisions and have control over able to take decisions and have control over oneone’’s circumstances, and by ensuring that the s circumstances, and by ensuring that the society one lives in creates conditions that society one lives in creates conditions that

allow attainment of health by all itallow attainment of health by all it’’s memberss members””

From the Ottawa CharterFrom the Ottawa Charter

““ Falls occur by people within their own settings Falls occur by people within their own settings of everyday lifeof everyday life……………….falls incidences can be .falls incidences can be

reduced by individuals gaining the facts and then reduced by individuals gaining the facts and then by being able to make decisions and act on them by being able to make decisions and act on them to have control over their circumstances as much to have control over their circumstances as much

as is realistically and feasibly possibleas is realistically and feasibly possible””

Falls Falls -- A MultiA Multi--Layered Approach Layered Approach The Bits of the Jigsaw PuzzleThe Bits of the Jigsaw Puzzle

EvidenceEvidencePolicies Policies

Systems Systems Strategies Strategies

StructuresStructuresSettings Settings

Assessments Assessments Personnel Personnel

Programs Programs Training Training

Evaluations Evaluations People People

Physical Activity & Falls PreventionPhysical Activity & Falls PreventionThe Big Picture The Big Picture -- A MultiA Multi--strategy Approachstrategy Approach

Advocate and provide for Advocate and provide for supportive physical and supportive physical and social environments through social environments through settings where people livesettings where people live

Build Build ‘‘activeactive’’ public policiespublic policies

Promote the benefits and Promote the benefits and need for PA and provide need for PA and provide access to information and access to information and life skills to enable life skills to enable participationparticipation

Focus on the different Focus on the different levels of behaviour change levels of behaviour change and tailor programs and tailor programs accordinglyaccordingly

Provide program options to Provide program options to suit varying social and suit varying social and cultural circumstances and cultural circumstances and motivations throughout the motivations throughout the life cycle life cycle

Provide accurate advice on Provide accurate advice on key professionalskey professionals

Establish partnerships to Establish partnerships to pursue a crosspursue a cross--community community and interand inter--sectoral sectoral approachesapproaches

Advocate for due priority Advocate for due priority to be given to PAto be given to PA

Falls Prevention StrategiesFalls Prevention StrategiesMultiMulti--component strategiescomponent strategies

Comprehensive clinical Comprehensive clinical assessments (with follow assessments (with follow up)up)Exercise Exercise --tailored tailored including gait, strength including gait, strength & balance components& balance componentsMedication management Medication management Referrals to health care Referrals to health care providers for treatment providers for treatment of chronic conditionsof chronic conditions

Vision assessment & Vision assessment & improved visionimproved visionFalls risk educationFalls risk educationOsteoporosis prevention & Osteoporosis prevention & treatment treatment Nutrition Nutrition -- calcium & calcium & vitamin D supplementationvitamin D supplementationHip protectorsHip protectorsEnvironment modificationsEnvironment modifications

Exercise & Falls OverviewExercise & Falls OverviewMultiple strategies and recommendations related to Multiple strategies and recommendations related to falls prevention issuesfalls prevention issuesMultiple settings; many personnel with many Multiple settings; many personnel with many different skills; many programs to contribute to the different skills; many programs to contribute to the big picturebig pictureMany issues with many barriers that need to be Many issues with many barriers that need to be addressed in order to bridge the gaps from one addressed in order to bridge the gaps from one setting to another setting to another

Many levels of abilities with manyMany levels of abilities with many assessments toassessments toaccommodate these variables accommodate these variables

Many programs and interventionsMany programs and interventionsHowever However …………

Questions Questions ((From the exercise perspectiveFrom the exercise perspective))

What we are currently doing What we are currently doing …….are we doing it .are we doing it right / well ?right / well ?

Are the issues and problems related to falls Are the issues and problems related to falls reduction addressed sufficiently well?reduction addressed sufficiently well?

Are there still gaps and how can they be filled?Are there still gaps and how can they be filled?

Guidelines? Guidelines?

Training? Training? -- standardsstandards

Sufficient support and growth ? Sufficient support and growth ? -- infrastructures infrastructures / personnel etc. / personnel etc.

Exercise EvidenceExercise EvidenceGoals of ManagementGoals of Management…………

Maintain muscle strength, endurance, balanceMaintain muscle strength, endurance, balanceLevel 1Level 1

Progressive resistance trainingProgressive resistance training effective to increase effective to increase strength & some functional outcomesstrength & some functional outcomes

Endurance trainingEndurance training increases functional capacity. increases functional capacity. FITT still needs further investigation FITT still needs further investigation

Tai chiTai chi –– improves balance and postural control, positive effect improves balance and postural control, positive effect on FOF and postural control on FOF and postural control

Falls specific interventionsFalls specific interventions –– multimulti--disciplinary, multidisciplinary, multi--factorial, health/ environmental risk factor screening and factorial, health/ environmental risk factor screening and intervention intervention –– risk assessment; education/ awareness ;equipment risk assessment; education/ awareness ;equipment check, labels or bracelets for high risk; alarmscheck, labels or bracelets for high risk; alarms

Exercise EvidenceExercise EvidenceLevel 2Level 2

Balance trainingBalance training ..-- Specific to level of function which is to be Specific to level of function which is to be achieved achieved –– Static and dynamic balance (gait training) required Static and dynamic balance (gait training) required * Sitting balance exercises insufficient* Sitting balance exercises insufficient

Individual tailored programsIndividual tailored programs including strength, balance and including strength, balance and functional retraining increases mobility & reduces use of assistfunctional retraining increases mobility & reduces use of assistive ive devicesdevices

Group exercisesGroup exercises –– strength, balance, aerobic and functional strength, balance, aerobic and functional activities improves mobility and functionactivities improves mobility and function

Falls specific interventionsFalls specific interventions multimulti--disciplinary, multidisciplinary, multi--factorial, health/ environmental risk factor screening and factorial, health/ environmental risk factor screening and intervention intervention –– risk assessment; education & awareness; equipment risk assessment; education & awareness; equipment check in residential care check in residential care –– staff education; gait training & staff education; gait training & appropriate use of assistive devices; review of medication etc. appropriate use of assistive devices; review of medication etc.

Best practice approaches to prevent functional decline in older Best practice approaches to prevent functional decline in older persons persons -- quick guide Clinical epidemiology & Health Services Evaluatioquick guide Clinical epidemiology & Health Services Evaluation unitn unit

Gaps between Research Gaps between Research and Practiceand Practice

The evidence should be able to be translated from The evidence should be able to be translated from research into practice but research into practice but …………

* * Few interventions are consistently or poorly implemented in applied settings (“the real world””))

* * More demonstrations are needed of how to effectively implement research in typical settings and locations

* * Greater attention is needed towards documentation of efficacy and effectiveness of interventions relating to reach, adoption, implementation and maintenance (RE-AIM)

Excerpts from Why donExcerpts from Why don’’t we see more translation of Health Promotion Research into t we see more translation of Health Promotion Research into practice? practice?

Rethinking the EfficacyRethinking the Efficacy--toto--Effectiveness Transition Effectiveness Transition AM j Public Health. 2003; 93: 1261AM j Public Health. 2003; 93: 1261--12671267

Community Service IssuesCommunity Service Issues““The real worldThe real world””

Community Service IssuesCommunity Service Issues““The real world The real world ””

In the big health picture In the big health picture –– many different priorities many different priorities therefore limitations and barriers ontherefore limitations and barriers on……Time & staffing levelsTime & staffing levelsBudgetary allowancesBudgetary allowancesGP & health care referral issuesGP & health care referral issuesReaching & providing the information to the people Reaching & providing the information to the people Lack of feedback & evaluation of effectiveness of Lack of feedback & evaluation of effectiveness of interventionsinterventionsStaff skill developmentStaff skill development--trainingtrainingAccess & provision of appropriate programs in different Access & provision of appropriate programs in different settings with limited number of trained personnel settings with limited number of trained personnel Inadequate infrastructure and systems to support Inadequate infrastructure and systems to support research translation research translation

Program SelectionProgram SelectionMany different exercise and training programs Many different exercise and training programs

developed mainly from research; different focus & developed mainly from research; different focus & elements for different target groups; conducted by elements for different target groups; conducted by different professionals organisations different professionals organisations

The Big Questions The Big Questions Which prescription Which prescription

? Protection and reducing falls risks? Protection and reducing falls risks? Rehabilitation and prevention of further falls? Rehabilitation and prevention of further falls

Which program for which target group ?Which program for which target group ?What assessments to use ?What assessments to use ?What What exercise personnelexercise personnel to provide the programs etc. ?to provide the programs etc. ?Program levels Program levels –– group and individual?group and individual?

Differences Differences Settings Settings

Acute CareAcute Care -- Hospital Hospital –– basebase

Community Community –– fit (40 fit (40 --60 baby boomers), early 60 baby boomers), early retirement( retirement( 6565--75) and frail (75+)75) and frail (75+)

Residential / supported careResidential / supported care

Target GroupsTarget GroupsLevel 1Level 1Very fit, healthy, active and independentVery fit, healthy, active and independentLevel 2Level 2Average fitness levelAverage fitness level / / moderately healthy managing normal moderately healthy managing normal daily activitiesdaily activitiesLevel 3Level 3Lower fitness levels Lower fitness levels --frailer with multiple health / activity frailer with multiple health / activity issues and limited capacitiesissues and limited capacities

Assessments at Different LevelsAssessments at Different Levels(Based from (Based from the Nagi Modelthe Nagi Model))

Physical activity level & health statusPhysical activity level & health status

Functional ability Functional ability --Difficulty in task performanceDifficulty in task performance

Impairment Impairment -- IAL DependenceIAL Dependence

Disability Disability ADL Dependence ADL Dependence

Cognitive decline Cognitive decline High fall riskHigh fall risk

Screening & AssessmentsScreening & AssessmentsMany measures for falls, the choice is dependent on Many measures for falls, the choice is dependent on

the setting, level of ability of target group etc.the setting, level of ability of target group etc.Examples :Examples :

PPA – Physiology profile assessment - Lord Simple PPA – GP assessment -Tiedeman FRAT pack3 - gait / mobility/ efficacy -TinettiSenior fitness test* Berg & FAB balance scalesABC confidence scale

And many more!!And many more!!The level of risk is not the same for all people especially oldeThe level of risk is not the same for all people especially older r

adults with changes over time, ongoing and different adults with changes over time, ongoing and different assessments often need to be undertakenassessments often need to be undertaken

Program OptionsProgram OptionsIndividual Individual –– advantages and disadvantages advantages and disadvantages

Incidental Incidental –– shower /dressing,shower /dressing, bed and chair bed and chair exercises exercises Home programHome programIndividual tailored program Individual tailored program

Group Group -- advantages and disadvantages advantages and disadvantages Group classes, Tai Chi, GE, bowls etc.Group classes, Tai Chi, GE, bowls etc.Strength and balance training Strength and balance training -- progressive and progressive and specificspecificCircuits comprising functional activitiesCircuits comprising functional activitiesSpecific falls reduction group classSpecific falls reduction group classThe great mixing pot The great mixing pot –– a bit of everythinga bit of everything! !

Programs, Programs, ProgramsPrograms, Programs, Programs

Fall Reduction Community ExamplesFall Reduction Community Examples“No Falls” - Victoria “Steady Steps”- Queensland“Upright and Active”-NSW“Stepping On”- NSW“Stay on Your Feet” – NSW; Western Australia & Canada“Stepping out” - NSW “Better Balance” – South AustraliaFallproof - America - (Program & training)

More ProgramsMore Programs!!Strength Training ExamplesStrength Training Examples

Staying Active Staying StrongLiving longer – Living Stronger Lift for Life

Individual Home ExamplesOttago Staying Active - Staying Safe

Residential care* Staying Active - Staying Safe

Older AdultOlder Adult Community Program Community Program organisation examplesorganisation examplesPRYME Movers -YMCA –CanberraHealthy Lifestyle / -SHARE / WAVES / Active over 50’s- NSWActive Ageing – SACOTA – all states

And many more…

Can links between programs Can links between programs & levels be made?& levels be made?

Falls & Exercise SelectionFalls & Exercise SelectionThere are multiple exercise recommendations, research There are multiple exercise recommendations, research

evidence, choices and programs to select from but..evidence, choices and programs to select from but..

One Program Does Not and One Program Does Not and Will Not Suit AllWill Not Suit All

A variety of appropriate exercise programs are needed A variety of appropriate exercise programs are needed to reduce fall risk and associated fall related to reduce fall risk and associated fall related

injuriesinjuries

Program ChoiceProgram ChoiceSome programs may need to be very specific to the Some programs may need to be very specific to the identified falls deficits and tailored to suit the identified falls deficits and tailored to suit the individuals level of ability whilst others can be individuals level of ability whilst others can be more general dependent on health state, fitness more general dependent on health state, fitness level and lifestyle level and lifestyle

Key issues Key issues to consider are that to consider are that strategies and strategies and programs need to be in context, accessible, programs need to be in context, accessible, relevant, flexible and realistic with the major goal relevant, flexible and realistic with the major goal being an ongoing lbeing an ongoing lifeife--long involvement in long involvement in appropriate appropriate PAPA

Exercise & Exercise & Background Background Factors Relating Factors Relating

to to Workplace Workplace ApplicationApplication

Participant BackgroundParticipant BackgroundThe older adult considerations The older adult considerations -- many variables many variables

personality traitspersonality traits

age & sex age & sex abilitiesabilities

health stateshealth states

exercise needsexercise needsprioritiespriorities

attitudeattitude

living accommodation

educationeducation

family & social support

expectations & perceptionsexpectations & perceptions

life & previous exercise experiences

motivationmotivation

aptitude

culture

fitness/ activity level

Overall Exercise ProgramOverall Exercise Program AimsAims

Reduce the impact and number of Reduce the impact and number of injuries that injuries that result from falls by increasing the number of result from falls by increasing the number of people undertaking appropriate exercise programs.people undertaking appropriate exercise programs.

Improve the identified falls related physiological Improve the identified falls related physiological problems with exercise strategies that reduce the problems with exercise strategies that reduce the individualsindividuals’’ potential risk of sustaining a fall potential risk of sustaining a fall

Design & provide appropriate programs for Design & provide appropriate programs for individuals that provide the proper amount of individuals that provide the proper amount of physical activity to attain maximal benefits at physical activity to attain maximal benefits at lowest risklowest risk

Effectiveness & Practical Effectiveness & Practical Application ChallengesApplication Challenges

Getting the basics/ facts - Background information, assessments and screening etc.Providing the programs – content / choices / level etc.

Awareness & EducationDaily functional application

Extra training and skills requirementsMotivation and continual upgrade challenges

Teaching & leading skills.Variety – pairs; groups; circuits etc. Use of equipment

Demonstration of end results -Documentation …. evaluation and review effectiveness to share with others

Background PlanningBackground Planning IssuesIssuesSafety; roles and responsibility (work parameters)Training (needs/ upgrades/ support)Community awareness, education and promotionEnvironmental issuesAccess and availability – cost/transport etc. Leadership, teaching and communicationProgram sustainabilityMaintaining motivation (participants and leaders) Variety – Grading/Recreation/Equipment use* Health related behaviour modification * Social / community/ organizational support

Exercise Planning Exercise Planning Programs need to be evidence based (as far as Programs need to be evidence based (as far as possible) & in context with the participants fitness possible) & in context with the participants fitness levels, conditions, abilities and interests to be most levels, conditions, abilities and interests to be most effective and sustainable effective and sustainable

□ Simple □ Safe□ Structured □ Progressive □ Systematic □ Graded□ Effective □ Specific □ Relevant □ Realistic□ Appropriate □ Tailored □ Challenging □ Motivating

Multiple Systems contribute to BalanceMultiple Systems contribute to BalanceThe Musculo skeletal componentsThe Neuromuscular componentsThe Somatosensory system – provides information about our spatial location and movements of the body relative to the support surfaceThe Vestibular system - determines whether the world or we are movingThe Visual system – provides information about the outside environmentThe Cognitive system changes eg. Depression / dementia

Falls risk increase…. A systematic physical decline………………....””as the number of intrinsic system problems exceed the critical threshold of function, ability to accomplish daily tasks is compromised”

Movement Pattern ChangesMovement Pattern ChangesSubtle changes occur in balance and the Subtle changes occur in balance and the gait cyclegait cycle

some are due to a mixture ofsome are due to a mixture of ……..

““AA fusion of motor, sensory & cognitive activity to create directedfusion of motor, sensory & cognitive activity to create directed, , safe locomotionsafe locomotion””

Cognitive changesCognitive changes& Confidence levels& Confidence levels

Sensory changesSensory changesvision, vestibular, vision, vestibular, kinaesthetic kinaesthetic painpain

Muscle weaknessMuscle weakness(ankle, knee, hip, trunk (ankle, knee, hip, trunk --inactivity & chronic inactivity & chronic conditions)conditions)

Changes in BodyChanges in Body ControlControlWhen stationaryMoving through space

In different situationsAt different levelsIn different environmentsFor different circumstances and reasons

Involving co-ordination and fine tuning of the entire body a. Variables in muscle and joint control including

Speed ; Power; Endurance; Flexibility (stability and mobility)

b. Good processing & thinking required for efficient, effective and appropriate responses & reactions

Basic Strength Exercise ComponentsBasic Strength Exercise ComponentsImproving muscular / body control Improving muscular / body control

Increase and maintain Increase and maintain muscle mass, power, strength and endurancemuscle mass, power, strength and endurance…………

Lower limb strength mainlyLower limb strength mainly

Maintain bone strengthMaintain bone strength

Reduce the Reduce the problems associated problems associated with osteoporosiswith osteoporosis

Improve stamina and Improve stamina and general fitnessgeneral fitness, , to make everyday activities easier to doto make everyday activities easier to do

Practice functional Practice functional applications applications

egeg. Sit to stand, . Sit to stand, pushing & pulling pushing & pulling

activitiesactivities

Increase and maintain Increase and maintain joint stability joint stability (and mobility)(and mobility)

Core stability & strength Core stability & strength

Postural correction and alignmentPostural correction and alignment

Basic Balance Exercise ComponentsBasic Balance Exercise Components

C of G control including C of G control including body sway & body sway &

weight transference trainingweight transference training

Postural strategiesPostural strategies

Reaction time and Reaction time and coco-- ordinationordination

ReRe--educate muscle educate muscle timing & movement timing & movement

patternspatterns

Improve gait Improve gait & motor & motor controlcontrol

Somatosensory Somatosensory stimulation & stimulation & challenges challenges

Work on the fundamental and fine movementsWork on the fundamental and fine movements

Progress with task and environment challenges Progress with task and environment challenges

Provide variety, stimulation and ongoing challengesProvide variety, stimulation and ongoing challenges

Promoting Functional Health Promoting Functional Health ((Changing Health Related Changing Health Related BehaviourBehaviour))

““Individual adapted behaviour change is critical to Individual adapted behaviour change is critical to facilitate a long term physical activity lifestylefacilitate a long term physical activity lifestyle…………....

The process includes a series of complex variables The process includes a series of complex variables including personal, social, programmatic, including personal, social, programmatic, environmental and related factors as well as medical environmental and related factors as well as medical factors which need to be addressed collectively factors which need to be addressed collectively ““

ACSM / AHA Updated recommendations for Adults 2007ACSM / AHA Updated recommendations for Adults 2007

Program Uptake & ContinuationProgram Uptake & ContinuationExample …A 12 week strength and balance program will only be

effective if Maximal input and all sessions attended Exercise undertaken as prescribed, progressed and then continue after completion of course …

Comments / observationsInitial enthusiasm …. Maximal effect over the 3 months

intervention and then a drop off …? Lack of interest/ support / infrastructure/ cost /

minimal results or benefits/ adverse event

Stages of ChangeStages of Change

Many theories/ models – many stages many barriers1. Initial step – reason and decision to

start exercising eg. insight / event 2. Interim - developing habit to be

active eg. fun, friends, function3. Long term adherence – eg. active

life

Applying the Research into Practice Applying the Research into Practice Exercise & Falls Injury ReductionExercise & Falls Injury Reduction

Help bridge the gap……when planning and undertaking programs consider the “big picture” in relation to exercise access (falls prevention focus) that is able to accommodate the overall community with factors pertaining to…………....

ReachEfficiency / Effectiveness(Ways of) Adoption(Ways of) Implementation(Ways of) Maintenance

““Think globally Think globally –– Act locallyAct locally””Principles based from RE – AIM- R McKenkie .

Program evaluation unit School of Population Health. University of Melbourne

Exercise & Falls PreventionExercise & Falls PreventionDevelop Develop good infra structures and support good infra structures and support mechanismsmechanismsRaise awareness & provide relevant informationRaise awareness & provide relevant informationcontinually to the entire community concerning injury continually to the entire community concerning injury prevention issues prevention issues

Provide the appropriate Provide the appropriate training,training, leadership, support leadership, support and skills applicationand skills application where ever needed where ever needed Assist the Assist the community and individualcommunity and individual’’ss in what ever in what ever appropriate way possible to apply the acquired appropriate way possible to apply the acquired knowledge and skillsknowledge and skillsWork on Work on ongoing evaluationongoing evaluation initiatives to measure initiatives to measure effectiveness & reacheffectiveness & reach

Finally Finally ………………Ensure that there are the means for Ensure that there are the means for ongoing ongoing support & quality controlsupport & quality control to sustain any effective falls to sustain any effective falls

prevention initiatives prevention initiatives

Final CommentsFinal Comments““ Because of their low functional status and high Because of their low functional status and high

incidence of chronic disease, there is no segment incidence of chronic disease, there is no segment of the population that can benefit more fromof the population that can benefit more fromexercise than the elderlyexercise than the elderly””

American College of Sports Medicine Exercise training for the ElAmerican College of Sports Medicine Exercise training for the Elderlyderly

““Emphasis should be placed on factors that Emphasis should be placed on factors that result in permanent lifestyle change to encourage result in permanent lifestyle change to encourage a lifetime of physical activity.a lifetime of physical activity.”” Pollock M., Pollock M., GaesserGaesser

““Those at the lowest level of a condition have Those at the lowest level of a condition have the most to gainthe most to gain””