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January/February 2014
Interventions Bolster Fall PreventionBy Tiffany E. Shubert, PhD, MPT An innovative prescription, featuring a dose of balance and strength exercise, can effectively prevent falls and fall-related injuries. The statistics present a cause for alarm and concern: Each year, one in three older adults over the age of 65 falls1; falls are the leading cause of emergency department admissions2; and the United States spends more than $30 billion each year in direct and indirect fall-related medical costs.2 Could something as simple as a standardized strength and balance program really make a difference? Indeed, it can. Even though the majority of falls are caused by multiple interacting risk factors—leg muscle weakness, polypharmacy, poor vision, and difficulty walking are among the most common3—exercise has proven to be a robust intervention available for community-dwelling older adults. A Cochrane review conducted in 2009 and revised in 2012 assessed the effects of interventions to reduce the incidence of falls in older people living in the community.4,5 The review examined multiple types of interventions, including home modifications, medication management, pacemakers, and exercise. Both versions of the review reported that group and home-based exercises were the only interventions that significantly reduced both the rate and risk of falling. Pause Before Prescribing Second, for exercise to be effective for older adults, it must be done per the FITT principle (frequency, intensity, time, and type). Athletes and coaches often use this training principle to optimize performance. The optimal frequency of balance exercises has not been established; however, there are data supporting a total of two hours per week to achieve a protective effect against falls.8 The intensity of the exercises focuses on challenging balance and strength.9 For the greatest benefit, strength exercises should be performed in a standing position and should be challenging and progressive. A good rule of thumb is to determine the maximum weight a patient can lift one time and then prescribe 60% to 80% of that weight to be lifted for two or three sets of 10 repetitions. For example, if a patient can lift a 10-lb ankle weight one time while doing a hip extension exercise, then he should be prescribed up to two sets of 10 repetitions with a 6-lb weight. The prescription should be regularly reassessed and the weight increased to continue challenging the patient. The total time required for exercise has not yet been established; however, research indicates that achieving a protective effect against falls and fall-related injuries requires a minimum of 50 hours of exercise.10 The type of exercise is the most important factor, with balance exercises being the main focus and involving minimal to no upper extremity support. An example of this is standing on one leg for 30 seconds without holding on to a chair or other stationary item. Walking is not included in optimal exercises for fall prevention. Strong evidence indicates that walking, as a single intervention, is not effective in preventing falls or improving fall risk factors.10 While walking is an excellent aerobic exercise for older adults who have the strength and balance abilities to remain on their feet, starting a walking program too early in the rehabilitation process, especially for older adults with poor balance or lower extremity weakness, actually may increase an individual’s risk of falling.11,12 Clinical Tools and Resources However, the practice guidelines fail to link the risk level to the appropriate intervention. In 2012, the Centers for Disease Control and Prevention (CDC) released the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool.13 It further simplifies the guidelines and provides decision trees to help clinicians stratify and link older adults to appropriate clinical and community interventions based on risk. Concurrent with the release of the STEADI tool, the CDC supported the rollout of three evidence-based fall prevention interventions: tai chi, Stepping On, and the Otago Exercise Program.14-16 Tai chi is an exercise-only intervention taught by certified instructors; Stepping On is an exercise and behavior change program taught by certified lay leaders; and Otago is a strength and balance program delivered by physical therapists. These three interventions provide the infrastructure for older adults to develop the optimal exercise regimen per the FITT principle. Several highly effective fall prevention programs are available for use by both health care and community providers. Physical therapists and other allied health professionals can integrate programs that specifically target older adults with significant impairments into patients’ care plans, and fitness professionals at YMCAs and senior centers, for example, can offer evidence-based programs for higher-functioning older adults who may not require a licensed health care provider to monitor their progress. The CDC chose tai chi, Stepping On, and Otago because these programs are considered to be evidence-based fall prevention programs, meaning each program was tested in its entirety in a randomized controlled trial. The programs are designed to be disseminated by trained providers and implemented with fidelity, which means the program content and format is delivered the same way it was tested to ensure the same results. For example, tai chi must be a scripted program, such as the National Council on Aging’s Tai Chi: Moving for Better Balance or the Arthritis Foundation’s Tai Chi Program, and the exercises must be done as intended. For instance, if a tai chi class were offered in sitting position, it would no longer be an evidence-based program. Otago Program In seven published studies with more than 1,500 participants, Otago has consistently demonstrated a reduction in both fall rates and the risk of death. More importantly, one year after participating in the program, more than 35% of all patients were still doing their exercises. Designed to maximize patient engagement, the Otago program is delivered in two phases: the physical therapist phase and the self-management phase. The first day of Otago can occur either at the beginning of therapy for a patient with a specific diagnosis of balance and gait impairment or later in the physical therapy episode of care if the patient originally was referred for a different issue and the therapist identifies balance and gait impairments. On day 1, the physical therapist assesses the patient and selects the appropriate exercises. The program becomes progressively more challenging. Therefore, the patient is not prescribed all 17 exercises on the first day. Typically, a patient is prescribed between 10 and 12 exercises per session. The therapist returns in one week to ensure the patient understands the exercises and performs them safely and appropriately, following up with visits scheduled every other week for six weeks, for a total of five visits. During follow-up visits, the patient is reassessed with objective functional measures such as walking speed, the timed up and go, the 30-second chair rise, and the standing balance sequence. The therapist reviews the exercises and, if appropriate, progresses the patient either by increasing the balance challenge (no hands) or adding weights or repetitions to the exercises. Once the therapist determines the patient is safe, he or she also prescribes a walking program for the patient. Depending on the patient’s ability, the walking program for exercise may be prescribed on the first day of the program or several months later. At the end of eight weeks, the therapist transitions the patient to the self-management phase. The patient does exercises and the walking program independently, and the therapist calls monthly to check the patient’s progress and problem solve issues. The therapist schedules follow-up visits, if appropriate, at six, nine, and 12 months. After one year, the patient should be discharged to the appropriate evidence-based program, such as tai chi or Fallproof!, a comprehensive balance and mobility training program, to continue his or her progress. The Otago program was designed to be delivered over the course of six to nine visits in a one-year period. However, a therapist can see a patient more frequently in the event of a setback or to ensure exercise mastery. Challenges and Opportunities The first major challenge is that Otago was designed for delivery in the home. However, many older adults who qualify for home health are too frail to participate in the program, and once they are strong enough to participate, they no longer qualify for home health. Researchers at the University of North Carolina at Chapel Hill in the Center for Aging and Health and the Center for Health Promotion and Disease Prevention are developing and evaluating models that ensure Otago can be delivered to elders who need it. The first model is for a physical therapist, billing under Medicare Part B, to deliver the program in the home. This delivery model has been used by physical therapists in the United States for about 10 years and is rapidly expanding among both private practice and home health therapists. The second model involves delivering Otago in an outpatient facility. Both of these models offer viable delivery mechanisms and are being studied to determine whether they result in similar outcomes. A final model involves starting Otago in home health and then continuing it in an outpatient setting. However, results to date indicate this model poses the greatest challenge because of different providers and different agencies working together without the infrastructure to support communication. A second challenge is the low frequency and long duration of an episode of care. Physical therapists billing under Medicare Part B can keep patients who require skilled therapy on caseload for these long durations, but keeping a patient on caseload requires additional documentation every 90 days of the patient’s progress and needs. More importantly, this is a dramatic shift from the traditional rehabilitation model of a high frequency of visits over shorter durations. However, more research is emerging from both the stroke literature17 and the fall prevention literature9 that therapy is more effective when fewer doses are provided over a longer duration. A third challenge lies in training the workforce. Physical therapists receive extensive training in managing balance and gait impairments, but they do not receive universal training in fall risk management. The Otago exercises are not innovative; however, the delivery of the exercises and low frequency is a big change for physical therapists. In addition, Otago is an evidence-based program, which is a new concept for many physical therapists. To meet this challenge, the Center for Aging and Health, in partnership with the CDC, developed a three-hour online training session for physical therapists that presents the research behind Otago, the importance of delivering the program with fidelity, and the implementation process. (Additional resources are available at www.med.unc.edu/aging/cgec/exercise-program, including copies of all the exercises, downloadable videos for patients, a Spanish translation of the exercises, and marketing tools.) A final challenge is assessing Otago’s impact when it is delivered in different settings (eg, home vs. outpatient) to different populations (eg, those with mild cognitive impairment or in assisted living). I procured a grant at the Center for Health Promotion and Disease Prevention to develop a database to “crowdsource” this challenge. Physical therapists who are implementing Otago complete the database. They can report on as few or as many patients as is feasible, including the completion of four data points: baseline, eight weeks, six months, and discharge. This method efficiently and effectively acquires a significant amount of data to determine what additional barriers and facilitators are in place for widespread dissemination of Otago for elders who would benefit most from participating in the program. Offering Otago to Your Patients Additional resources to help with fall prevention in your practice and community include mobile apps for clinicians to manage fall risk, mobile apps for patients to perform balance exercises, monthly webinars hosted at the University of North Carolina at Chapter Hill to support clinicians who are implementing Otago, and several technological solutions that will be available soon to support older adults with adherence and compliance. The CDC’s National Center for Injury Prevention and Control offers several resources, including “A CDC Compendium of Effective Fall Interventions,” demonstration videos, and the STEADI materials. In Conclusion — Tiffany E. Shubert, PhD, MPT, is the president of Shubert Consulting and a research associate at the University of North Carolina at Chapel Hill School of Medicine.
References 2. Costs of falls among older adults. Centers for Disease Control and Prevention website. http://www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html. Last updated September 20, 2013. Accessed December 1, 2012. 3. Tinetti ME, Kumar C. The patient who falls: “It's always a trade-off.” JAMA. 2010;303(3):258-266. 4. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009;(2):CD007146. 5. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9:CD007146. 6. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012;12:CD005465. 7. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157. 8. Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull. 2011;22(3-4):78-83. 9. El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f6234. 10. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56(12):2234-2243. 11. Ebrahim S, Thompson PW, Baskaran V, Evans K. Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis. Age Ageing. 1997;26(4):253-260. 12. Faber MJ, Bosscher RJ, Chin A Paw MJ, van Wieringen PC. Effects of exercise programs on falls and mobility in frail and pre-frail older adults: a multicenter randomized controlled trial. Arch Phys Med Rehabil. 2006;87(7):885-896. 13. Stevens JA, Phelan EA. Development of STEADI: a fall prevention resource for health care providers. Health Promot Pract. 2013;14(5):706-714. 14. Li F, Harmer P, Fisher KJ, et al. Tai chi and fall reductions in older adults: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2005;60(2):187-194. 15. Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial. J Am Geriatr Soc. 2004;52(9):1487-1494. 16. Campbell AJ, Robertson MC. Otago Exercise Programme to Prevent Falls in Older Adults: A Home-Based, Individually Tailored Strength and Balance Retraining Programme. Wellington, New Zealand; Accident Compensation Corporation: 2003. http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_providers/documents/ 17. Duncan PW, Sullivan KJ, Behrman AL, et al. Body-weight-supported treadmill rehabilitation after stroke. N Engl J Med. 2011;364(21):2026-2036.
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