Strong, Steady and Straight - Raising the bar on keeping older people active

1. Strong, Steady and Straight
Raising the bar on keeping
older people active in their
communities
Vanda Cummins HSE Primary Care Physiotherapist
Oct 22nd 2019

2. Job: HSE Primary Care Physiotherapist in Ballymun.
Locations: Health Centre, Clients house or exercise groups.
Referrals: Majority older clients with loss of mobility and
poor function/pain. Most from GPs, hospitals or
Primary Care Team colleagues.
(also accept self referrals)
Interventions: Assessments, falls and frailty risk, rehabilitation of
mobility and function, support, education & training.
HRB Applied Partnership Research Grant:
Since April 2019, Part-time clinical researcher
with RCSI looking at feasibility of enhancing
existing state funded carer support for older
adults using ‘Care to Move Approaches’

3. Screening &
Assessment
1:1 Interventions or Group
Rehabilitation
Monitoring
Education
Role of physiotherapist in
the integrated care of falls
prevention & bone health
Acute Care Primary Care Community & Social Care
Risk
detection
Education
Multidisciplinary, Multi-agency, Multi-level approach
National Strategy 2008
•Targeted, specific home based or group based exercise
programmes to suit needs and preferences
•Exit strategies to self directed active lifestyles

4.  Discuss evidence for strength and balance
training for independence & reduced risk of
falls & injuries.
 Highlight importance of working partnerships
to improve the quality and effectiveness of
exercise pathways for older people
‘consistent messages across agencies’
 Look at currently practice in Ireland and the UK
and discuss ways to try build on this.
“Right Care, Right exercises, Right Professionals,
Right time”

6.  Low muscle strength linked to a decline in
ability to carry out activities of daily living
such as bathing, dressing and going out.

 Muscle weakness and poor balance- Two
most common modifiable risks for falls.
 In UK for those aged 65+ only 13% of men
and 10% of women met the recommended PA
guidelines which included strength, balance
and co-ordination exercises x 2 weekly.

7. “Strong older people fall and get back up.
Weak older people fall and stay down.
Falling isn’t the problem, deconditioning is”
Prof Dawn Skelton Webinar on ROI on Otago and FaME programmes 2018

9. So what if I’m inactive?

10. Over cautious/fearful

11. Increasing the fracture risk?
No standing activity leads to
active loss of bone and
muscle
1 wk bed rest  strength by ~ 20%
1 wk bed rest  spine BMD by ~1%
Nursing home residents spend
80-90% of their time seated or
lying down
CTM Copyright Later Life Training Ltd
2016

12. Sedentary Behaviours
Increases risk of:
•Stiffness, pain
•Muscle weakness
•Falls & fractures
•Frailty
•Dependence
•Decreased quality of life
•Decreased social engagement
Consistent messages from all health care
providers to help prevent the risks

13. Moving
Moving
More
Often
Moving
regularly
and
frequently
Sedentary
Meeting
physical
Activity
guidelines
Increased physical activity
Increased benefits

14. Skelton, Mavroeidi (2018) How do muscle and bone
strengthening and balance activities (MBSBA) vary across
the life course and are there particular ages where MBSBA
are important? Journal of Frailty, Sarcopenia and Falls

16. EVERYONE
No Matter what your age, size or fitness
level, its never too late to start.
Exercise follows dose response curve.
The lower the baseline level the greater the
health benefits associated with increased
activity.
Research nursing home residents age 90+
Increasing exercise levels shown
rejuvenation of muscle strength of 10-20
years in only 12 weeks (Fiatarone 1990)
Who should we target?

20. Top tip if you wish to change sitting patterns
Start small & achievable
Have a plan for what you want to do when breaking sitting
time
Build the routine, then you can make the break times more
challenging
Don’t be too hard on yourself it’s not easy to change

23. Skelton D, Mavroeidi (2018) Which S&B activities are safe and efficacious for
individuals with specific challenges (Osteoporosis, vertebral fractures, frailty,
dementia?) A Narrative Review Journal of Frailty, Sarcopenia and falls

24. Foster C, Armstrong M (2018) What type of physical activities are effective
in developing muscle and bone strength and balance? Journal of frailty,
Sarcopenia and Falls

26. Key components of Strength and balance
exercise programmes researched and
evidence based for falls prevention
 At least three times weekly (group and/or home based)
 Include an assessment by appropriately qualified health
professional/instructor before commencing
 Fidelity – i.e individually tailored with clear progressions
 Comprise of 50 hours or more over at least 6 months
 Involve challenging and progressive balance and resistance
training and exercise in a standing position.
 Monitored by appropriately trained professional

27. www.hse.ie/eng/about/who/cspd/videos/
We need a multi dimensional, multi-
disciplinary quality service across agencies
for our vulnerable older adults
Consequences after a fractured hip
with examples of a positive and a not so positive pathway

28. Need to build on good work already being done
One size does not fit all- Tailored to suit needs and preferences

29. Free fitness testing (NCT) event as part of Positive Ageing Week 2016
Poppintree Community Centre
Event included strength, balance, flexibility and BMI testing, exercise and
dietetic advice free exercise and Tai Chi ‘taster’ sessions and refreshments
Sustainability ideas – functional fitness testing

30. Falls prevention taskforce (Wales)

31. 1. Raise awareness
2. Encourage uptake
3. Exercise referral pathways that work
4. Stick to the evidence
5. Monitor for outcomes and
improvements

33.  Understand S&B programmes are cost effective and
achieve good outcomes
 Design and support services than enable EB
approaches
 Include funding for S&B education and awareness
raising campaigns
 Include funding for assessment time and conversations
around behaviour change/motivators
 Develop collaborative pathway with a supporting
decision making tool
 Embed QA and evaluation into all programmes

34.  Identify training to suit your target audience with ongoing
CPD and opportunities.
 Facilitate instructor meetings for shared learning and
standardised delivery
 Embed S&B messages across all classes
 Foster good communication pathways between referrers
and professions
 Allow time for pre and ongoing assessments
 QA sessions to support fidelity
 Ensure health and safety including emergency plans.

36. Later life training UK:
Accredited, quality assured :Blend of online learning, assignments, MCQ’s & face to face training
Teaching manuals, safety checks, behaviour change strategies, assessments, written feedback.
Ongoing networks & learning, social media (twitter and facebook), study days, conferences
Cascade trainers: 5 days ( including OEP leader training and assessment)
OEP Leaders:
3 days for Fitness Instructors -2 day training + 1 day practical exams
2 days for Physiotherapists - 1 day training + 1 day practical exams

37. Back knee
strengthening: helps
with stair climbing, getting
in/out of chairs/cars and
getting up and down from
the floor
Toe raises:
helps with
stepping
backwards and
on/off pavements
Heel toe walking:
improves balance and
walking in narrow spaces,
stepping sideways to
avoid objects or when on
uneven surfaces.
Blend of Home programme x 2 weekly and Group x 1 weekly

38. Cross Agency Memorandum of understanding
Developed by Catherine Devaney, HSE
Physiotherapy Manager Dublin North Central

39. Client feedback:
I feel a lot steadier….I took the bus
into town for the 1st time in 2
years.
The pace of this group suits
me……
I feel listened to…..
I like the small numbers
Otago Instructor feedback:
‘I love this because it’s got evidence and I feel supported by the physios’
The training was a lot more work than I thought, but I like the structure and
progressions
It’s great to see the group motivate each other along
I’m surprised how much they like it..It definitely seems to be working

41. Falls prevention websites:
www.nhsinform.scot/aboutfalls NHS information on falls section
www.fallsassistant.org.uk check your risk of falls & create personalised plan
http://www.knowledge.scot.nhs.uk/fallsandbonehealth/the-national-falls-
programme/take-the-balance-challenge.aspx
www.laterlifetraining.co.uk training for health and exercise professionals
www.csp.org.uk/public-patient/keeping-active-and-healthy/staying-
healthy-you-age
Physical activity: websites
www.makingeverycontactcount.com training for health professionals.
www.movingmedicine.ac.uk/
https://www.nhs.uk/live-well/exercise/physical-activity-guidelines-older-
adults/
https://theros.org.uk/ Royal Society of Osteoporosis UK
http://www.cotawa.org.au/physical-activity/ Living Longer Living Stronger
Strength and Balance Programmes for Older Adults
Apps and games:
Otago exercises app- Video and audio of leg strength and balance
exercises designed to reduce falls in older adults who are at risk of falls.
Clock yourself app. consists of progressively challenging cognitive and
balance tasks to improve balance reaction times.www.Clockyourself.physio/

43. ‘Exercise is a journey not a destination.
We do not stop exercising because we
grow old,
we grow old because we stop exercising’
Kenneth H Cooper