ageing and performance - bacpr · reader in ageing and health, ... potentially reverse loss of...
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Dr Dawn Skelton PhDDr Dawn Skelton PhD
Reader in Ageing and Health, HealthQWest, Reader in Ageing and Health, HealthQWest,
Glasgow Caledonian UniversityGlasgow Caledonian University
CoCo--ordinator of Prevention of Fallsordinator of Prevention of Falls
Network Europe, University of ManchesterNetwork Europe, University of Manchester
Exercise and Physical Activity for Older People
11--2% in functional ability p.a.2% in functional ability p.a.
–– StrengthStrength
–– Power Power
–– Bone densityBone density
–– FlexibilityFlexibility
–– EnduranceEndurance
–– Balance and coBalance and co--ordinationordination
––Mobility and transfer skillsMobility and transfer skills
AGEING AND PERFORMANCEAGEING AND PERFORMANCE
Sedentary Sedentary behaviourbehaviour accelerates the loss of performance...accelerates the loss of performance...
3 Dimensions of Human Frailty3 Dimensions of Human Frailty
TIME
DISEASE DISUSE
HUMAN FRAILTY
Spirduso, 1995
INACTIVITY
A VISCIOUS CYCLE OF A VISCIOUS CYCLE OF INACTIVITYINACTIVITY
Physical deteriorationPhysical deteriorationPhysical deteriorationPhysical deterioration- Heart disease- High blood pressure- Aches and pains- Osteoporosis
Further decrease in Further decrease in Further decrease in Further decrease in physical activityphysical activityphysical activityphysical activity
Social / psychological Social / psychological Social / psychological Social / psychological ageingageingageingageing- Feeling ‘old’- ‘Acting’ one’s age- Increased stress- Anxiety, depression- Low self-esteem- Fear of falling
Increasing ageIncreasing ageIncreasing ageIncreasing age
Less exerciseLess exerciseLess exerciseLess exercise
Decreased physical Decreased physical Decreased physical Decreased physical abilitiesabilitiesabilitiesabilities- Increased body fat- Sagging muscles - Decreased energy
SEDENTARY WAYSSEDENTARY WAYS
40% of people 40% of people aged 50 or over in aged 50 or over in the UK are the UK are sedentary sedentary sedentary sedentary sedentary sedentary sedentary sedentary
More than half of More than half of those who are those who are sedentary think sedentary think they are doing they are doing enough exercise enough exercise to keep fitto keep fit
Skelton et al. ADNFS >50 Skelton et al. ADNFS >50 analysis, 1994analysis, 1994
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69 yr old woman, active, strength-trained
71 yr old woman, sedentary
(Adapted from Sipilä & SuominenMuscle Nerve 1993;16:294)
Size difference is equivalent to a 30 year old (L) and an 70 year old (R)
ACTIVE BONE AND MUSCLE ACTIVE BONE AND MUSCLE LOSS LOSS
�� No standing activity leads to active No standing activity leads to active loss of bone and muscleloss of bone and muscle
�� Fractures more common in people Fractures more common in people who spend < 4 hrs a day on their feetwho spend < 4 hrs a day on their feet
�� 1 wk bed rest 1 wk bed rest
–– ⇓⇓ strength by ~ 20% strength by ~ 20%
–– ⇓⇓ spine BMD by ~spine BMD by ~1%1%
�� Nursing home residents spend 80Nursing home residents spend 80--90% of their time seated or lying down90% of their time seated or lying down
INTERNATIONAL CONSENSUSINTERNATIONAL CONSENSUS
�� WHO, 1993WHO, 1993 -- ““exerciseexercise and and
lifestyle modification before drug lifestyle modification before drug
treatment for treatment for mild hypertensionmild hypertension” and ” and
in in 19961996 ““regular physical activityregular physical activity
helps to preserve helps to preserve independent livingindependent living” ”
and “and “postponepostpone the age associated the age associated
declines in balance and codeclines in balance and co--ordination ordination
that are major risk factors for that are major risk factors for fallsfalls””
�� US Surgeon General, 1996US Surgeon General, 1996 --
““regular physical activityregular physical activity in older in older
adults adults with chronic illnesswith chronic illness can can
potentially potentially reverse loss of mobilityreverse loss of mobility””
UK & WHO POLICY UK & WHO POLICY AGENDASAGENDAS
�� National Service Framework for National Service Framework for
Older People (Older People (DoHDoH, 2001), 2001)
–– Standard 8 Standard 8 –– the promotion the promotion
of health and active life for of health and active life for
older peopleolder people
�� National Quality Assurance National Quality Assurance
Framework for Exercise Referral Framework for Exercise Referral
((DoHDoH, 2001), 2001)
�� WHO Active Ageing Policy WHO Active Ageing Policy
(2002)(2002)
�� Choosing activity: a physical Choosing activity: a physical
activity action plan (activity action plan (DoHDoH, 2005), 2005)
HOLISTIC EXERCISE…. HOLISTIC EXERCISE…. wider than CR?wider than CR?
�� PsychologicalPsychological
–– Reduce Anxiety, depression, fear of falling; Improve Reduce Anxiety, depression, fear of falling; Improve
sleepsleep
�� Physiolog icalPhysiolog ical
–– Maintain bone density, ability to perform everyday Maintain bone density, ability to perform everyday
activities, reduce breathlessness and stiffness; activities, reduce breathlessness and stiffness;
reduce effects of disease and fallsreduce effects of disease and falls
�� PsychosocialPsychosocial
–– Reduce Isolation, Increase self efficacy, social Reduce Isolation, Increase self efficacy, social
contacts, peer support, playing with grandchildren, contacts, peer support, playing with grandchildren,
using the bathusing the bath
�� Even the very frailEven the very frail
–– DVT, constipation, transfer skills DVT, constipation, transfer skills
AGEING & LUNG FUNCTION
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AGEING & POSTURE AGEING & FALLS
When do we become “fallers” When do we become “fallers” instead of “trippers”?instead of “trippers”?
Fracture site changes
with age, wrist
fractures more common
in younger people, hip
fractures more common
in older people
Reaction times and gait
speed slowswww.bbc.com – from BBC News
Fall risk factors Fall risk factors [Rubenstein & Josephson 2002][Rubenstein & Josephson 2002]
�� Accident /Environment 31%Accident /Environment 31%�� Gait /Balance /Weakness 17%Gait /Balance /Weakness 17%�� Dizziness vertigo 13%Dizziness vertigo 13%�� Drop attacks 9%Drop attacks 9%�� Confusion 5%Confusion 5%�� Postural hypotension 3%Postural hypotension 3%�� Visual disorder 2%Visual disorder 2%�� Syncope 0.3%Syncope 0.3%�� Other 15%Other 15%�� Unknown 5%Unknown 5%
�� Weakness 11/11Weakness 11/11�� Balance deficit 9 /9 Balance deficit 9 /9 �� Mobility limitation 9/9Mobility limitation 9/9�� Gait deficit 8/9Gait deficit 8/9�� Visual deficit 5/9Visual deficit 5/9�� Cognitive impairment 4/8Cognitive impairment 4/8�� Impaired ADL 5/9Impaired ADL 5/9�� Postural hypotension 2/7Postural hypotension 2/7
Individual risk factors: 16 controlled studies
Summary of 12 major
studies of fall causes
www.profane.eu.org
Activity and Fall RiskActivity and Fall Risk
Fall risk reduced
Only with sufficient tailoring,
duration, f requency, intensity
and with specif ic components.
For example:
� balance and Tai Chi� strength and power
� co-ordination
Fall injury
(e.g. head
injuries,
f ractures)
Fall risk increased
unsaf e practice
acute fatigue
displacement of centre of grav ity
environmental risk exposure
+
-
Exercise
Physical Activity
Adapted from Skelton, 2001, Age Ageing
Positive effects on fall risk factors
balance coordination
strength & power mobility
functional ability gait
depression fear of f alling
EXERCISE TO PREVENT FALLSEXERCISE TO PREVENT FALLS
Exercise Exercise couldcould help fallers in a number of ways:help fallers in a number of ways:
�� Reducing Falls (or injurious falls) Reducing Falls (or injurious falls)
�� Reducing known Risk Factors for Falls Reducing known Risk Factors for Falls
�� Reducing Fractures ? (or changing Reducing Fractures ? (or changing
the site of fracture)the site of fracture)
�� Increasing Quality of Life & Social Increasing Quality of Life & Social
ActivitiesActivities
�� Improving bone densityImproving bone density
�� Reducing Fear and avoidance of activityReducing Fear and avoidance of activity
�� Reducing InstitutionalisationReducing Institutionalisation
Gardner 2000; Skelton & Dinan 1999, 2005; Robertson & Campbell 2001; NICE 2004;
Sherrington 2008
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FaME – Falls & Bone Strength
Signif icant difference with time and group for L2-L4 spine and Wards Tr iangle (F=3.46, p<0.05). Exercisers n=32, Controls n=14.
Time betw een visit 1 and visit 2 = mean 10.9 (sd 2.7) months
Skelton et al. JA PA 2004; Age Ageing 2005
9 month duration
3 p/w – 1 hr
DURING FOLLOW UP
Exercisers had half the risk of falls compared to
controls (RR 0.53)
+ less likely to sustain injurious falls (RR 0.39)
New technologies ?
•• Whole Body Vibration Whole Body Vibration
•• 66 mthsmths, 3 x p/w, 3 x p/w
•• postpost--menopausal women menopausal women •• Strength 15%, Balance 20%,Strength 15%, Balance 20%,•• Hip BMD 1%Hip BMD 1%
VerschuerenVerschuerenSM et al. 2004SM et al. 2004
Wii-fit (Nintendo) ?
WIDE RANGE OF ABILITIES WIDE RANGE OF ABILITIES AND NEEDSAND NEEDS
NOT ALL EXERCISE IS SAFENOT ALL EXERCISE IS SAFE
�� Type of Exercise Reoccurrence Type of Exercise Reoccurrence
of Vertebral of Vertebral
FractureFracture
�� Back extensionBack extension 16%16%
�� Flexion (Flexion (abdabd. curls). curls) 89%89%
�� CombinedCombined 53%53%
�� No exerciseNo exercise 67%67%
SinakiSinaki 19871987
EXERCISE FOR OLDER EXERCISE FOR OLDER PEOPLEPEOPLE
SPECIAL CONSIDERATIONSSPECIAL CONSIDERATIONS
AvoidAvoid
�� Spinal stress and disc compressionSpinal stress and disc compression
�� Moves with prolonged isometric effortMoves with prolonged isometric effort
�� Moves with risk of fallingMoves with risk of falling
ACSM 1999
BRISK WALKING IS NOT BRISK WALKING IS NOT
THE ANSWER FOR ALLTHE ANSWER FOR ALL
�� Women >55 yrs; wrist Women >55 yrs; wrist
fracturesfractures
�� Intervention: Brisk walkingIntervention: Brisk walking
�� Control: exercise of upper Control: exercise of upper
armarm
�� Falls risk (Brisk walking > Falls risk (Brisk walking >
control)control)
�� Beware uneven pavements!Beware uneven pavements!
EbrahimEbrahim et al. (1997)et al. (1997)
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Independently mobile older people
Independent with assistance/aids/carer
Physically frail housebound/outpatient
LEVEL 2Exercise Leader
Exercise Instructor
StudentDinan, 1999; DoH 2001; REPS 2008
LEVEL 3Advanced Exercise Instructor
Referred Patients 1Advanced Exercise InstructorExercise for the Older Person
LEVEL 4Specialist Exercise Instructor
Referred Patients 2Falls, Cardiac, Stroke Rehab
Clinical Exercise Practitioner
General PopulationsGeneral PopulationsGeneral PopulationsGeneral Populations
Special PopulationsSpecial PopulationsSpecial PopulationsSpecial PopulationsSpecial PopulationsSpecial PopulationsSpecial PopulationsSpecial PopulationsLow RiskLow RiskLow RiskLow RiskLow RiskLow RiskLow RiskLow Risk
Patient Patient Patient Patient Patient Patient Patient Patient PopulationsPopulationsPopulationsPopulationsPopulationsPopulationsPopulationsPopulationsMedium RiskMedium RiskMedium RiskMedium RiskMedium RiskMedium RiskMedium RiskMedium Risk
HighHighHighHighRiskRiskRiskRisk
THE EXERCISE REGISTER UK
THE EXERCISE PROFESSIONALTHE EXERCISE PROFESSIONAL
�� Chair Based Exercise Leader : Chair Based Exercise Leader :
�� Strength and Balance Exercise Leader :Strength and Balance Exercise Leader :
�� Exercise for the Older Person Advanced Instructor : Exercise for the Older Person Advanced Instructor :
�� Exercise for the Prevention of Falls and Injuries in Exercise for the Prevention of Falls and Injuries in
Frailer Older People Specialist Instructor :Frailer Older People Specialist Instructor :
EXERCISE FOR OLDER PEOPLEEXERCISE FOR OLDER PEOPLE
Level 2Level 2
Level 2Level 2
Level 3Level 3
Level 4Level 4
Pre Exercise AssessmentPre Exercise Assessment
Tailored Tailored ProgrammesProgrammes
Evidence Based Evidence Based ProgrammesProgrammes
PREPARATIONPREPARATION
Skelton & Dinan Physiotherapy Theory & Practice J. 1999
EXERCISE FOR OLDER PEOPLEEXERCISE FOR OLDER PEOPLE
EVIDENCE BASED TRAININGEVIDENCE BASED TRAINING
Dynamic Balance Dynamic Balance Strength and PowerStrength and PowerEnduranceEnduranceMobility and Flexibility Mobility and Flexibility Functional MovementFunctional MovementFloor skillsFloor skillsGait and Posture Gait and Posture
Skelton & Dinan Age and Ageing 2005, Campbell 1997, Robertson 2001, Lord 2003 ACSM 2007, 2009
EXERCISE FOR OLDER PEOPLEEXERCISE FOR OLDER PEOPLE
also:also:
Load the bonesLoad the bones
Target postural, functional, pelvic floor Target postural, functional, pelvic floor
musclesmuscles
Target minor and major jointsTarget minor and major joints
Train balance and coTrain balance and co--ordination skillsordination skills
Train body awareness and body Train body awareness and body
managementmanagement
Provide opportunities for Provide opportunities for socialisationsocialisation
Young & Dinan Brit Med J 2003
EXERCISE FOR OLDER PEOPLEEXERCISE FOR OLDER PEOPLE
THE TEACHERTHE TEACHER
Posture and techniquePosture and technique
Teaching positionTeaching position
Teaching points and reinforcementTeaching points and reinforcement
Observation, communication and Observation, communication and adaptationsadaptations
Cueing techniqueCueing technique
Patient, polished, persistent and Patient, polished, persistent and punctualpunctual
Young & Dinan Brit Med J 2003
EXERCISE FOR OLDER PEOPLEEXERCISE FOR OLDER PEOPLE
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STRENGTH
Examples of Examples of
ExercisesExercises
seated le g seated le g
press, press,
prone back prone back
extensi onextensi on
side leg l iftside leg l ift
standing standing
knee knee
flexion, flexion,
standing standing
hip hip
abducti onabducti on
Special Consi derati ons Special Consi derati ons
for fall ersfor fall ers
Functional abdominal work Functional abdominal work
Postural and bonePostural and bone--load for load for
back extenso rsback extenso rs
SpecificSpecific
TargetedTargeted
Muscles: Hip, Knee, AnkleMuscles: Hip, Knee, Ankle
Older Pers on Gui deli nesOlder Pers on Gui deli nes
2 2 –– 3 Times3 Times
WeekWeek
12 12 ––15 reps to begin15 reps to begin
1 1 –– 3 sets3 sets
progress up to 70 progress up to 70 –– 80 % IRM80 % IRM
66--8 reps8 reps
20 20 ––1hr 1hr
6 6 –– 9 9 secssecs per Isotonic Rep per Isotonic Rep
55 SecsSecs IsometricIsometric
Body weight / WeightsBody weight / Weights
Open/closed chainOpen/closed chain
Isometric/isotonicIsometric/isotonic
Fun / Relaxe dFun / Relaxe d
VarietyVariety
SafeSafe
WarmWarm
SocialSocial
WhatWhat
is it ?is it ?
WorkingWorking
Muscle + Muscle + BonesBones
AgainstAgainst
ResistanceResistance
To GainTo Gain
StrongerStronger
MusclesMuscles
And BonesAnd Bones
To Make To Make
EverydayEveryday
ActivitiesActivities
EasierEasier
F
I
T
T
AACSM Guidelines
adapted for PSI
Manual, LLT, 2009
Think holistically….Think holistically….
Functional strength Functional strength work that loads work that loads
bonebone
Examples of Examples of
ExercisesExercises
Functional reach Functional reach
while sittingwhile sitting
Toe & heel walkingToe & heel walking
Tandem walksTandem walks
calf raisescalf raises
Flamingo swingsFlamingo swings
Picking objects off Picking objects off
the floorthe floor
Backward wal kingBackward wal king
Special Special
Considerations for Considerations for fallersfallers
Start with ‘win win’ Start with ‘win win’
taskstasks
((egeg –– seated ball seated ball
games)games)
Ensure appropriate Ensure appropriate
ratio of supervision for ratio of supervision for
each taskeach task
Explain benefitsExplain benefits
Method o f using Method o f using
supportsupport
Older Pers on Gui deli nesOlder Pers on Gui deli nes
3 x per week3 x per week
Increase slowly Increase slowly ––
graded to gro upgraded to gro up
10 10 minsmins –– building up to 1 building up to 1
hour. hour.
Dynamic balance Dynamic balance
i.e weight transferencei.e weight transference
Varying activities & Varying activities &
weaning off support slowly weaning off support slowly
–– vary positionsvary positions
WhatWhat
is it ?is it ?
Maintaining upright Maintaining upright
posture during posture during
position changeposition change
((egeg. Standing up and . Standing up and
to preven t falls)to preven t falls)
BALANCE
F
I
T
T
A.
ACSM Guidelines
adapted for PSI
Manual, LLT, 2009
Think holistically….Think holistically….
Dynamic endurance work that also improves balanceDynamic endurance work that also improves balance
Think holistically….Think holistically….
Floorwork Floorwork to improve transfer skills, to improve transfer skills, use of the bath, reduce fear of use of the bath, reduce fear of fallingfalling
Think holistically….Think holistically….
Work on coWork on co--ordination and reaction skills and gaitordination and reaction skills and gait
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Perceived barriersPerceived barriers
�� Health problems (actual and perceived interference)Health problems (actual and perceived interference)
�� No observed positive effects when tried programmeNo observed positive effects when tried programme
�� Not liking social contacts in classes (peers or leader!)Not liking social contacts in classes (peers or leader!)
�� Unpleasant experiences (fatigue, pain etc.) or not enjoyableUnpleasant experiences (fatigue, pain etc.) or not enjoyable
�� Low motivation or perceived relevanceLow motivation or perceived relevance
�� Other priorities (caring for dependents, holidays, other Other priorities (caring for dependents, holidays, other
appointments, housework) appointments, housework)
�� Transport Transport
(Yardley et al 2005a)(Yardley et al 2005a)
Perceived positive factors and Perceived positive factors and
benefitsbenefits
�� Noticeable benefit/improvement Noticeable benefit/improvement
�� Feel and look goodFeel and look good
�� Able to do more things Able to do more things
�� Maintaining and increasing independenceMaintaining and increasing independence
�� Social contact (bond formed through prolonged contact with groupSocial contact (bond formed through prolonged contact with group))
�� Confidence/pride in achievement (general increase in selfConfidence/pride in achievement (general increase in self--
confidence, approval of family/friends/doctor)confidence, approval of family/friends/doctor)
�� Enjoy the activity (get out of house, use equipment)Enjoy the activity (get out of house, use equipment)
(Yardley et al 2005a)
PEER MENTORS TO PEER MENTORS TO ENCOURAGE EXERCISEENCOURAGE EXERCISE
�� Kirklees Kirklees Kirklees Kirklees Kirklees Kirklees Kirklees Kirklees PALsPALsPALsPALsPALsPALsPALsPALs referral programmereferral programmereferral programmereferral programmereferral programmereferral programmereferral programmereferral programme
�� 70 + mentors trained in 3 yrs70 + mentors trained in 3 yrs�� Work as buddies Work as buddies –– meeting, greeting and meeting, greeting and
exercisingexercising
�� 96% uptake + adherence beyond 12 96% uptake + adherence beyond 12 mthsmths
�� Extended to home visiting programme.Extended to home visiting programme.
�� 1 mentor attracted 240 participants in 12 1 mentor attracted 240 participants in 12 monthsmonths
ASSISTED WALKING FOR ASSISTED WALKING FOR CONFIDENCECONFIDENCE
�� Walk from Home Scheme Walk from Home Scheme Mary Moffat Mary Moffat -- 9393
–– Referred by physiotherapist Referred by physiotherapist
after a fallafter a fall
–– Loss of confidence and fear of Loss of confidence and fear of
fallingfalling
–– Isolated and lonely and Isolated and lonely and
dependent upon others to get dependent upon others to get
outout
–– Mentoring with peers / Mentoring with peers /
volunteers / rehabilitation volunteers / rehabilitation
assistantsassistants
Creative, interactive, flexible, fun
EXERCISE FOR THE OLDEST OLD
ACSM 1999; Dinan 1999
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Data presented at the 2nd National Conference on Falls and Postural Stability, Royal College Physicians, London, 2001
Improvements in 4 weeks in
• Ankle Strength
• Lower limb Power
• Balance
• Balance confidence
• Timed Up and Go
CHAIR BASED EXERCISE CHAIR BASED EXERCISE
Improvements in wide range of ages Improvements in wide range of ages
/settings:/settings:
�� Strength and Power Strength and Power ((FiataroneFiatarone 1990, 1994; 1990, 1994;
Skelton 1995, 1996)Skelton 1995, 1996)
�� Flexibility and Functional Ability Flexibility and Functional Ability (McMurdo (McMurdo
1993; Skelton 1995, 1996)1993; Skelton 1995, 1996)
�� Arthritic Pain Arthritic Pain (Hochberg, 1995)(Hochberg, 1995)
�� Orthostatic Hypotension Orthostatic Hypotension (Millar, 1999)(Millar, 1999)
�� Depression Depression (McMurdo, 1993)(McMurdo, 1993)
�� Rehabilitation following hip fracture Rehabilitation following hip fracture (Nicholson, 1997)(Nicholson, 1997)
SummarySummary
�� Most of your patients are “older people”Most of your patients are “older people”
–– User involvement in development of appropriate programmeUser involvement in development of appropriate programme
�� Potentially different motivators and barriersPotentially different motivators and barriers
–– Transport issues Transport issues
–– Activity restriction due to fearActivity restriction due to fear
–– Significant others / peersSignificant others / peers
�� May have to adapt the CR programmeMay have to adapt the CR programme
–– Other chronic medical conditions and disabilitiesOther chronic medical conditions and disabilities
–– Higher r isk of falls and poor functiona l capacityHigher r isk of falls and poor functiona l capacity
�� Holistic approach to CR:Holistic approach to CR:
–– Strength and Balance work Strength and Balance work
–– Flexibility and functional floor workFlexibility and functional floor work
“Man does not cease to play because he grows old. Man grows old because
he ceases to play”
George Bernard Shaw
August 13-17th 2012, Glasgow SECC.
www.wcaa2012.com