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


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


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


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


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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


Dynamic endurance work that also improves balanceDynamic endurance work that also improves balance


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


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

[email protected]

August 13-17th 2012, Glasgow SECC.

www.wcaa2012.com

ageing and performance - bacpr · reader in ageing and health, ... potentially reverse loss of...

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