It really is a way of dichotomizing the data that’s there. And we found that this time with these additional studies in the analysis that it really was three hours rather than two hours that was associated with a greater fall prevention effect.
Welcome to FOXcast Physical Therapy, a podcast for clinicians made by clinicians. It’s brought to you by FOX Rehabilitation. Find out more at foxrehab.org.
Jimmy McKay, PT, DPT: Walk into FOXcast physical therapy. I’m your host Dr. Jimmy McKay. On the show today no stranger to the program Dr. Will Dieter is on the show. Welcome back. Will.
Will Deiter, PT, DPT, GCS, FSOAE: Jimmy, I’m happy to be back.
Jimmy: Bringing in one of our colleagues from down under, professor Cathy Sherrington is an NHMRC senior research fellow at the Institute for Musculoskeletal Health at the School of Public Health Sydney Medical School the University of Sydney. She leads the physical activity Ageing and Disability Research team within the institute. Prior to completing her Ph.D. and Masters of Public Health, Cathy was a physiotherapist in aged care and rehabilitation settings. She describes herself as a physiotherapist, recreational runner and a parent on the program today. Cathy Sherrington, Cathy, welcome to the program.
Cathie Sherrington, PhD, MPH, BAppSc: Thank you very much for having me.
Jimmy: And the audience can find you on the Twitter sphere @ Cathy_Sherr that’s Cathie_Sherr. Thanks for taking some time out. I know it’s it’s tomorrow in the morning for you in Australia. Thanks for taking some time out to talk with us.
Cathie: My pleasure. Welcome to the future.
Jimmy: I know it’s whenever we talk to someone when we bring people in from around the world quite frequently on this show. That’s one thing we always have to point out. Because to me I’m still a nine year old kid confused by time zones. Well, we bring on the program today along with Will to talk about an article that came out, the audience can find it in the British Journal of Sports Medicine December of 2017. The article was titled exercise to prevent falls in older adults an updated systematic review and meta analysis. Cathy what got you excited to go down this avenue about this particular article?
Cathie: I guess it really is trying to summarise the evidence to guide clinical physiotherapists or physical therapists and others to really help older adults to prevent falls. And I guess it came from my background as a clinician always looking for evidence to guide practice. And then having done a Masters of Public Health I realised that in the area of falls prevention really brings together physical therapy and public health and physical therapists have a massive role to play in and really preventing these very important health problem.
Jimmy: The article really is a different kind of systematic review expanding on a previous study results from a meta analysis that found that exercise prevents falls in older adults. This study in particular looked more deeply at exercise as a single characteristic to explore its association with greater fall prevention. You look at randomised control trials from seven different data sources: Cochrane Cinahal, Medline, Mbase, pub med, Pedro and safety lit. And then span there was from January 2010 to January 2016 and the criteria exercise had to be a single intervention with fall rates compared to this group and to a control group that sounds pretty comprehensive to me.
Cathie: Yeah that’s right. As you might have alluded to we were updating previous systematic reviews that were done were published in 2008 and also 2011. And really it’s very encouraging that the results are really very consistent. But now there’s more evidence to guide practice. So this time we actually found 88 randomised controlled trials that had compared exercise with control interventions. And so because of the amount of evidence that’s out there now we are able to explore things more fully and really investigate which features of exercise interventions had greater fall prevention effects.
Jimmy: Well since we’ve got you on the show and you’re the person that is going to know this article better than anybody. Where would you like to start?
Cathie: That’s that’s pretty much it. Just as I said with really the amount of evidence that is there now we were able to look at evidence of studies conducted in different settings separately. And so really the main bulk of evidence is actually in people living in the general community. Yet really most of evidence is there. And so really this is your general older population not necessarily those people with particular health problems and not necessarily those people in residential care. So that’s actually the group that we know most about how to prevent falls. And it’s really in that group that we found that exercises is that had or exercise programs with certain features were more effective. And so these were programs that more specifically targeted balance and also were of a higher dose of exercise. And so it didn’t seem to matter exactly how it was delivered. So there was actually a number of different options for how you could deliver such a program. So some were home based some were done in groups some some involve tai chi others a different exercises. But the key characteristics of the exercises really were that safe challenge to balance.
Jimmy: What’s something is difficult to do when you’re taking on a project of this size in the span trying to separate all these different things?
Cathie: Yeah it is. It is very difficult. And really the bulk of evidence that’s published so you know there’s really new studies coming out all the time from all around the world. Yes that’s one key challenge just the actual searching the literature to really identify those different studies. And fortunate to have a fantastic team working on that with the. And then I guess the next challenge is that we really are trying to categorize exercise programs. And they weren’t necessarily described in the paper for that purpose. And so we are needing to make some assumptions about the actual nature of the exercise programs and what they really look like. We’ve done various explorations to sort of see how stable. The results are and they really do seem to be quite stable. So we are confident that overall we can make these recommendations.
Will: A quick question Cathie because the thing that I think initially drew me to your research was. If you break sort of rehab interventions down into groups you know you’ve got strength training you’ve got aerobic training. Balance is always in my understanding as being a section where dosage isn’t exactly what you should do for someone has always been sort of up in the air and maybe is a way to sort of be solved. I think you seem to be the one that starting to solve it. So I guess my question really is for a clinician that is out there treating an older adult. What are the two or three big hurdles in terms of you know it multifactorial as much as one exercise but what should they look like? What should they include and how much of it should be done to really get a good result?
Cathie: Yeah I think that that’s a fantastic question and I think you’re exactly right that people use the word balance and pick a lot of people will actually interpret that differently. And if we look at sort of more traditional aspects of exercise prescription. People know about strength training and they know about aerobic or fitness training but I agree that balance is more difficult to characterize and as a result is often neglected. So I guess I’ll start by saying that we took a more general definition of balance and which you know really is consistent with the definitions by the by the biomechanists such as Winter. But really is the ability to do tasks while maintaining control over the body position. And so I think that definition is really important when we’re looking at prescribing exercise because it really does need to be individually matched to the person’s ability. And so the way we talk about it is being sort of challenging but safe because you know obviously if an exercise is going to be too easy for an individual then they’re not going to get much benefit from it. If it’s too difficult then you know their risk of actually falling while doing the exercise which is obviously not good. And what is obviously exactly what we’re trying to prevent. But then also if it’s too difficult I think people can also lose motivation and be really less inclined to actually carry out that program. So really it is about finding that sort of sweet spot of something that’s challenging that can be done safely and really working with the older individual to try and teach them that. We’ve actually summarized it in a box one of the paper. Really our kind of recommendations for how to actually prescribe the balance training. And that’s really come from our categorization of the individual programs tested in the individual trials. So we’re basically suggesting that people should try and be reducing the base of support. And so standing with the two legs close together or if that’s already manageable to be standing with one foot in front of the other. So a semi tandem position or progressing to a tandem position with one foot directly in front and then progressing that to be able to stand on one leg. And so I guess that’s the first aspect we think is important of balance is reducing the base of support and the next aspect is really about controlled movement. And so while standing to be able to actually do other tasks. So initially starting with reaching and moving on to stepping, stepping in different directions. And so we figure that in really things like Tai Chi and also dancing can achieve that. You know as can more individualze isolated exercises for people who are more affected. And then the third component is really not using the arm support or aiming not to use and support. So obviously if we want the person to be able to maintain an upright position while walking and if they’re not using walking aide and walking in different environments then you know ideally they wouldn’t need to use their arms for support. Obviously some people do need to but the aim of the exercises should to try and decrease the reliance on our support. So we might do that by starting off by holding on and then moving on to progressing that by holding on just with one hand or even just with one finger and then progressing that to having you know the hand hovered about something stable a bench or a wall or a rail without actually holding on. So I guess they are set of principles.
Will: And I think that was a great way to think about it because it’s like you said it’s general. So you can apply this to anyone, depending on what level they’re at which is very important and that’s again multifactorial it’s got to be specific to them. What about how much of it needs to be done? To me maybe the most interesting piece is because you know from your earlier work in 11 possible two hours a week for six months would be like the 50 hour threshold which maybe was more of a way to dichotomized high and low intensity but the newer one talks about three hours a week and how that really bumps fall reduction up to about 39 percent if you can really do that well. And that’s so interesting because we have a program we do in senior living where we give people a ton of exercise and we actually reduce their forest by 39 percent. Exactly the same number you have in your article I find that so interesting what’s so magical about that number in your mind?
Cathie: That is really interesting. Was it really as you’ve alluded to it really is a way of kind of dichotomizing the data that they have. And we found that this time with these additional studies in the analysis that it really was three hours rather than two hours that was associated with a greater fall prevention effect. And it was also difficult to tease out exactly how much balance exercise there was. So this is actually three hours of total exercise that does include a balance component. And so we don’t know exactly how much balance exercise the person needs to do. But, we think that also fits with the physical activity guidelines about general benefits of being more active. And I guess also because we’re looking at it from a skill point of view that really the more practice the better. And so that’s not always a good message to be telling people because yes sometimes people can find that discouraging. But really there doesn’t appear to be an upper limit of benefit. So we really need to be working with our clients to get them to be able to do as much as possible. But they’re certainly aiming for three hours a week.
Jimmy: Kathy you up a point on walking. We found the presence of walking program was not associated with a reduction in intervention effectiveness we suggest walking should not be prescribed as a single fall prevention intervention. Talk about that for a second.
Cathie: That’s potentially be due to increased exposure to risk. So there actually have been a few studies that have just been walking programs that have actually increased the rate of falls. And so however basically we think also just walking is not going to be enough and might actually increase risk because if we’re just walking then we’re not necessarily really targeting improving the balance in the way that we’ve talked about before we might be just now practicing the habits that we already have. But you know by actually breaking down the task and really making it more challenging then there seems to be additional benefits of that. So I guess if you’re just doing walking you’re probably not doing that specific balance training as well as potentially the exposure to increased risk. But where it’s a bit complex is that some of the successful interventions have actually included walking where it’s safe to do so. And so we think that’s really the key aspect. So for example the entire go home exercise program that was developed in New Zealand and the resources are freely available for that now on the Internet. And so that really is a home exercise program that focuses on improving balance in the way that we’ve talked about and also strength in a functional way. So practicing sit to stand and walking up steps and things like that. But then if the health professional judges that that individual would be safe to also walk outside for example. And they would be advised to do that as well. So it really we think that’s the best model for physical therapists to take because you know we do you know there are benefits of overall physical activity. But it does need to be individualized.
Will: That makes so much sense. One other question. I think it’s just more trying to shine a light on something that drives me insand. So i’m interested on your thoughts on it. I can’t tell you how many conditions have said to me they have poor balance. I’m going to strengthen our legs in a way to strengthen their leg and I’m going to do it some more and they’re going to balance better. And sure at times it might work. A lot of this is also seated you know strength training. I’m just curious what your thoughts are about strength training and its impact on fall reduction and balance.
Cathie: That’s a really good question. We don’t really yet know they’r haven’t been very many studies of just strength training. But at this stage none of the studies that have only had strength training have prevented falls. However strength can be important and we do know that strength really does deteriorate with increased age. And a number of successful programs have had a mixture of strength and balance training. So I would say that it is OK to add strength training as well as balance training. But I certainly wouldn’t do it as the first target to improve balance. And really that’s because that’s what we know about the task specificity that really the system gets better at things that are practiced. And so you know that’s the approach we take with athletes so you know why wouldn’t we also take that with older people? And really if I’ve got a limited time to exercise then yeah let’s actually target those things that are more directly related to the tasks that they’re trying to do. And so you know we can add additional resistance for that. And so you know particular exercise that a lot of people like to use these practicing sit to stand. And so you know the person can be standing up from the chair without using their hands and that can be progressed by decreasing the height of the chair to make that more difficult. We can you know lift up one leg so it’s really a single leg stand. You know the person can have a backpack or a weight belt or can hold something so we can provide resistance to that more functional activity to provide that muscle overload. So in terms of what we know about task specficity that certainly would be my my first approach if that can be prescribed safely for an older individual. There has also been some observational work looking at a kind of curved linear relationship between strength and function. And so that’s if you’re really very weak. It does seem that getting stronger might actually improve your function but if you already have kind of enough strength for general function getting stronger is not necessarily going to improve function I think that’s another piece of evidence to put it in the mix as well.
Jimmy: One we’re not one special population or populations that we found interesting results of exercise as a single intervention in people with Parkinson’s disease and cognitive impairment was promising. Some more trials needed talk about that just a little bit because a fair amount of our clinicians are working with individuals with Parkinson’s disease and similar cognitive impairments.
Cathie: Yeah we don’t have the volume of evidence of evidence that we have in the general community. And so again we can’t be as sure and as firm in our recommendations. I guess the other thing that’s really important to note is that the actual intervention might look different in those people. While it can still apply those same principles that we’ve talked about, actually delivering is going to be different. And with people with Parkinson’s Disease we might need to be targeting other impairments. Know for example the phrasing and yeah we might be needing to work closely with the medications that the person is on giving other more general advice as well. And so really the programs in those high risk groups do need to actually look different and be really run by specialized people. And so it’s probably not just the case if someone has more advanced Parkinson’s disease of sending them along to a community exercise class for example. But yet the results are very promising in terms of the reduction in falls that is possible with exercise as a single intervention. And similarly with the cognitive impairment. So again the actual exercises might look reasonably similar. We’ll also need to be individually tailored but you know the skills in delivering those are obviously going to be different and you know we might be needing to use different methods to be encouraging people to exercise so you know more modeling and examples and encouraging and things like that rather than more complex instructions that you might be able to get away with someone without a cognitive impairment.
Will: Absolutely. Cathie the article also talks about residential care settings, stroke survivors and people discharged from the hospital and that exercise maybe isn’t the answe,r is that the reason because of the lack of evidence or just the fact that in what you looked out there weren’t a whole lot of people with that criteria. Or was that a real thing that you found more just a lack of evidence?
Cathie: It’s hard to tell at this stage because there has been left less evidence in that area. In each of those areas but certainly the trials to date have not been able to successfully prevent falls with exercise as a single intervention in each of those settings that you mentioned. And although having said that there is actually a new Australian trial that have come out since our review was published actually that actually does look at exercise as a single intervention in a nursing home setting. And so that was actually a mixture of strength training and and their purpose prescribed balance training and so actually using very similar principles to this. And that actually did prevent falls in a residential aged care setting in Australia. So you know it is something we need to investigate more fully. But you know other residential care interventions that have been successful have involved other factors as well. So they’ve involved looking at the environment. You know staff training, provision of equipment and aides. So you know broad interventions. Similarly in people after hospital we actually did a trial where unfortunately with a home exercise program people who’d recently been discharged from hospital actually fell more so they did improve their mobility they became more able to stand up and walk and balance. But they did actually report more falls and so to us really we do need to be supplementing this exercise intervention with safety advice and so it’s not just all those physical factors are important risk factors for falls. It doesn’t necessarily mean that we can prevent falls by just addressing those physical risk factors in a high risk population. And so we think particularly people who have recently been in hospital have had a deterioration in their mobility and really they do need to adjust their behaviour to that. And so just improving their mobility with exercise actually and in our study wasn’t enough. But we have done a study in hip fracture survivors where we did add safety advice and we didn’t increase falls. So it really is you know a matter of developing and testing different interventions.
Jimmy: Cathy was there anything that you found that just made you scratch your head when you’re dealing with with data this large. There’s got to be some things that can pop up that are just a little bit surprising anything that comes to mind?
Cathie: Possibly that walking issue you know initially we were surprised with that. Something were also a little bit surprised about but we have found consistently is this idea about risk level. So a lot of in the general community a lot of clinicians and programs want to screen for risk of falls and just target their interventions to those people who are at high risk. However about half as studies in the general community actually have not done that and they have actually prevented falls to the same extent and as those studies that have screened for risk factors for falls. And so we think that there actually is potential to reduce the rate of falls in the general community with exercise and we think that you know that’s something that there’s not a great awareness about.
Jimmy: Also on an unrelated to this particular article note. We saw that you had spoken at the WCPT international congress in South Africa in 2017 three times actually on bone health and fall prevention and assistive technology and then fragility and fractures with Becky Craik amongst others who we’ve had on this program before. What was that experience like being down there with literally that you know the world congress of physical therapy?
Cathie: Yeah it was fantastic. I mean it was amazing to meet a physiotherapist from all around the world. You know really with very similar aims and you know it’s amazing actually how much we have in common in different settings even though we have you know very different health systems you know very different settings different financing arrangements. But it’s amazing how you know really very common issues affecting physiotherapists around the world.
Jimmy: Something you’d do again?
Cathie: Oh yes definitely. Now that was fantastic really you know to take the opportunity to go and see what was happening in the local area as well. And I went on a trip to as a community rehabilitation centre in kind of the outskirts of Capetown and yeah that was amazing. The work that the health professionals were doing there in kind of therapy assistance to go into a kind of very poor kind of sickly slum type of areas. And really linking with the local community and really teaching people about home exercises and other rehabilitation strategies. It was very inspiring.
Jimmy: Patient education something that is something that we as a profession are good at need to do more of it’s good to see that you got a chance to do that while you’re in South Africa.
Cathie: Yeah it was fantastic.
Jimmy: Last question we ask on the show Cathie is your FOXtale. You ready for that?
Cathie: Sure.
Jimmy: Why did you start working with older adults in your career what about our population really drew you in?
Cathie: It’s really you can just learn so much from older people the experience and you know all the incredible rich lives that they’ve had. And I think it’s also very rewarding as a physiotherapist because you can really make a massive impact in people’s lives and yet personally I think the impact of our interventions in the city populations really astonishing. And it’s very rewarding and exciting.
Jimmy: Couldn’t agree more physiotherapists recreational runner parent Cathie Sherrington on the show. Appreciate you taking the time out to talk about that article and again for the audience. You can find it in the British Journal of Sports Medicine December 2017. Exercise to prevent falls in older adults an updated systematic review and meta analysis. Thank you very much for doing what you do for older adults and taking some time with us here to share it.
Cathie: My pleasure. Congratulations on a fantastic initiative and all the best to everybody.
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