Download Effectiveness of Otago exercise program on reducing the fall

Imperial Journal of Interdisciplinary Research (IJIR)
Vol-2, Issue-6, 2016
ISSN: 2454-1362, http://www.onlinejournal.in
Effectiveness of Otago Exercise Program on
Reducing the Fall Risk in Elderly: Single Case
Report
Dr. Deepti Wadhwa1 & Dr. Deepali Hande2
1
Postgraduate Student, 2 Associate Professor,
Department of Community Physiotherapy, Dr. APJ Abdul Kalam College of Physiotherapy,
PIMS, Loni, Maharashtra, India, 413736.
Abstract
Objectives- To find out the effectiveness of Otago
exercise on reducing the fall risk in elderly
Design- Single case study
Setting- Out Patient Department and at home
Participants- A single individual with fall risk
participated in this study
Methodology- Interventions used in this study
included Otago Exercise Program which included
strengthening exercise, balance re-training and
walking. The interventions were given for 8 weeks.
The outcome measures were 30 Second Chair
Stand Test, Four-Stage Balance Test, Timed Up
and Go test and Berg Balance Scale. The outcome
measures were taken on first day, last day of 4th
week and 8th week.
Results- The scores of 30 Second Chair Stand Test,
Four-Stage Balance Test, Timed Up and Go test
and Berg Balance Scale were improved
Conclusion- Otago exercise program can be used
for elderly with fall risk.
Keywords- fall risk, otago exercise, 30 Second
Chair Stand Test, Four-Stage Balance Test, TUG.
INTRODUCTION
The major problems in the elderly are falls and they
are considered one of the “Geriatric Giants”.
Recurrent falls are an important cause of morbidity
and mortality in the elderly and are a marker of
poor physical and cognitive status. Most often the
cause of fall is multifactorial. Falls and their
sequalae are potentially preventable and hence the
risk factors for falls plays an important role in the
elderly.1,2 According to the World Health
Organization global report on fall prevention in
older age, risk factors for falls involve biological,
environmental, behavioral, and socio-economic
factors. In Indian adults older than 70 years,
intrinsic causes for falls and recurrent falls are the
most likely factors. Biological (intrinsic) risk
factors include sex, race and age-related declines in
strength, balance, vision, cognition, and chronic
diseases. The most common predictors of falls are
Imperial Journal of Interdisciplinary Research (IJIR)
abnormalities of gait or balance and a history of fall
in the past year. Compared with elderly without a
history of falls, elderly with a history of fall have
decreased lower limb strength, impaired balance
and functional mobility, decreased balance
confidence, and more co morbidities.2,3 A recent
study has shown that the risk of falling increases in
proportion
to
the
severity
of
chronic
musculoskeletal pain, the number of joint groups
affected, and the amount of interference with daily
activities.4 Fear of falling is mentioned frequently
as an adverse outcome of falling, little is known
about it. The individuals at risk of developing fear
of falling can be identified and fear of falling
proves to be an independent factor in functional
decline.2 the intervention by American Geriatric
Society guidelines for prevention of falls are
exercises,
environmental
modification,
medications, assistive devices, behavioral and
education program other interventions included are
bone strengthening medications, cardiovascular
intervention,
visual
intervention,
footwear
intervention.5,6,7
A CDC Compendium of effective fall interventions
are Stay Safe, Stay Active, The Otago Exercise
Program, LiFE (Lifestyle approach to reducing
Falls through Exercise, Erlangen Fitness
Intervention, Senior Fitness and Prevention
(SEFIP), Adapted Physical Activity Program, Tai
Chi, Australian Group Exercise Program etc. 8,9
The Otago Exercise Program (Otago) is an
individually tailored, home-based, balance and
strength fall prevention program. The program was
developed by Professors John Campbell, MD,
FRACP, and Clare Robertson, PhD, researchers at
the University of Otago in Dunedin, New Zealand
and the New Zealand Falls Prevention Research
Group, in response to the frequency and severity of
fall injuries among elderly in New Zealand. Otago
is a leg muscle strengthening and balance retraining
program delivered at home.10
The Otago exercise program was selected because
of following reasons firstly it is a home- based and
individually tailored fall prevention program. As
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Imperial Journal of Interdisciplinary Research (IJIR)
Vol-2, Issue-6, 2016
ISSN: 2454-1362, http://www.onlinejournal.in
the socioeconomic status of the patient living in
rural area in low or middle class, they cannot afford
the travelling expenses as the hospital is far away
from their homes. Secondly as these are old
persons, they may need assistance or some family
members with them while coming for taking
treatment.
CASE DESCRIPTION
The patient 74 year old male was referred for the
complaint of fear of fall by physician. The case was
attended by Physiotherapist.
Patient history: Patient lives at home with 69 year
old wife, 2 sons married. He had complained
restriction of activities, low confidence and fear of
falling since 15 days. There is history of one fall in
the past year at home, but didn’t have any bleeding
or fracture. He has history of hypertension since
one year and type 2 diabetes four years which was
controlled by diet and medications. Personal
history was patient had no addictions, sleep was
unaltered, bowel and bladder were unchanged. The
socioeconomic status according to modified
kuppuswamy scale was lower middle class. The
environmental history consisted of cemented
house, 3 rooms, 5 stairs at entrance, slippery and
uneven surfaces, Indian toilet. Vision was checked
by an ophthalmologist, it was normal. Patient uses
no mobility aids.
Assessment of risk factors of falls: The intrinsic
risk factors included age-related declines in
strength and balance. The most common predictors
of falls in this patient were abnormalities balance
and a history of fall in the past year. Behavioral
risk factors included risky behaviors such as
hurrying, sedentary lifestyle, and multiple
medications. Socio-economic risk factors included
low education, low income, inadequate housing,
and limited access to health care services.
Environmental (extrinsic) risk factors included
physical environmental features in the home or
community that may posed hazards, such as
slippery or uneven surfaces, steps, and poor
building design.
Physical Examination: Physical examination was
performed on eight day of the symptoms. On
examination the ROM of hip, knee and ankle were
within normal limits. Manual Muscle Testing of
hip, knee and ankle were 3+. The superficial and
deep sensations were intact. Fall risk was assessed
using short form Falls Efficacy Scale11, scoring was
18 that patient is at high concern for falling. The
cognitive screening was done using Mini Mental
State Examination12, scoring was 26 which is
considered normal. The depression was assessed
using Geriatric Depression Scale (long form)13,
scoring was 5 which is considered normal means
patient had no depression.
Imperial Journal of Interdisciplinary Research (IJIR)
The outcome measures for balance were FourStage Balance Test14,15 and Berg Balance Scale16,17,
for muscle strength was the 30 second Chair Stand
Test18,19 and for walking ability was Timed Up and
Go test20,21.
TREATMENT
The patient received physiotherapy including the
muscle strengthening exercises 3 times a week for
two weeks to improve strength and mobility. Then
the patient was progressed to otago exercise
program.
The Otago exercise program focused on major
lower limb muscles knee flexors, knee extensors,
and hip abductors, which are important for function
and mobility and the ankle dorsiflexors and plantar
flexor muscles, which are important for
maintaining balance. The starting level of each
exercise by the amount of ankle weight the patient
can lift to perform eight to ten good quality
repetitions before fatigue. The exercise was started
with half kilogram weight which would minimize
both muscle soreness and compliance problems.
The patient did the exercises slowly (two to three
seconds to lift the weight, four to five seconds to
lower the weight) through the functional range of
active joint movement. The patient took a one to
two minute rest between sets. Muscle strengthening
exercises such as trunk movements, knee flexion
and extension, hip abduction, ankle dorsiflexion
and plantarflexion, heel raising and toe raising.
Progression was done by increasing ankle weights
or the number of sets performed, according to the
Levels and Repetitions for the Exercises. Patient
completed two sets of 10 repetitions before
progressing to the next level.
Balance retraining such as backward walking,
walking and turning around (figure of eight), one
leg stand, sit to stand, sideways walking, heel to toe
standing, heel to toe walking and stair walking.
Patient was observed during the holding portion of
each balance exercise. Progression was done from
holding onto a stable structure to performing the
exercise without support and also progression
through the levels of exercise according to the
levels and repetitions for the exercises.
Walking was done 3 times a day for 10 minutes so
total duration 30 minutes/ day for twice in a week.
The muscle strengthening exercise and balance
retraining was given for 3 times/ week.9 (table 1).
The physiotherapist visited at home on 1st day and
3 times a week for first 4 weeks at home and then
for next 4 weeks regular phone contact was
maintained to motivate the patient for doing
exercises and last visit was on last day of 8th
week.9,22
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Imperial Journal of Interdisciplinary Research (IJIR)
Vol-2, Issue-6, 2016
ISSN: 2454-1362, http://www.onlinejournal.in
Strengthening
Table 1 Main features of Otago
Balance Retraining
Walking
Assessment
30 Second Chair Stand Test
Four-Stage Balance Test
Timed Up & Go
Activity
Five leg muscle strengthening
exercises
Four levels of difficulty
Advice about walking
Intensity
Moderate Challenge
8-10 repetitions before fatigue
Progressions
Increase from one to two sets
Increase amount of ankle
weight after 2 sets of 10
Twelve balance retraining
exercises
Four levels of difficulty
Not all exercises were
prescribed
Moderate Challenge
Each exercise at a level that
the patient can safely perform
unsupervised
Supported
exercise
to
unsupported exercise
Length of Exercise
Sessions
Approximately thirty minutes total for exercises; Exercises can
be divided up over the day
Frequency
3 times/ week with rest day
between
8 weeks
Duration
3 times/ week
RESULTS
The scoring for Berg Balance Scale was (40 on first
day, 43 on last day of 4th week, 48 on last day of
8th week), Four-Stage Balance Test (semi tandem
stand for 8 sec on first day, tandem stand for 6 sec
on last day of 4th week, one leg stance for 3 sec on
last day of 8th week), 30 second Chair Stand Test
(11 times on first day, 14 times on last day of 4th
week, 18 times on last day of 8th week), Timed Up
and Go test (17 seconds on first day, 13 seconds on
last day of 4th week, 9 seconds on last day of 8th
week).
DISCUSSION
The results of the study showed that 8 weeks
session of Otago exercises is useful in the treatment
of fall risk. Despite the emphasis in the fall
prevention literature on the importance of balance
training for preventing falls,23 it is likely that
strength training is also important since strength
declines steadily after the age of 65 years24and
impaired lower limb muscle strength has been
identified as an important fall risk factor. Exercises
that focus on building strength in the lower limb
muscle groups and muscles of the ankles and feet
have been included in successful fall prevention
programs.25 For elderly, these activities may
increase risk of falling with poorer postural control
so individually prescribed exercises which safely
challenge.
Imperial Journal of Interdisciplinary Research (IJIR)
Usual pace
Walk indoors
Advance to walking
outdoors
when
strength and balance
have improved
3 times/day for 10 min
Total: 30 min
2 times/ week
Balance is defined as the ability to maintain the
projection of the body’s centre of mass within
manageable limits of the base of support, as in
standing or sitting, or in transit to a new base of
support, as in walking. Therefore balance involves
anticipatory and ongoing postural adjustments and
is thus a co-ordination task. Effective challenge to
balance is provided with exercises such as standing
in which participants aim to stand with their feet
closer together or on one leg, minimize use of their
hands to assist balance and practice controlled
movements of the body’s centre of mass. The use
of a systems approach to understanding balance
enables the contribution of the physiologic systems
to be evaluated and the effects of ageing
considered. The systems are sensory, central
processing, neural pathways for motor control, and
musculoskeletal. Balance exercises help maintain
postural control, which is an essential element in
maintaining the balance. Spink et al said that
exercises that focused on muscles of the ankles and
feet were considered to be important components
of a successful podiatry fall prevention trial.
Strength is a key element of fall prevention;
however, strength training alone without a balance
component is not an effective strategy to prevent
falls. Training specificity is also an important
concept. The key components of strength training
that translate to improved balance and reduced falls
risk including focus on lower-extremity and
postural muscles; minimal upper-extremity
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Imperial Journal of Interdisciplinary Research (IJIR)
Vol-2, Issue-6, 2016
ISSN: 2454-1362, http://www.onlinejournal.in
support; delivered at moderate intensity to achieve
the desired results. Observable changes in strength
can be expected due to initial neural and
neuromuscular adaptations. A study was conducted
in which strengthening exercises using body weight
and general exercises were of sufficient intensity to
improve strength in the lower limb and to decrease
accidental falls. 26
Walking is one of the safest and easiest forms of
aerobic exercise and may be an appropriate
addition to a fall-prevention program in higher
functioning individuals.
Otago showed increase in strength and balance
which are improved by backward walk, walking
and turning around, heel to toe walking and stair
walking in the exercise program. These factors are
an important predictors or causes of walking. In
addition, through stair walking, the patient
practiced with a fixed foot support, acceleration,
balance control, contraction of the lower limb and
ankle dorsiflexion to move the centre of gravity to
control the afferent, efferent and contraction of the
lower limb muscles. As a result, coordination and
weight shifting were learned through movement of
the lower limbs and this improvement resulted in
an increase in mobility. Thus by improving the
parameters there can be reduction in the rate of
falls of elderly.
CONCLUSION: The results of this study
suggest that otago exercise program is an effective
management strategy for a patient with fall risk in
an older adult when treated for 8 weeks.
IMPLICATION FOR PRACTICE AND
FUTURE RESEARCH: Adherence of
exercise program was good. As exercises were in
home environment, the frequency of exercise can
be altered, timings to do the exercises were flexible
and it was cost effective. Future study can be done
on long term follow up larger population.
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