Physiotherapy and Falls · one year period (Tinetti, 1988), ... rise steadily with age and frailty level. Of those who are 75+ ... Group exercises

WSYBCSU Evidence briefing 2014

Int roduction

There is a substantial body of evidence that clearly

demonstrates that tailored physical exercise programmes

are highly effective in reducing risk and rate of falls in older

adults (aged 65+). The aim of this document is to provide a

balanced overview, synthesising the key findings from the

published evidence, to provide commissioners with a clear

understanding of the effectiveness of physical therapy and

exercise in preventing falls in the elderly population.

How common are fal ls?

Studies estimate that approximately a third of adults aged

65+ in the community will experience at least one fall over a

one year period (Tinetti, 1988), equating to over 3 million falls

per year. The risk of falls and their associated complications

rise steadily with age and frailty level. Of those who are 75+

years, approximately 32%-42% fall each year. Additionally,

previous fallers are more likely to have another fall; studies

estimate between 50% - 67% risk of experiencing a fall in the

subsequent year (Tinetti, 1989; Nevitt, 1989).

Physiotherapy and Falls Finding the ba lance

1 in 3 people aged 65+ (over 3 million) fall every year The rate of falls is estimated to be 0.5 falls per patient Previous fallers have over 50% risk of experiencing a fall in the subsequent year

Phone: (555) 555-5555

Fax: (555) 555-0000


Many population based studies have described the rate of

falls in various settings, most notably the community and in

long-term care settings such as nursing homes. In the 65+

age group, conservative estimates of the rate of falls range

from 0.3 – 1.6 per person annually. The figure is estimated to

be double for those in the 75+ age group. Similarly, older

adults living in nursing and care homes have much higher

rates of falls, ranging from 0.6 – 3.6 falls annually (Rubinstein,

2006). Overall, NICE (2013) suggests that in the UK, the rate

of falls is 0.46 falls per patient annually.

The burden on the NHS

Falls and fractures have a major impact on the NHS, costing

more than £2.3 billion per year (College of

Optometrists/British Geriatrics Society, 2011). The number of

people aged 65+ is projected to rise by nearly 50% (48.7%)

from 10.8 million to over 16 million in the next 20 years; a

crude estimate of the cost (excluding inflation) is assessed

to be in the region of £3.4 billion. Therefore, the cost

implications for the NHS are likely to be significantly greater

in the future.

Hip fractures are the most expensive osteoporosis fracture

with the cost per patient estimated to be £25,000. Although

only 5% of falls result in fracture (Tinetti 1988), the impact on

the NHS is significant, with the total annual cost of these

fractures calculated as £1.7 billion (Torgerson 2001). This

figure increases to over £2 billion when the social care costs

are also included (The National Hip Fracture Database

National Report, 2011).

Falls and fractures cost the NHS more than £2.3 billion every year The projected rise in the aging population could increase this cost to over £3.4 billion Although only 5% of falls result in factures, they cost the NHS £1.7 billion annually Falls account for over half of hospital admissions for accidental injury


Falls also has a significant impact on emergency care; falls

account for 10 – 25% of all ambulance call-outs (Dept of

health 2009, Snooks et al, 2006) at an average cost of £115

per call out (Newton et al, 2006). In addition, falls account

for over half of hospital admissions for accidental injury.

Besides the economic cost, there is also the significant

human cost to the patient resulting in the loss of

confidence, loss of independence, diminished quality of life

and mortality. Falling also affects the family members and

carers of people who fall (NICE, 2013).

Can exercise prevent fal ls?

There is now clear evidence falls in the elderly population

can be prevented using carefully designed and tailored

physiotherapy programmes, delivered as either group

exercise or individualised therapy in the home.

Falls intervention programmes can vary greatly from one

programme to another; some programmes deliver only one

type of exercise with the aim of addressing one issue (such

as balance), whereas others may include a variety of

exercises with the aim of addressing multiple attributes (such

as balance, gait speed and strength). Both types of

physiotherapy interventions have been shown to be

effective.

Falls result in loss of confidence, independence, quality of life and mortality Falls also affects family members and carers


Community - Group exercises

The much revered and highly independent Cochrane

group recently published an updated review of the

evidence in falls prevention (Gillespie, 2013). The authors

considered 16 randomised controlled trials (RCTs)

comparing physiotherapy programmes delivering exercise

and standard care (in many cases, this was no intervention).

A total of 3072 patients were included in the analysis. Of the

16 RCTs comparing exercise against the control, all but one

trial favoured exercise in reducing falls with half also

demonstrating statistical significance. A meta-analysis of

the combined data demonstrated the effectiveness of

physiotherapy: the rate of falls was shown to be reduced

by 29% and the risk of falls reduced by 15%. Group exercise

was observed to be effective in both populations that were

at a higher risk of falls as well as populations that were not

identified as high risk.

Exercise interventions should be supervised and supported

by physiotherapists in order to monitor progress. NICE (2013)

guidelines stress that where group exercises are used, they

must be targeted and tailored to an elderly population to

be effective.

Community - Individual exercise regimes

Group exercise programmes may not always suitable for all

patients depending on their overall health and

comorbidities. For these patients, a one-to-one approach

may be more appropriate where highly bespoke exercise

programmes can be tailored by a physiotherapist.

Physiotherapy programmes can reduce the rate of falls by a third Group exercises must be targeted and tailored to an elderly population


The Cochrane review (Gillespie, 2013) examined 7 RCTs

consisting of 951 patients assessing the effectiveness of

individual exercise programmes. Home-based exercise was

shown to reduce the rate of falls by 32% and the risk of

falling by 22%.

Overall effectiveness in the community

In a separate systematic review, Sherrington et al (2011)

reviewed 54 randomised controlled trials considering the

effectiveness of well-designed exercise interventions. Unlike

the Cochrane review, the authors did not distinguish

between the mode of delivery (group or home-based). The

authors estimated a more conservative but nonetheless

statistically significant reduction (16%) in the rate of falls

when compared to control (no intervention or standard

care). The authors concluded that this provided

confirmation that exercise as a single intervention can

prevent falls.

Hospitals and Nursing homes

Unfortunately, the effect of single exercise programmes on

reducing the rate or the risk of falls in adults aged 65+ seems

to be unclear in hospitals and nursing homes. Both

Cochrane (Cameron et al, 2010) and Sherrington et al

(2013) concluded that the reduction in falls in

institutionalised individuals was inconclusive. However, the

Cochrane review found that when the intervention

programme was delivered as part of multidisciplinary co-

ordinated team of healthcare workers, the impact was

significant; the rate of falls was reduced by 31% and the risk

The most effective intervention programmes in nursing homes are delivered by a multidisciplinary co-ordinated team of healthcare workers


of fa l l s by 27%. The use of mul t i factor ia l

in te rvent ions has a l so been advocated by NI CE

(2103) gu idel ines .

The ef fect on fal ls re lated injur ies

Whilst it is clear that tailored exercise programmes are

effective in reducing the rate and risk of falls in the

community, until recently, it was unclear whether these

programmes can also prevent injuries caused by falls. El-

Khoury el al (2013) conducted a systematic review of 17

RCTs (4305 patients), showing overwhelmingly that fall

prevention programmes not only reduce the rates of falls

but also prevent injuries resulting from falls in older adults in

the community setting. For all injurious falls, the reduction

was estimated at 37%.

The protective effect appeared to be the greatest for the

most severe fall related injuries, with an estimated reduction

of 43% for serious injuries and 61% for falls resulting in

fractures.

How much exercise is required?

Sherrington et al (2011) considered the effect of the amount

of exercise delivered in reducing the rate of falls in the older

adult population. The authors found that the effect was

considerably more pronounced on falls from programmes

that delivered 50+ hours (23% reduction in the rate of falls)

compared to those that had less than 50 hours (7%

reduction). This is also supported by the recent Cochran

review (Gillespie, 2013) where successful exercise

programmes delivered an average (median) of

approximately 50 hours of exercise. Sherrington et al (2011)

therefore recommend that exercise programmes should be

delivered for 6 months with a duration of 2 hours per week.

Falls prevention exercise programmes can reduce injuries by 37% Serious injuries can be reduced by 43% and fractures by 61%


The current dose of physiotherapy where available is

inadequate to be effective; The Royal College of Physicians

(2011) survey highlighted that most (79%) exercise

programmes are delivered for a duration of 12 weeks or less

at a rate of one session per week (74%). This is vastly less

than the recommended 50+ hours.

Access to physiotherapy

Whilst it is known that approximately a third of adults aged

65+ will have at least one fall annually, it is less clear what

proportion of this age group have access to physiotherapy.

In nursing homes, where the risk of falls has been shown to

be higher than in the community (Rubinstein, 2006), a survey

indicated that only 10% of residents were in receipt of

physiotherapy, mostly through private physiotherapists

employed by the nursing home (Barodawala el al, 2001).

Therefore it is likely that the provision of physiotherapy

available through the NHS in the wider community setting

may be less than 10%.

Cost ef fect ives of physiotherapy

Currently, economic evaluations of falls prevention

programmes are very limited. This is further complicated by

the fact that where economic evidence does exist, they are

derived from international studies where the underlying

healthcare system may differ from the NHS. Nonetheless,

simple estimates can be extrapolated from the reduction in

falls related fractures. The cost of falls related fractures

alone has been estimated at £1.7 billion. A 61% reduction in

fall related fractures (as estimated by El-Khoury el al, 2013)

would reduce this cost by £1 billion, though the net saving

50+ hours of physiotherapy is required to be effective Currently, most exercise programmes are inadequate – majority at for 12 weeks or less Only 10% of residents in nursing homes have access to physiotherapy.


would also need to account for the cost of delivering

physiotherapy.

Using data from a retrospective study, Robertson and

Campbell (2008) demonstrated that the Otago falls

prevention exercise programme was cost-effective. The

cost to deliver the programme to a 1000 participants aged

80+ was calculated as $213,000 (NZ dollars), which was

anticipated to have prevented 541 falls resulting in a net

saving of $148,303 (NZ dollars) per 1000 participants. When

translated into British Pounds (May 2014 conversion rates),

this would convert to a saving of approximately £76,000 per

1000 patients or a total of £220 million pounds saving when

extrapolated to the population of aged 80+ adults in the UK;

for every £1 spend, a potential saving of £0.70 may be

realised. It must be noted that these estimates have the

caveat that the healthcare system in New Zealand may not

operate the same tariffs as the NHS and the currency

conversions may also fluctuate. Nonetheless, with limited

health economic evaluations to provide an accurate

costing, these studies provide a good barometer for

potential savings achievable under a well-designed and

tailored exercise programme.

Economic evaluations for falls prevention programmes are very limited. International studies have shown falls prevention exercise programmes to be cost effective saving approximately £76,000 per 1000 patients (aged 80+)


References

Barodawala S., Kesavan S., Young J., (2001). A Survey of physiotherapy and occupational

therapy provision in UK nursing homes. Clinical Rehabilitation; 15: 607-610.

British Geriatrics Society and The College of Optometrists. (2011). The Importance of Vision in

Preventing Falls.

Cameron ID, Gillespie LD, Robertson MC, et al., (2012). Interventions for preventing falls in

older people in care facilities and hospitals. Cochrane Database Syst Rev; 12:CD005465.

El-Khoury F, Cassou B, Charles MA, Dargent-Molina P., (2013). The effect of fall prevention

exercise programmes on fall induced injuries in community dwelling older adults: systematic

review and meta-analysis of randomised controlled trials. BMJ 2013; 347: f6234

Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE.,

(2013). Interventions for preventing falls in older people living in the community. Cochrane

Database of Systematic Reviews.

Nevitt MC, Cumming SR, Kidd S, Black D. (1989). Risk factors for recurrent non-syncopal falls:

A prospective study. Journal of the American Medical Association;261(18):2663–8.

J.L. Newton et al., (2006). The Costs of Falls in the Community to the North East Ambulance

Service. Emergency Medicine Journal, 23: 479–81 doi:10.1136/emj.2005.0288

NICE (2013). Falls: assessment and prevention of falls in older people, NICE.

Robertson MC and Campbell AJ, (2008). Optimisation of ACC’s fall prevention programmes

for older people. Report to ACC. Wellington, New Zealand.

Royal College of Physicians (2011). Falling standards, broken promises. Report of the national

audit of falls and bone health in older people 2010.

Rubenstein LZ, (2006). Falls in older people: epidemiology, risk factors and strategies for

prevention. Age and Ageing, 35-S2:ii37-ii4

Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR., (2011) Exercise to prevent falls in

older adults: an updated meta-analysis and best practice recommendations. New South

Wales Public Health Bulletin; 22:78–83

Snooks H, Halter M, Close J, Cheung W, Moore F, Roberts S. (2006). Emergency care of older

people who fall: a missed opportunity. Qual Saf Health Care;15:390-392.

Tinetti M, SpeechleyM, Ginter S. (1988). Risk factors for falls among elderly persons

living in the community. N Engl J Med; 319:1701-1707


Torgerson DJ, Iglesias CP, Reid DM, (2001). 'The economics of fracture prevention', in The

effective management of osteoporosis, London: Aesculapius Medical Press pp. 111-121


Physiotherapy and Parkinson ’s disease

Int roduction

Parkinson's disease is a chronic, progressive neurological

disease for which there is no treatment or therapy to slow or

stop the progression of the disease. The prevalence of

Parkinson’s disease in the UK has been estimated to be 1 in

500, amounting to approximately 127,000 people living with

the disease in the UK. The prevalence increases to 1 in 100

over the age of 65 years and 1 in 50 over the age of 80

years (Macdonald et al, 2000).

Medications and devices address only the symptoms.

Parkinson’s is the second most common neurological

condition after Alzheimer’s disease, costing the NHS an

estimated £2 billion annually (Fineberg et al, 2013).

Despite advances in medical research, the natural course

of the disease, gait and balance worsen over time,

progressively leading to major disability (Franz´en et al,

2009).

127,000 people in the UK live with Parkinson disease Parkinson’s is the second most common neurological disease after Alzheimer’s Annual cost to the NHS of £2 billion pounds



Fal ls in Parkinson’s d isease

The estimated prevalence of falls in those with Parkinson’s

disease ranges from 40% to 90%, with about half of those

falls occurring when walking. The most common reason for

hospital admissions is falls. (Kelly et al., 2012).

Parkinson’s disease patients are more likely to have

impaired stride-to-stride control, leading to an increased risk

of recurrent falls. Studies showed that Parkinson’s disease

patients have a greater than two-fold increased increase

risk of fractures and more than 3 times greater risk of hip

fractures compared to non-Parkinson disease patients after

adjusting for age and gender (Schaafsma et al, 2003).

How effect ive is physiotherapy in

Parkinson’s disease?

A recent Cochran review (2013) of 39 randomised

controlled trials, involving 1827 patients showed that

Physiotherapy was effective in improving the majority of

walking outcomes, with significant improvements

demonstrated in walking speed, walking endurance and

freezing of gait. Improvements were also observed in

mobility and balance with physiotherapy as well as

improvements in the severity of Parkinson’s disease (using

UPDRS scale).

The Cochrane review noted that the majority of the studies

assessed the effects of physiotherapy over the short-term

(less than 3 months). However, the long-term benefits of

127,000 people in the UK live with Parkinson disease Parkinson’s is the second most common neurological disease after Alzheimer’s Annual cost to the NHS of £2 billion pounds


Physiotherapy in Parkinson’s disease has been confirmed in

recent studies. The Michael J Fox foundation conducted an

RCT of 210 patients with Parkinson’s disease over 12 months,

comparing two different Physiotherapy programmes

(Movement strategy training [MST] and progressive

resistance strength training [PST]) with usual care (control

group receiving a PD education program without falls

education). The study showed that there was a significant

reduction in the rate of falls and the severity of Parkinson’s

disease in both physiotherapy treatment groups over 12

months. The rate of falls was reduced from 18.6 falls per

patient in the control group to 6.58 in the MST and 2.79 in

the PST physiotherapy groups (Morris et al, 2014).

The long-term benefits of physiotherapy were also assessed

by Frazzitta et al (2013). In a preliminary study of 20 patients

who underwent a 4-week intensive physiotherapy

programme, balance and gait speed was demonstrated to

have improved significantly after the treatment

programme. At 1-year follow-up control, walk and

Comfortable-Fast gait speeds remained significantly better

than baseline measures.

Studies have demonstrated the short and long-term effectiveness of physiotherapy in Parkinson’s disease The rate of falls was significantly reduced from 18.6 per patient in the control group vs 6.58 and 2.79 in two physiotherapy groups.


References

Frazzitta G, Bertotti G, Uccellini D et al. (2013). Short and long-term efficacy of intensive

rehabilitation treatment on balance and gait in parkinsonian patients: a preliminary study

with a 1-year followup. Parkinsons Disease; 2013:583278

MacDonald, B.K., Cockerell, O.C., Sander, J.W., Shorvon, S.D., (2000). The incidence and

lifetime prevalence of neurological disorders in a prospective. Brain, 123, 665–676

Morris, M et al (2014). Preventing Falls & Improving Mobility in People with Parkinson’s . Journal

movement disorders – AWAITING PUBLICATION.

Kelly VE, Eusterbrock AJ, Shumway-Cook A. (2012). The effects of instructions on dual-task

walking and cognitive task performance in people with Parkinson’s disease. Parkinson’s

Disease vol. 2012

Schaafsma, J.D., et al. (2003). Gait dynamics in Parkinson's disease: relationship to

Parkinsonian features, falls and response to levodopa. Journal of the Neurological Sciences,

212(1-2): p. 47-53.


Physiotherapy and Frailty

Int roduction

Frailty is a state of vulnerability that carries an increased risk

of poor outcomes in older adults. Though common in the

elderly, frailty is not an inevitable consequence of the

ageing process. Frailty is a term that described a subset of

adults that greater risk of adverse health outcomes, such as

falls, less mobility, less independence, hospitalisation,

disability, and death. Unfortunately, there remains no

common consensus on the definition of frailty. It is widely

accepted as a multifactorial, clinical syndrome, consisting

of a combination of weight loss, fatigue, impaired grip

strength, diminished physical activity or a slow gait (Fried et

al, 2001).

Definitions of frailty fall into two groups: One group of

researchers define frailty as a purely physical condition,

whilst a second group of researches define frailty according

to a broader definition to include social and psychological

components of the condition (Collard, 2012).

There is no consensus on the definition of frailty Characteristics of frailty include weight loss, fatigue, impaired grip strength, diminished physical activity or a slow gait


Prevalence of f rai l ty Frailty is increases in prevalence with age and is generally

believed to be higher in women than in men. However, there

are wide discrepancies in the estimated prevalence rates of

frailty, to which the lack of common definition will have certainly

contributed to the variability is estimations. A systematic review

of 21 studies, estimated the prevalence of frailty in a community

dwelling to be in the range of 4.0% to 59.1%. In studies where

frailty was defined as a physical condition, the estimates of

frailty ranged between 4% - 17%. When a broader definition of

frailty was employed, there was a greater variability in the

estimate of prevalence (between 4.2% - 59.1%) (Collard et al,

2012).

Where frailty was specified by gender, a higher rate of frailty

was observed in women (9.6%) compared to men (5.2%). Frailty

was also observed to increase with age, ranging from

approximately 4% for adults aged 65-69, rising to 27% in the 85+

age group (Collard et al, 2012).

Ef fects of physical activ i ty on f rai l ty.

Two systematic reviews have examined the effect of physical

therapy on frailty (Arantes et al 2009, Clegg et al 2012). The

diversity of criteria used to define frailty makes it difficult to

compare and synthesise outcomes from studies to draw firm

conclusions. Both studies agreed that there was preliminary

evidence from one trial to suggest that physical therapy may

have a positive effect on reducing disability compared to

patients receiving solely an educational programme, with the

effects maintained for 12 months. The effects were most

pronounced in older adults with moderate frailty rather than.

Estimates of frailty vary considerably, between 4% - 59% depending on the definition used.

Frailty increases with age. Women have a greater prevalence than men


severe frailty, where no improvements were observed.

Both systematic reviews emphasised the limitations of the

studies and could not provide any certainty on the effects of

physical therapy on outcomes such as quality of life, long-term

care admissions and the progression of frailty until further

adequately designed RCTs are conducted. Greater consensus

is also required in the definition of frailty to help synthesise

studies.

Preliminary studies suggest physical therapy may reduce disability in frail adults. More studies are required provide greater clarity on the effectiveness of physical therapy in frailty.


References

Arantes, Paula M. M., Alencar, Mariana A., Dias, Rosângela C., Dias, João Marcos D., &

Pereira, Leani S. M.. (2009). Physical therapy treatment on frailty syndrome: systematic

review. Brazilian Journal of Physical Therapy, 13(5), 365-375. Epub November 13, 2009.

Clegg AP; Barber SE; Young JB; Forster A; Iliffe SJ., (2012). Do home-based exercise

interventions improve outcomes for frail older people? Findings from a systematic review.

Reviews in Clinical Gerontology.; 22 (1):68-78.

Collard RM, Boter H, Schoevers RA and Oude Voshaar RC, (2012). Prevalence of Frailty in

Community-Dwelling Older Persons: A Systematic Review. J Am Geriatr Soc; 60(8):1487-92

Fried LP, Tangen CM, Walston J et al., (2001). Cardiovascular Health Study Collaborative

Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med

Sci; 56: M146–56.

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Physiotherapy and Falls · one year period (Tinetti, 1988), ... rise steadily with age and frailty level. Of those who are 75+ ... Group exercises