Evidence based programs for balance retraining
Unfortunately people rarely volunteer for balance retraining and falls prevention when they first notice that they are becoming less steady on their feet. Rehabilitation physiotherapists often first meet a client when their balance has deteriorated significantly, and they have been experiencing frequent falls for some time. Usually this is when a family member, doctor or physiotherapist impress upon the client the need to address their issues to prevent a catastrophic fall.
Some hospitals offer time limited outpatient falls prevention classes to clients who are identified as being at high risk of falls. However, research has shown that falls prevention programs that have broader inclusion criteria achieve greater relative reductions in falls rates. This provides support for a population-based approach to falls prevention with appropriate exercise programs. [i]
A 2008 meta-analysis by Sherrington et al.[ii] found that the falls rate was more effectively reduced when a balance strategy training program (targeting the multiple aspects of balance) was used during exercise interventions. The meta-analysis showed that effectiveness of exercise programs was related to exercise dose: duration of session, frequency of activity and program length.
The Sherrington et.al. meta-analysis found that group therapy programs that included a higher challenge to balance and a higher dose of exercise, but did not include a walking program, had the greatest effect on falls. These programs reduced fall rates by 42%.
The fact that programs without a walking component were more effective possibly indicates that time spent walking in programs of limited duration reduces time spent undertaking more intensive balance training.
Brisbane colleagues Comans, Brauer & Haines (2010) performed a randomized controlled trial comparing an 8 week centre-based group balance therapy with a comparable home based intervention.[iii] They proved that the group intervention delivered in the community health centre was indeed superior in terms of falls reduction outcomes. They concluded that community-dwelling older adults with a history of falls should be provided with center-based programs in preference to home-based programs where they are available.
The Specific Balance Strategy Training (SBST) program developed by Nitz and Low Choy (2004) was found to be an effective program when delivered to fallers aged over 65 years once weekly for 10 weeks. Falls in the follow-up period were reduced by 30%.[iv]
Each workstation target in the Nitz & Low Choy SBST training program trained different elements of balance; sensory system function, integrative and dual task capacity, flexibility, strength and control in all planes of movement and at the limits of stability.
Each workstation in the SBST program was adjusted to suit the capacity of each participant while placing an appropriate level of demand on each participant. Participants work in small groups but at a level to suit their individual need.
Meggen Lowry, the Principal physiotherapist at Next Step Physio, was trained to design and deliver this model of balance strategy training program by Jenny Nitz & Nancy Low Choy at the University of QLD. It was the SBST model that inspired the development of the model that Next Step Physio uses today in our Falls & Fracture Prevention Class.
The Next Step Physio model outlines four levels of progressively challenging (motivating) activities for every rehabilitation goal. Colour-coded exercise instruction posters for each level complement the physiotherapist’s explanation and demonstration of an exercise, and prompt a client’s memory of an exercise previously practiced.
The Bronze, Silver, Gold & Platinum concept can be applied to group therapy that is delivered collectively, or in a workstation circuit model allowing clients to exercise alongside each other, while each derives therapeutic benefits from exercises that are tailored to their ability. The following is a simplified example of how the bronze, silver, gold and platinum concept is applied to forward reaching exercises in our Falls & Fracture Prevention Class.
The key point of difference in our model for falls (P)rehabilitation is that it is structured to open avenues for continuity of care. The Next Step Physio model affords the opportunity to simultaneously service clients at risk of developing a disease or disability alongside rehabilitation clients with established disease or disability. Furthermore, it aims to prevent regression in rehabilitation clients, by allowing for long-term participation in supervised exercise for maintenance of their outcomes.
[i] Australian Commission on safety and quality in health care (2009). Preventing Falls and Harm from Falls in Older People, Best Practice Guidelines for Australian Community Care, 2009
[ii] Sherrington, C., Whitney, J. C., Lord, S. R., Herbert, R. D., Cumming, R. G., & Close, J. C. (2008). Effective exercise for the prevention of falls: a systematic review and meta‐analysis. Journal of the American Geriatrics Society, 56(12), 2234-2243.
[iii] Comans, T. A., Brauer, S. G., & Haines, T. P. (2010). Randomized trial of domiciliary versus center-based rehabilitation: which is more effective in reducing falls and improving quality of life in older fallers?. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 65(6), 672-679.
[iv] Nitz, J. & LOW CHOY, N. (2004). The efficacy of a specific balance-strategy training
programme for preventing falls among older people: a pilot randomised controlled trial. Age and Ageing, 33, 52-8.