Falls can result in serious injuries, which inevitably result in poorer quality of life. People with a history of neurological conditions are associated with an increased risk of falls. In the Fairfield district it was identified that a gap existed for falls prevention specifically with this patient population. In 2006, the Move to Improve exercise group was established at Braeside Rehabilitation Day Hospital (RDH) with the goals of objectively decreasing the incidence of falls by increasing balance, functional mobility and confidence. This 8 week program successfully decreased the incidence of falls by 72%, improve Berg Balance scores (BBS) on average by 2.2 points and improve Timed Get Up and Go (TGUG) scores by 4.5 seconds.

To decrease the risk of falls and incident of falls by 80% with the introduction of a targeted falls prevention program, especially for clients with neurological conditions.

In the Fairfield district there was no opportunity for people with a neurological condition to attend a falls prevention program. The Fairfield Hospital falls prevention exercise group specifically excludes people with a neurological condition.

Due to therapist demand in the outpatient system, providing ongoing guidance and education to this client group was not possible on an individual basis although it was highlighted that these clients would benefit greatly from such a program and the opportunity to network with people in the same situation.

The occurrence of a fall can have a devastating effect on the client and their family including serious injury, multiple hospital re-admissions, decreased quality of live and the possible need for increased community services and/or residential care. Literature in this area has indicated that 70% of stroke patients fells within 6 months of discharge from a rehabilitation setting (Forster 1995) and approximately 50 % of Parkinson's disease patients have sustained recurrent (2 or more) falls within a one year period (Wood 2002).

A review of the literature in early 2006 concluded that there is evidence to suggest that a small group community-based program can reduce the incidence of falls in the elderly, a proportion of who have a history of stroke (Clemson et al, 2004). Treatment modalities involved in such a group are similar to those currently available through RDH.

Falls prevention is a necessary component of health management as highlighted by the NSW Health goal to keep people healthy by prevention of health problems. This program is a practical strategy to make prevention everybody's business by providing education in the area's of nutrition, safe environments and the benefits of ongoing exercise. It directs greater effort towards health improvement and the prevention of the many risks and costs associated with falls. In 2005 the Australian Council for Safety and Quality in Health Care released best practice guidelines for the prevention of falls, components of which have guided this program’s development.

After discussions with a number of potential community participants, it was determined that the program would best be developed to fit into the current RDH structure, utilising the wealth of knowledge of the multidisciplinary therapists and transport systems which the RDH already had access to.

The RDH physiotherapist has the primary role of organising and overseeing the program. Appropriate participants are determined after detailed assessment and client's willingness to commit to the program. The program consists of 12 weekly sessions for 90-120 minutes, which includes both education and exercise sessions. The 30 minute multidisciplinary education sessions occur on alternate weeks which cover issues such as healthy eating, medication side effects, community resources, falls prevention in the home, and motivation strategies. The first 7 sessions occur in the gym and are divided into 10 minutes stations which have either a balance, strength, functional or endurance focus. These exercises are progressive in nature and aim to provide a moderate intensity of exercise. Equipment used was already available within the gym. The final 5 sessions incorporate all that is learnt into the community, with visits to a local shopping centre and accessing public transport. The maximum number of participants in a given group is 10, with the exercise session being supervised by a minimum of a physiotherapist and an assistant.

Proposed assessment tools to evaluate the effectiveness of the group intervention included participant’s falls history, Activities-specific Balance Confidence scale (ABC scale), BBS, TGUG and consumer evaluation questionnaire. These tools have been shown to be a reliable and valid measure in trials as found in our evidence based practice literature review. Pre and post group data was collected for all participants, with a 6 month phone follow up after completion of the program, which also served to ensure continued community input into the program.

Upon the completion of the third Move to Improve group, a review occurred of all the collected data. Average session attendance was 76.5%.

In the literature, exercise groups of 2 to 3 sessions per week across 8 weeks have resulted in an improvement of 2.1 to 4.2 points in the BBS (Eng 2003, Leroux 2005). Our participants showed an average increase of 2.2 points. Considering the group was held only weekly, these results are a good outcome.

Regarding the TGUG, the literature provides comparison data from other similar exercise groups with an improvement of 3.5 seconds after 30 sessions (Leroux 2005) and 4.6 seconds after 16 sessions (Marigold 2005). The RDH exercise group participants improved an average of 4.5 seconds over only 8 sessions.

The ABC scale showed an average increase of 5.25 points. It also provided insight into patients understanding of their own abilities, highlighting the need for falls prevention education as many participants were over confident in performing unsafe tasks.

The intervention of the exercise group resulted in a 65% decrease in the incidence of falls at the 6 month follow up.

 
After completing the program, participants reported feeling stronger (91%), better balance (100%), an improved level of fitness (83%) and feeling that they were walking safer (100%). The feedback from the RDH team was also positive as it allowed provision of a more efficient and effective service to a larger number of patients.

The Move to Improve program is currently into its 7th cycle. A detailed orientation and handover process has been implemented to sustain the ongoing success of the group with original team members mentoring new therapists to guarantee continuity in the event of therapist resignation or unavailability. At the suggestion of patients, a community mobility component (involving access to buses and shopping centres etc.) has been added this year to ensure the group continues to meet patient’s needs. Outcomes continue to be monitored at the end of each cycle to evaluate the success of the intervention.

The program is a permanent RDH meeting agenda item and is now an integral component of services available to RDH clients. The input of the community participants continues to be sought in regards to levels of interest and change.

As per NSW health directions and best practise guidelines, all community health services should be exploring avenues to improve efficiency of service in the quest for falls prevention. The Move to Improve program is a successful example of providing a new falls prevention intervention at no extra cost and could be transferred into other settings with gaps in falls prevention strategies.

Australian Council for Safety & Quality in Health Care (2005) Preventing falls and harm from falls in older people. Best practice guidelines for Australian hospitals and residential aged care facilities.

Clemson L, Cumming R, Kendig H, Swann M, Heard R and Taylor K (2004) The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial. Journal of the American Geriatrics Society 52(9): 1487-94.

Eng J, Chu K, Dawson A, Carswell A and Hepburn K (2003) A community-based group exercise program for persons with chronic stroke. Medicine & Science in Sports & Exercise 35 (8): 1271-1278.

Forster A & Young J (1995) Incidence and consequences of falls due to stroke: A systematic inquiry. British Medical Journal. 311: 83-86.

Leroux A (2005) Exercise training to improve motor performance in chronic stroke: effects of a community-based exercise program. International Journal of Rehabilitation Research 28: 17-23.

Marigold D, Eng J, Dawson A, Inglis J, Harris J and Gylfadottir S (2005) Exercise leads to faster postural reflexed, improved balance and mobility, and fewer falls in older persons with chronic stroke. American geriatric Society 53: 416-423.

Wood B, Bilclough J & Walker R (2002) Incidence and prediction of falls in Parkinson’s disease – a prospective multidisciplinary study. Journal of Neurological Psychiatry 72: 721-725.

Physiotherapist, Braeside Hospital
Locked bag 82 Wetherill Park 2164
Ph: 02 9616 8616