Effectiveness of physical therapy discharge plans in preventing recurrent falls among
at-risk older adults
November 6th, 2019
Patrice Hazan, PT, DPT, MA
GroupHab Physical Therapy and Wellness
Martha R. Hinman, PT, DPT, EdD, MHEd
Professor and Chair,
School of Physical Therapy
Anderson University at University Center of Greenville
TITLE. Effectiveness of physical therapy discharge plans in preventing recurrent falls among at-risk older adults
Falls, fall prevention, Exercise adherence, quality of life, physical therapy
For individuals who received physical therapy (PT) treatment for falls, repeated falls, or unsteady gait, is a discharge plan of PT designed and supervised group exercise classes more effective than discharge plan of home exercise and community resources in preventing future falls, increasing confidence in mobility, and improving perceptions of one’s quality of life?
Background: This study compares the long-term results of the traditional model of physical therapy (PT) care to a PT wellness model of care known as GroupHab. The traditional model included discharge with a home exercise program and recommendations for community resources at the senior centers. The wellness model included discharge from PT treatment with participation in a PT-designed and supervised group exercise program in an outpatient clinic setting.
Objective: To determine if a PT-led program of functionally based group exercise classes is more effective than a home exercise program (HEP) and community resources in preventing falls and improving exercise adherence.
Design: This original research used a quasi-experimental design to compare outcomes of the PT-led wellness program (i.e., GroupHab classes) and an HEP for older patients with a history of falls and had recently completed a standard course of physical therapy. Independent t-tests were used to compare the number of falls, exercise frequency, and exercise duration in the GroupHab exercise classes vs. HEP exercise groups. A repeated measures, analysis of variance (RM-ANOVA) compared changes in ABC scores both within and between groups, and a multivariate analysis of variance (MANOVA) analyzed group differences in multiple quality of life ratings (from the SF-20). All data were analyzed at the 0.05 alpha level using SPSS 24 statistical software.
Methods: Participants completed traditional out-patient physical therapy treatment for impaired balance and history of falls. Upon discharge they were given the choice to attend a physical therapy program of group exercise classes or attend community resources and follow a home exercise program. A comparison was made using the ABC scale, the number of falls, and exercise adherence at discharge and again 3 months following discharge.
Results: The results of the independent t-tests demonstrated a significantly greater reduction in subsequent falls among the GroupHab wellness group compared to the HEP group (t=2.811, p=0.009). One GroupHab exercise participant experienced a single fall while eight HEP participants experienced a total of 23 falls (Fig. 1). The resulting odds ratio for subsequent falls was 2.2among HEP participants and 0.2 among GroupHab participants. Exercise adherence was also greater for those who participated in the GroupHab wellness program. They documented greater exercise frequency (t= -3.253, p=0.002) and more exercise minutes (t= -7.188, p<0.001) than those who participated in the home program. When comparing changes in the participants’ balance confidence (Fig. 2), we found an average increase of 5% among GroupHab participants compared to a 6% decrease among HEP participants (F=16.877, p<0.001, power=0.981). Although our multivariate analysis of the SF-20 scores revealed no significant difference overall (F=0.768, p=0.73), the univariate analyses showed significantly greater improvements among GroupHab participants in selected areas of physical function.
Limitations: Participants were not randomly assigned to intervention groups. In addition, the study relies on subjective questionnaires to measure outcomes.
Conclusions: A program of physical therapy functionally based group exercise classes may be more effective than a referral to community resources and a home exercise program in preventing falls, improving exercise adherence and maintaining mobility in frail older adults with a history of falling after completing PT treatment for balance impairment.
Demographic projections are creating an urgent need for change in our healthcare system. The growth in the number and proportion of older adults is unprecedented in the history of the United States. Two factors—longer life spans and aging baby boomers—will combine to double the population of Americans aged 65 years or older during the next 25 years to nearly 72 million.1 By 2030, older adults will account for roughly 20% of the U.S. population. 85% of these older adults will be managing at least one chronic conditions and 60% will be managing at least two.2 In addition to managing multiple co-morbidities, unintentional falls have become an epidemic among older Americans. According to the National Council on Aging, every 11 minutes an older adult visits the emergency room for a fall-related injury, and every 19 minutes, an older adult dies from a fall.3 Each year, approximately one-third of adults aged 65 years or older falls; after experiencing their first fall, two-thirds will fall again.3 These falls are the leading cause of injury-related death in this age group and also cause disabling injuries such as hip fractures and head trauma, which increase the risk of early death.3 Many people who fall, even if they are not injured, develop a fear of falling.4 This fear may cause them to limit their activities, leading to reduced mobility and loss of physical fitness, which in turn further increases their actual risk of falling.4
Regular physical activity (PA) is one of the most important things older adults can do for their health. There is strong evidence to support the prophylactic effect of regular PA on fall risk as well as many other age-related health problems.2,5. However, many older adults avoid PA for a variety of reasons including physical limitations, lack of professional guidance, lack of healthcare provider support, and inadequate information on available programs.6,7 Even with exercise programs that are free or low cost (e.g., Silver Sneakers, Enhance Fitness) older adults are attending in very low numbers,7 and those who are most vulnerable do not utilize these services at all. 7
The combination of falls and lack of PA comes at a great economic cost. Treatment for this population accounts for 66% of the country’s health care budget.2 In 2017, Medicare spending totaled $702 billion, an expenditure projected to increase to $903 billion by 2020.8 In 2015, the estimated medical costs attributable to fatal and nonfatal falls was approximately $50.0 billion.7 For nonfatal falls, Medicare paid approximately $28.9 billion, Medicaid $8.7 billion, and private and other payers $12.0 billion.7 Overall medical spending for fatal falls was estimated to be $754 million,8 not including the costs associated with rehabilitation and long-term care. In addition to the sheer number of older adults who die or experience a disabling injury from a fall, these staggering economic numbers provide further incentive to find effective long-term prevention strategies.
Healthcare providers are facing a “silver tsunami” of individuals. We know that many chronic conditions are managed and prevented with exercise; however, many of these individuals do not exercise due to a health condition.6 Physical therapy (PT) is effective in improving a patient’s strength and balance as well as reducing fall risk among older adults. PTs also have the expertise to counsel individuals with specific health conditions on how to incorporate PA safely in their daily routine. However, the current medical model of PT consists of a short-term “bolus” of treatment followed by discharge with a home exercise program and/or recommendations to participate in community activity program.
Patients must continue to exercise to maintain the functional gains made in PT, because studies have shown that these gains begin to decline somewhere between one and nine months post-discharge.7,9,10 Barriers to exercise adherence include lack of interest, poor health, inclement weather, depression, fear of falling, and low expectations for positive outcomes.7 These barriers are similar to the ones that prevent older adults from participating in any type of PA6 and further support the ineffectiveness of the current model. Lack of adherence to the HEP on discharge and functional regression leads to recurrent falls, balance concerns, or other physical declines which require additional bouts of PT treatment. 11
As the number of older Americans requiring skilled, supervised exercise continues to grow, it is expected to surpass13 the number of physical therapists who have the skill to meet their healthcare needs.14 This combination creates a need for more efficient and effective systems that provide exercise to older adults managing health issues and prevent falls.
There have been numerous studies that have identified that older adults who participate in a group exercise classes regularly improve balance, strength, endurance and function. This study is different because it looks at individuals with known balance impairment who have completed a course of PT treatment and compares the difference between a PT led program and a HEP and community resources.
Thus, the objective of this study was to compare the effectiveness of a home exercise program (HEP) to a PT-supervised, group exercise program (GroupHab) for sustained improvement in fall prevention, confidence in balance, and quality of life following physical therapy care. This wellness approach is an alternative to the current medical model of care in that it emphasizes the PT’s role as the facilitator of PA in older adults with the goal of preventing falls and reducing the financial burden associated with traditional health care.
GroupHab Physical Therapy is a privately-owned physical therapy practice providing a unique model of PT-designed and supervised group exercise classes. The classes provide after-discharge options for maintaining gains made during physical therapy treatment as well as solutions for individuals wanting to exercise to stay strong and healthy under the guidance of a PT. A multi-component exercise program consisting of aerobic, strengthening, balance, and flexibility techniques is recommended to prevent falls among frail older adults.15-19 Thus, the PT designed classes include all four of these exercise components. Different classes target specific functional levels which are recommended by a PT based on a patient’s abilities at the time of discharge. Participation in these classes is tailored and individualized with the goal of maximizing each participant’s potential. The GroupHab option is encouraged for all individuals who have reached their PT discharge goals but may struggle to maintain their functional gains via a traditional HEP. These individuals are typically older adults who are managing multiple chronic conditions and find it difficult to exercise at home, or in a community-based setting, without the benefit of some skilled supervision.
The intervention investigated in this trial took place at the GroupHab Physical Therapy Clinic in Greenville, SC as part of the currently scheduled exercise classes that are designed and supervised by a PT. These group exercise classes fall under two broad categories including Wellness Classes and Specialty Classes. Wellness Classes include all four major exercise (i.e., aerobics, strengthening, balance, and flexibility) while Specialty Classes omit aerobic exercise and focus on the other aspects of wellness (i.e., YogaHab, CoreHab, JointHab). Classes are held Monday through Friday with multiple different classes offered throughout the day. Class sizes vary from 3 to 12 participants each. Class sessions last 60 minutes with use of tempo-appropriate music and typical exercise equipment (e.g., dumbbells, therabands, balance tools). Class instruction is provided by a PT or a physical therapist assistant (PTA) who has been trained and certified to provide the GroupHab Wellness classes. For this study, only those patients who were specifically recommended by the PT attended classes that were designed to meet their functional capabilities.
Selection of Participants
All patients were 65 to 95 years of age and had completed a standard course of physical therapy including balance exercise, gait training, strengthening, and fall risk education. All patients had an ICD 10 code for history of falls, repeated falls, and unsteady gait. Upon discharge, all patients were given the choice of attending a GroupHab exercise class or following a HEP, with or without the use of community exercise resources. Thus, the participants were not randomly assigned to their intervention groups. Nevertheless, the study sample included 29 GroupHab participants and 26 HEP participants, both of whom had a mean age of 76 years.
Individuals who did not wish to participate in the GroupHab classes were discharged with a HEP and recommendations for other community-based programs. The HEP included standing exercises, sit-to-stand strengthening, and static standing balance maneuvers to be performed near a supportive surface such as the kitchen counter or sturdy chair. Individuals were instructed to complete this program daily, striving for at least 3x/week. Supplemental community programs available in the area included: Matter of Balance, Silver Sneakers, free exercise at the local senior center, senior exercise classes led by group exercise instructors at the senior center, YMCA water exercise classes, Life Center hospital program (“Exercise is medicine”), and meeting with a nurse and/or personal trainer.
Individuals who chose to participate in the PT designed and supervised GroupHab program received a recommendation from their discharging PT for a specific exercise class based on their current functional level. Participants were encouraged to attend at least three wellness classes a week and other specialty classes as they desired. Actual attendance varied from one to five times a week. Participants were encouraged to continue the classes to maintain their level of health and wellness indefinitely; however, for the purpose of this study, participants had to attend classes for at least three months post-discharge. A GroupHab sponsorship was offered to individuals who felt that the cost of the classes ($100 per month) was a barrier to attending.
Study of the Intervention
To measure the effectiveness of each program, both groups were given a multi-item survey to fill out at time of discharge from PT and again three months later. The survey packet included data related to the number of post-discharge falls, activity levels, confidence in balance ability, and quality of life within that three-month time period. The three month post-discharge time frame was based on recommendations from a previous study which investigated adherence of older adults with a home exercise program.11
Falls History and Exercise Frequency
To determine an individual’s level of functioning and fall history, participants were asked if they had experienced a fall in the three months since discharge, if medical attention had been required because of a fall, how they felt they are doing physically since discharge, the frequency and type of exercise, and barriers to exercise if they had not been active. This survey was completed once at the end of the three-month exercise period.
Confidence in balance ability was measured using the Activities-specific Balance Confidence (ABC) Scale. This scale is a 16-item self-report measure of balance confidence in performing various activities without losing balance or experiencing a sense of unsteadiness. Items are rated on a scale from 0 – 100 with a score of zero representing no confidence and a score of 100 representing complete confidence in task completion. The ABC Scale has been shown to have good test-retest reliability and internal consistency among-dwelling older adults20 with no significant difference between men and women20 and no correlation between age and ABC scores20 Participants in the study completed the ABC scale twice; the first response was based on their balance confidence at the time of discharge and the second response was based on perceptions three months later. Participants were also asked whether they felt their balance was better or worse than it was at the time of discharge from PT.
Quality of Life
Quality of life report was measured using the 20-Item Short Form Health Survey (SF-20) which was developed in the study of patients with chronic health conditions. Item categories in this survey include physical functioning, role functioning, social functioning, mental health, and pain. The SF-20 has good valid and test-retest reliability among older adults living at home.21,22 Participants in the study completed the SF-20 one time at the end of the three-month exercise period. In addition, they were asked if they felt better or worse than they did at the time of discharge from PT.
Independent t-tests were used to compare the number of falls, exercise frequency, and exercise duration between exercise groups. A repeated measures, analysis of variance (RM-ANOVA) compared changes in ABC scores both within and between groups, and a multivariate analysis of variance (MANOVA) analyzed group differences in multiple quality of life ratings (from the SF-20). All data were analyzed at the 0.05 alpha level using SPSS 24 statistical software.
Conflict of Interest
GroupHab Physical Therapy offers group exercise certifications for clinicians to purchase if interested in providing the GroupHab Wellness class programing.
The results of the independent t-tests demonstrated a significantly greater reduction in subsequent falls among the GroupHab wellness group compared to the HEP group (t=2.811, p=0.009). One GroupHab participant experienced a single fall while eight HEP participants experienced a total of 23 falls (Fig. 1). The resulting odds ratio for subsequent falls was 2.152 among HEP participants and 0.189 among GroupHab participants. This indicates a two-fold increase in fall risk among HEP participants and a reduction of fall risk (approximately 80%) among GroupHab participants. Exercise adherence was also greater for those who participated in the GroupHab wellness program. They documented greater exercise frequency (t= -3.253, p=0.002) and more exercise minutes (t= -7.188, p<0.001) than those who participated in the HEP. When comparing changes in the participants’ balance confidence (Fig. 2), we found an average increase of 5% among GroupHab participants compared to a 6% decrease among HEP participants (F=16.877, p<0.001, power=0.981). Although our multivariate analysis of the SF-20 scores revealed no significant difference overall (F=0.768, p=0.73), the univariate analyses showed significantly greater improvements among GroupHab participants in four components of the SF-20 including “bending, lifting, stooping” (F=7.862, p=0.007, power=0.786), “walking one block” (F=4.7-6, p=0.035, power=0.567), “bodily pain” (F=6.099, p=0.017, power=0.679) and “feeling bad lately” (F=4.589, p=0.037, power=0.557).
Figure 1. Comparison of subsequent falls among participants in the wellness program (Group PT exercise) vs. home exercise program (HEP)
Figure 2. Comparison of changes in ABC scores (over 3 months) between groups
It is a well-researched fact that older adults who participate in group exercise classes regularly improve balance, strength, endurance and function.2 Older adults who are frail face barriers to exercising including fear of not being able to keep up, fear of falling, and lack of support from healthcare providers.17.
Regrettably, it is a well-known fact that older adults are exercising at a very low rate at home or in the community despite national initiatives.6,11,15 Physical therapy is effective in preventing falls, which are epidemic, especially among older adults who are frail. 3-5 Unfortunately, physical therapy support and intervention is short term. There is an urgent need to explore other ways to keep vulnerable patients exercising in an effective manner. The current model of physical therapy does not allow PT’s to continue to follow patients in a prevention and wellness model.
An alternative model of physical therapy, including the PT-designed and supervised exercise classes used in this study, appears to provide older adults with a greater opportunity to continue progressing after their discharge from rehab, as opposed to regressing. Past recommendations that have resulted from initiatives such as the Exercise and Physical Activity and Aging Conference (ExPAAC) have emphasized the need to tailor such exercise programs to each person’s functional level and use a variety of progressive exercise approaches to keep seniors actively engaged.23 These strategies were incorporated successfully into the GroupHab exercise approach and yielded better outcomes than a traditional HEP including fewer reported falls, greater exercise times and frequency, improved balance confidence, and improvements in some quality of life ratings. Some possible reasons why the older adults who participated in the GroupHab classes may have had better outcomes than those who chose the HEP program include:
1. A PT recommended the correct functional level of the class, and recommended modifications or adaptations based on each participant’s medical conditions and functional capabilities.14 This most likely made participants feel safer and confident when performing their exercise program.
2. The PT was available to detect any problems before they became serious concerns.
3. The classes were designed by a physical therapist, so exercises were based on sound physiological principles such as intensity of training, power, specificity of exercise, and neuroplasticity.
4. Previous research has demonstrated that exercise programs for older adults typically underdose the exercise program.15,16 This tendency may be due to fear or overstressing weak muscles, painful joints, or an inefficient cardiopulmonary system. PTs are better able to safely challenge older adults when they have first-hand knowledge of their medical history and functional capabilities. Individuals discharged with a standardized HEP often abandon the program due to boredom or the perception that it is not making a difference in their functional mobility.
5. The group setting and the social support that occurs in the group classes may possibly contribute to an increase in adherence to exercise as well as improvement in quality of life.8,17,24
Future studies could examine a delivery of PT care that includes a combination of individual PT treatment and group PT exercise. In addition, it would be interesting to compare outcome measures of community group classes with PT led, tailored exercise classes.
Studies could be conducted to understand why some older adults do not choose to attend group classes at community centers or PT outpatient settings. Potential obstacles such as cost, transportation, or depression may be underlying causes that are manageable if we are aware of them.
Summary and Conclusion:
Changing the delivery of physical therapy to include long-term solutions of PT-designed and supervised group exercises for individuals with balance impairment could possibly reduce the incidence of subsequent falls. A PT-designed and supervised exercise class may provide a missing link in the continuum of care, that will be more effective in keeping this population physically active and well as they continue to age.
Cost and transportation can limit participation in group classes.
We had to rely solely on subjective questionnaires and patient’s perception of their abilities.
The older adults choose either to participate in group or a HEP so the groups were not randomly-selected.
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