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Image Source: https://escapefitness.com/us/blog/why-clubs-need-to-look-beyond-millennials-and-embrace-training-for-older-adults

Background:

My interest in falls prevention amongst older adults began during my clinical experience at Piedmont Health Senior Care. Falls prevention became an interest of mine particularly as fall risk appeared to be a prevalent issue amongst the older adult population I was serving and this was an issue which physical therapists were often expected to take the lead in addressing. Recognizing that evidence-based practice is critical to the delivery of quality care, I wanted to become more knowledgeable regarding the most effective treatments to employ when attempting to mitigate fall risk amongst the older adult population. This led to my interest and subsequent involvement in a quality improvement project which was centered around the improvement of falls prevention within the UNC healthcare system. As part of this initiative, we took into consideration the frequency at which the Otago Exercise Program (OEP), an evidence-based falls prevention program, was being utilized amongst physical therapists working within the UNC healthcare system.1Interviews conducted on physical therapists practicing at a UNC outpatient clinic suggested that there were a number of obstacles challenging their implementation of the original OEP. Additionally, a recent study suggests that execution of the original OEP is difficult for physical therapist practicing in the US for a number of reasons.2In light of the many difficulties encountered by physical therapists attempting to execute the original OEP in United States, I decided to explore alternative implementation strategies.2In particular, I decided to explore the efficacy of the OEP implemented in a group format due to the improved adherence rates as well as the financial and social advantages associated with this implementation strategy.3–5My capstone was completed with the intent to promote increased utilization of the OEP amongst physical therapists and physical therapy students by providing information on effective, alternative implementation strategies of this program. I also wanted to share takeaways from my personal experience implementing a group exercise class based on the OEP. Completion of this capstone project increased my knowledge regarding the protocol and efficacy of the original OEP as well as variable group formats of this program. Furthermore, I was able to gain first-hand experience preparing for and assisting with the implementation of a group exercise class utilizing components of the OEP. In order to communicate this information, I created a literature review and voicethread presentation to share with physical therapy students and clinicians.

 

Purpose:

Over a one-year period falls have been found to occur in more than a quarter of older adults within the United States, many of which resulted in an injury.6Furthermore, the mortality rate of older adults over a one year period following hospitalization in response to an injurious fall has been found to be as high as 50%.7Over the course of 2015, falls which did not lead to mortality resulted in a Medicare expenditure of roughly 31.3 billion dollars and the projected expansion in the number of older adults will likely lead this cost to continually increase without improvements in falls prevention strategies.6,8

Physical therapists have the opportunity to address fall risk amongst the older adult population through utilization of an evidence-based program called the Otago Exercise Program (OEP).9This program is considered to be highly successful as a 35% decrease in fall frequency has been found following implementation of the OEP amongst community-residing adults at or above the age of 65.10Unfortunately, utilization of the OEP, in its original format, amongst physical therapists practicing in the United States has proven difficult.2The OEP has been demonstrated to be effective when implemented in variable group formats, with and without the inclusion of alternative exercises.4,5,11–13Therefore, group implementation of the OEP may provide an additional implementation strategy ideally leading to increased program utilization.4,5,11–13

 

Statement of Need:

This project was developed following my participation in the continuation of a previously initiated quality improvement project centered around the improvement of falls prevention strategies within the UNC healthcare system. Through the conduction of interviews of physical therapists practicing in an outpatient physical therapy clinic, it was discerned that implementation of the original OEP was challenging for theses therapists due to a number of reasons. In effort to provide physical therapists and physical therapy students with information on alternative implementation strategies of the OEP in variable group formats along with their respective effectiveness, I sought to create a VoiceThread which would clearly convey this information. A need for this project was initially confirmed by my capstone advisor, Vicki Mercer, and later confirmed by my capstone committee members, Charron Andrews and Lesley Hlad.

 

Products:

Deliverables for this project include a systematic review and a VoiceThread presentation. Both products include a description of the original OEP as well as a description of the demonstrated efficacy of this program. Additionally, both products provide up-to-date information on variable group implementation strategies of the OEP along with descriptions of their respective efficacies. The VoiceThread presentation also provides a description of my experience with implementation of an exercise class utilizing components of the OEP including results found and any difficulties encountered. 

https://unc.voicethread.com/myvoice/thread/13872218/84651125/79122068

Literature Review – The Otago Exercise Program- Alternative Delivery Models*

 

Evaluation:

I communicated with my committee members multiples times throughout the semester via email. In addition to email communication, I met with Charron Andrews twice weekly for the first half of the semester while I assisted her with implementation of a group exercise class which incorporated components of the OEP. Drafts of my deliverables were disseminated to my committee members at midterm and feedback was incorporated into the creation of my deliverables. My deliverables were submitted to my committee for review along with evaluation forms and the feedback received was incorporated into the final products.

Additionally, I created an evaluation tool which I have utilized to attain feedback on my VoiceThread presentation by disseminating it to first, second, and third-year DPT students. This tool allows for the provision of feedback with regards to various components of my VoiceThread presentation including the title, learning objectives, narration, images, content, and audience engagement. Sub-components of each of the aforementioned categories are assessed on a one to five scale, with five representing the best score and one representing the poorest score. Additionally, I provided individuals with the opportunity to provide any specific or general comments they had regarding my presentation.

Voicethread Evaluation Form

 

Self-Reflection:

Through the completion of this capstone project I gained a comprehensive understanding of the protocol of the original OEP as well as research supporting the efficacy of this program. Furthermore, I gained a thorough understanding of group implementation strategies of the OEP, in addition to research considering the efficacy of these various protocols. I originally had intended on incorporating research considering the efficacy of the OEP implemented in an outpatient setting, however, research in this area was extremely limited. Through my involvement assisting with implementation of a group exercise program based on the OEP, I gained experience recruiting participants, securing the necessary equipment, and assisting with implementation of a group exercise class. I have also gained experience creating a presentation utilizing VoiceThread in effort to clearly and effectively convey my research findings and personal findings to my peers.

General feedback I received on my project included suggestions to provide more personal clinical examples throughout my presentation as well as additional slides emphasizing the main dissimilarities amongst the group implementation strategies explored. Additional feedback received included suggestions with regards to font size and images utilized. I plan on incorporating suggestions regarding fonts and images utilized in my presentation in the short term. I will also consider all of the suggestions which will require more significant changes to my presentation, and due to time constraints regarding final capstone deliverable submission, I will adjust my VoiceThread presentation in response to these suggestions at a later date. By taking suggestions for improvement into account, I hope to provide an effective educational tool for the future utilization of physical therapy students and clinicians.   

 

Acknowledgments:

I would like to publicly acknowledge and thank the individuals who played an integral role in the completion of my capstone project. Firstly, I would like to thank Vicki Mercer for serving as my capstone advisor. I am greatly appreciative of the time and effort Vicki put into overseeing my capstone project and providing me valuable feedback on my capstone deliverables. I would also like to thank Charron Andrews and Lesley Hlad for serving on my capstone committee. It was extremely helpful to receive feedback from physical therapists who closely work with the older adult population. I would also like to thank Charron Andrews for allowing me to assist her with recruitment and implementation of an exercise class based on the OEP.

 

Bibliography

  1. The Otago Exercise Program | Carolina Geriatric Education Center (CGEC). Available at: https://www.med.unc.edu/aging/cgec/exercise-program/. Accessed December 7, 2019.
  2. Shubert TE, Smith ML, Ory MG, et al. Translation of the otago exercise program for adoption and implementation in the United States. Front Public Health2014;2:152. doi:10.3389/fpubh.2014.00152.
  3. Martins AC, Santos C, Silva C, Baltazar D, Moreira J, Tavares N. Does modified Otago Exercise Program improves balance in older people? A systematic review. Prev. Med. Rep.2018;11:231-239. doi:10.1016/j.pmedr.2018.06.015.
  4. Alhambra-Borrás T, Durá-Ferrandis E, Ferrando-García M. Effectiveness and Estimation of Cost-Effectiveness of a Group-Based Multicomponent Physical Exercise Programme on Risk of Falling and Frailty in Community-Dwelling Older Adults. Int. J. Environ. Res. Public Health2019;16(12). doi:10.3390/ijerph16122086.
  5. Waters DL, Hale LA, Robertson L, Hale BA, Herbison P. Evaluation of a peer-led falls prevention program for older adults. Arch. Phys. Med. Rehabil.2011;92(10):1581-1586. doi:10.1016/j.apmr.2011.05.014.
  6. Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years – United States, 2014. MMWR Morb. Mortal. Wkly. Rep.2016;65(37):993-998. doi:10.15585/mmwr.mm6537a2.
  7. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing2006;35 Suppl 2:ii37-ii41. doi:10.1093/ageing/afl084.
  8. Burns ER, Stevens JA, Lee R. The direct costs of fatal and non-fatal falls among older adults – United States. J. Safety Res.2016;58:99-103. doi:10.1016/j.jsr.2016.05.001.
  9. Accident Compensation Corporation (ACC). OTAGO Exercise Programme To prevent falls in older adults .
  10. Robertson MC, Campbell AJ, Gardner MM, Devlin N. Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J. Am. Geriatr. Soc.2002;50(5):905-911. doi:10.1046/j.1532-5415.2002.50218.x.
  11. Liston MB, Alushi L, Bamiou D-E, Martin FC, Hopper A, Pavlou M. Feasibility and effect of supplementing a modified OTAGO intervention with multisensory balance exercises in older people who fall: a pilot randomized controlled trial. Clin. Rehabil.2014;28(8):784-793. doi:10.1177/0269215514521042.
  12. Kyrdalen IL, Moen K, Røysland AS, Helbostad JL. The Otago Exercise Program performed as group training versus home training in fall-prone older people: a randomized controlled Trial. Physiother Res Int2014;19(2):108-116. doi:10.1002/pri.1571.
  13. Skelton D, Dinan S, Campbell M, Rutherford O. Tailored group exercise (Falls Management Exercise — FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing2005;34(6):636-639. doi:10.1093/ageing/afi174.

10 Responses to “The Otago Exercise Program: Alternative Delivery Models”

  1. Katherine Lewis

    Hi Katherine,
    I unfortunately did not find any recommendations with regards to suggestions on guarding in any of the research I considered, although I do admit that this would be helpful information to have. It is possible that variability amongst individuals’ physical fitness levels in the studies made it difficult to describe appropriate guarding practices which would could be translated into other clinical scenarios. The program I assisted with has since concluded, but I agree that perhaps implementation over a longer period of time would yield clinically significant results!

    Reply
  2. Katherine Carter

    Katie,

    Your project was enlightening and very well done. My Captstone also involved the Otago Exercise Program, so I was especially interested to see what your research uncovered regarding alternative versions of this intervention. I would like to congratulate you on the quality of your Voicethread presentation and literature review. You were able to convey a wealth of dense information on this topic in a clear and digestible fashion. I appreciated how you also incorporated your clinical experience with the OEP group class and the recommendations that you put forth to help improve attendance and participation.

    You noted that for the program that you helped administer there were 3-4 individuals that helped implement the program to ensure the safety of the participants. I wondered if you came across any information in your research about how those studies addressed the need for guarding and making sure that the participants were challenged by the activities? I was also curious if the program you participated in is continuing to collect data. I noted in the comments that you and Jonathan had discussed how a longer program may have produced stronger results, and I admit that I had the same thought.

    Additionally, I thought that the information you presented on supplemental interventions that can be added to the Otago program was also very helpful. As you noted, some individuals may not be significantly challenged by this program and these are helpful ideas of ways to make it more valuable to them. Also, I learned from my project that when participants do not feel sufficiently challenged this can negatively impact participation and adherence.

    Great job! Thank you for your hard work.

    Reply
  3. Katherine Lewis

    Hi Leslie,
    Thank you for all of your kind words, and I am so glad you found my VoiceThread presentation and literature review to be helpful! As a you are also interested in serving the older adult population, I hope that my presentation provided you with an understanding that the Otago Exercise Program is effective when implemented in a variety of ways and therefore I hope you are able to find one that best suits your future clinical practice setting!

    Reply
  4. Leslie

    Katie, really great work on your Capstone project! Assessing falls risk and preventing falls is such an important part of physical therapy for this vulnerable population. My clinical interests include working with geriatric patients and I know the information you provided will be useful and relevant to clinical practice. I have limited experience utilizing the Otago Exercise Program in my clinical rotations, partly due to the challenges you mentioned, but I have incorporated some of the exercises into a HEP with success.
    I appreciated how you incorporated knowledge checks and personal reflection into your VoiceThread. This was a great way to increase engagement in the presentation and encourage personal application of the material. You were also able to present a lot of evidence-based information in an organized and clear manner, which I appreciated. Your VoiceThread was not only informative, but engaging, organized and engaging.
    Your literature review was thorough and well-done as well. The evidence supporting the Otago Exercise Program is clear and you did a great job identifying the challenges that exist to implementing this program in the clinical setting. I imagine technology will only become a larger part of our practice as physical therapists, and the alternative ideas to include augmented reality and video-assisted intervention are innovative and promising. I also appreciated the emphasis on social interaction and group-based exercise classes because social and emotional health is just as important as physical health. After reading through your Capstone materials, I am better educated and informed regarding the Otago Exercise Program and know I will incorporate these exercises into my clinical practice. Thank you for a well-done and informative project!

    Reply
  5. Katherine Lewis

    Hi Jonathan,
    I am hopeful that our professors will continue to offer this VT to students in the program as a supplemental resource. However, as you said, I have also attempted to disseminate this information to individuals with an expressed interest in working with the older adult population in the current three PT classes. As I also aspire to work in a setting which primarily serves the older adult population, I plan on sharing this VT with my future co-workers as well!

    I also think you bring up a great point regarding the time-frame utilized for the exercise class I assisted with. I think it is highly possible that increased time was needed in order to attain clinically significant improvements on measured outcomes!

    Reply
  6. Katherine Lewis

    Hi Debbie,
    I am so glad you found my presentation to be helpful! It is also great to hear that you have been successful in utilizing the OEP amongst individuals with developmental disabilities. The efficacy of the OEP utilized amongst different patient populations could be an interesting area for me to explore in the future as well!

    Reply
  7. Jonathan Earles

    Katie,

    I was particularly interested in reading through your project, as, like mine, it was an Otago project – and you did an incredible job! In particular, I appreciated how clearly your literature review informed your other main product, the voicethread (VT). The VT was clearly evidence-based and offered a reasonably succinct overview of the OEP, alternative implementation in the literature, and your experience with alternative implementation. It appeared to be of a comparable length to a lot of the VTs we’ve seen in use in our courses (good for students to actually sit through and therefore learn), and I thought the self-reflection and knowledge-check components were useful for breaking up the material and producing greater audience engagement.
    One question about the VT: you disseminated this to the three current PT classes, is there a long-term plan in place for this presentation to be used?

    And one question about your experience with the group OEP: the Kyrdalen et al 2014 article you cite demonstrated improvements at 3 months of follow-up and I believe 3 additional months post-follow-up for the OEP group, and your experience showed limited improvement at 7 weeks. You mention motivation, distraction, and insufficient transportation as challenges to this OEP model, do you think the results may have been different if the class went for a longer period of time?

    Finally, I wanted to highlight your suggestions based in the conclusions of your VT: I think charging for completion of the class could both increase attendance and help offset some of the additional costs of the program, like having people on hand to assist, and the proposed transportation assistance. Good thought.

    Reply
  8. Debbie Thorpe

    Katie
    What a great project on alternative strategies for implementing OTAGO! I use OTAGO with my older adults with developmental disabilities and learned some great strategies from your presentation! Thank you for providing this valuable resource.
    Best Wishes….

    Reply
  9. Katherine Lewis

    Hi Vicki,
    Thank you so much! I really appreciate you letting me take part in the quality improvement project last semester. Additionally, all of the feedback you provided me with on my capstone project was very helpful. I am hopeful that clinicians will find my VoiceThread to be a useful resource!

    Reply
  10. Vicki Mercer

    Katie – Excellent job on this project! I think that all of the work you have done, from updating notebooks and Epic templates to creating the VoiceThread presentation, will be useful to UNC clinicians in the future. Best wishes –

    Reply

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