The Otago Exercise Program: Alternative Delivery Models

 

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.