Weight-bearing

Exercise for Better

Balance (WEBB)

A challenging, safe, evidence-based

physiotherapy program for older
people.
DRAFT 19, 1 September 2008
Developed by:
Dr Catherine Sherrington, The George Institute for International Health and Prince of
Wales Medical Research Institute
Dr Colleen Canning, University of Sydney
Dr Catherine Dean, University of Sydney
Ms Natalie Allen, University of Sydney
Ms Karyn Blackman, University of Newcastle and Tamworth Base Hospital.

With assistance from colleagues for the following aspects:

Medical screening
Dr Connie Vogler, University of Sydney and Royal North Shore Hospital, Dr Jacqueline
Close, Prince of Wales Medical Research Institute and Prince of Wales Hospital.

Gait analysis
Mr Karl Schurr, Bankstown-Lidcombe Hospital.

Physiology and biomechanics to guide exercise prescription for falls prevention

A/Prof Stephen Lord, Prince of Wales Medical Research Institute, Dr Hylton Menz, La
Trobe University.

Exercise for falls prevention systematic review

Ms Julie Whitney, King’s College Hospital, London, A/Prof Stephen Lord, Prince of
Wales Medical Research Institute, Dr Jacqueline Close, Prince of Wales Medical Research
Institute and Prince of Wales Hospital, Dr Hylton Menz, La Trobe University, Prof Bob
Cumming, University of Sydney School of Public Health.

Choice of exercises, prescription principles and practical aspects of exercise delivery

in research and clinical settings
University of Sydney School of Physiotherapy: Ms Joanne Munn, Dr Anne Mosley, Ms
Angela Stark, Ms Simone Dorsch (also Bankstown-Lidcombe Hospital)
Bankstown-Lidcombe Hospital: Ms Julie Nugent, Ms Pat Pamphlett
War Memorial Hospital: Ms Lynette Olivetti, Ms Jill Hall
Learn Movement Physiotherapy: Ms Eileen O’Neil
Prince of Wales Medical Research Institute: Ms Susan Murray, Ms Elizabeth Barraclough,
Ms Catherine Kirkham.

Choice of exercises and development of descriptions and diagrams for Physiotherapy

Exercises.com
Dr Lisa Harvey (Rehabilitation Studies Unit)
Ms Jo Glinsky (Rehabilitation Studies Unit)
Mr Tim Fairbain (Westmead Hospital)
Ms Anita Mudge (Sydney Children’s Hospital)
Ms Taryn Jones (Liverpool Hospital)
A/Prof Louise Ada (University of Sydney School of Physiotherapy).

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DRAFT 19, 1 September 2008
Contents

Overview 4
Background 5
Overview of RCTs on exercise for falls prevention 6
How to use this program 7
Pre-exercise screening and exercise safety 8
General principles of exercise prescription for improving
co-ordination, strength and endurance 10
Strategies to enhance adherence 13
Exercises 14
Warm-up
1. High stepping on the spot
Co-ordination exercises
2. Standing with a decreased base
3. Graded reaching in standing
4. Stepping in different directions
5. Walking practice
Strength/co-ordination exercises
6. Sit-to-stand
7. Heel raises
8. Lateral step-up
9. Forward step-up
10. Half- squats sliding down a wall
Endurance exercise
11. Bike, treadmill walk, overground walk or sit-to-stand
Other interventions if appropriate
Getting off the floor training
Additional strength/co-ordination exercises and stretches

Appendix 1. Safety advice to participants 29

Appendix 2. Doctor’s approval for commencement of exercise program 30
Appendix 3. Safe exercise prescription guidelines for physiotherapists 32
Appendix 4. Commonly observed gait problems 33
Appendix 5. Borg Rating of Perceived Exertion Scale 34
Appendix 6. List of equipment required for the program 36
Appendix 7. Tips for running the program in a group setting 37
Appendix 8. Managing freezing in people with Parkinson’s Disease 38
References 40

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DRAFT 19, 1 September 2008
Overview

This program has been developed from

o a recent systematic review (which established that exercise that challenges
balance is the key feature of successful exercise programs for the
prevention of falls in older people) [1]
o our collective clinical experience,
o previous research by ourselves and others [1-21].

This program aims to help physiotherapists to individually prescribe progressive

exercise which is challenging but safe. It is designed for use in either an individual or
small group context at home or at a centre. A combination of different settings can be
used such as a weekly group class with additional home exercise. If used in a group
setting we recommend the use of a circuit class design to facilitate individual
prescription.

The program is designed to be undertaken on a long-term basis and as such includes

suggestions for progression and variety.

The program also includes a range of practical resources e.g. contraindications to

exercise, sample letter to GP, guidelines for safe exercise and tips for group exercise.

An accompanying client manual has been developed to assist in the use of this
program and includes pictures of the exercises from the freely-available
www.physiotherapyexercises.com website.

This program is not intended to replace individualised assessment and intervention for
specific movement problems which some people will require from time to time.
Section 13 provides some examples of a range of intervention strategies.

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Background

• Impaired balance and mobility is a problem for many older people. Up to 50% of
people aged 65 years and older have some difficulty with mobility tasks [22] and
over one quarter of non-disabled older people will develop mobility disability
within three years [23].
• Impaired balance and mobility contributes to falls in the general older population
[24] and for people with neurological conditions such as stroke, Parkinson’s
disease and multiple sclerosis [25]. Impaired performance in tests of lower
extremity physical functioning also increases risk of nursing home admission and
mortality [26].
• “Balance” can be viewed as the ability to activate muscles with the amplitude and
timing necessary to control movements of the body to prevent a fall during a range
of tasks e.g. standing, reaching, stepping, walking [27]. Thus, avoiding a fall can
be viewed as reflective of lower limb muscle dexterity.
• Well-prescribed exercise programs can enhance mobility [28-31] and prevent falls
[32] among older people but programs which are not well designed and
implemented may not reduce falls. Key features of successful programs are
summarised in the next section.
• Exercise needs to be physically challenging, targeted to an individual’s skill level
and progressed as they improve, yet be conducted safely so as to avoid injuries,
falls and cardiac events.
• Home programs have been successful in preventing falls in older people [33].
There are likely to be additional benefits of group exercise in terms of socialisation
and motivation as well as efficient use of limited health resources. A circuit-style
program means that participants can complete various exercise stations
sequentially at individually prescribed intensity with supervision as required [34-
37].

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DRAFT 19, 1 September 2008
Overview of randomised controlled trials on exercise for falls prevention.

Dr Sherrington and colleagues recently identified 44 randomised controlled trials (RCTs)

investigating exercise programs for falls prevention in older people [1]. The programs
which were found to prevent falls in these studies included home-based balance and
strength training with the Otago Programmme[38, 39] group-based Tai Chi (eg [40-42]
and some other forms of group exercise (eg [43-48].

We used meta-analysis to assess whether various aspects of exercise programs were

associated with bigger reductions in falls. We found that greater reductions in falls
occurred with the inclusion of exercise which presented a high-level of challenge to
balance abilities.

This involved:

movement of the centre of mass,

narrowing of the base of support and

minimising upper limb support.

Programs which included more time exercising also had bigger effects on falls. While
walking has health benefits for older people, programs which included walking were
associated with smaller effects on falls. Therefore we suggest that walking only be
included in exercise programs aiming to prevent falls if it is clear that the individual is safe
to walk outdoors and that walking should not be conducted instead of balance training. We
found exercise programs reducedfalls rates by 40% (rate ratio = 0.58, 95%CI 0.48 to 0.69,
68% of between-study variability explained) if they included a combination of a higher
total dose of exercise (more than 50 hours over the trial period) and challenging balance
exercises and did not include a walking program.

To develop the WEBB program we have drawn on strategies used in successful programs
from individual trials as well as the meta-analysis findings.

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How to use this program

This program is designed to facilitate individual prescription of exercises based on the

ability of participants to complete exercises within the program. It includes a warm up
exercise, four coordination exercises and five strength/co-ordination exercises. Each
exercise has several levels of difficulty.

To use the program:

1. Conduct screening for safety to exercise, in conjunction with the participant’s

medical practitioner, based on the guidelines in this document.

2. Follow the safety protocol outlined in Appendices 1 and 3.

3. Select a series of exercises for an individual to complete. We suggest initially

completing:

the warm-up exercise,

three of the co-ordination exercises and

three of the strength/co-ordination exercises

Sit-to-stand or squats

Lateral step-up (or forward step-up if lateral not being done well)

Heel raises

4. Each exercise has several different levels of difficulty. Establish the appropriate
level for each exercise for each individual by assessing their ability to carry out the
exercises (aim for challenging but safe)

5. Establish a home program using the Participant Instructions and recording sheets
provided (most images and text from www.physiotherapyexercises.com).

6. The program can be upgraded by increasing level of difficulty, increasing

resistance, increasing the number of repetitions and/or by adding or changing
exercises.

7. Use the list of aspects common to successful exercise programs given on above to
guide the general nature of the program.

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Pre-exercise screening and exercise safety

Exercise can be undertaken by those with chronic disease if screening and prescription
are carefully done.

The American College of Sports Medicine [49] states that “sedentariness appears a far
more dangerous condition than physical activity in the very old” and that “the mere
presence of cardiovascular disease, diabetes, stroke, osteoporosis, depression, dementia,
chronic pulmonary disease, chronic renal failure, peripheral vascular disease, or arthritis
(which may all be present within a single individual) is not by itself a contraindication to
exercise”.

Similarly, a recent statement on physical activity for people with cardiovascular disease by
the National Heart Foundation of Australia [50, 51] recommends that: people with
established clinically stable cardiovascular disease should aim, over time, to achieve 30
minutes or more of moderate intensity physical activity on most, if not all, days of the
week; less intense and even shorter bouts of activity with more rest periods may suffice for
those with advanced cardiovascular disease; and regular low-to-moderate level resistance
activity, initially under the supervision of an exercise professional, is encouraged.

Some conditions require investigation prior to commencing an exercise program

The American College of Sports Medicine statement [49] suggests that when a person has
particular conditions, investigation by a medical practitioner should be undertaken prior to
commencement of a new exercise program i.e.
– acute illnesses, particularly febrile illnesses
– unstable chest pain
– uncontrolled diabetes
– hypertension
– asthma
– congestive heart failure
– musculoskeletal pain
– weight loss
– falling episodes
Temporary avoidance of certain kinds of exercise may be required during treatment of
hernias, cataracts, retinal bleeding, or joint injuries [49].

Exercise is contra-indicated in some individuals.

The American College of Sports Medicine statement [49] also stated that the following
conditions require permanent exclusion from vigorous exercise: inoperable enlarging
aortic aneurysm, malignant ventricular arrhythmia related to exertion, severe aortic
stenosis, end stage congestive heart failure, other rapidly terminal illness, severe
behavioral agitation in response to exercise.

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DRAFT 19, 1 September 2008
Screening prior to commencing the program:

We suggest that all individuals be required to present a letter from their medical
practitioner indicating that they are suitable to participate in a program of moderate
intensity aerobic and resistance training. A suggested format for such a letter is given in
Appendix 2.

Individuals with the following conditions and/or symptoms should not undertake the
program:
- Unstable angina
- Uncontrolled cardiac failure
- Severe aortic stenosis
- Uncontrolled hypertension or grade 3 (severe) hypertension (e.g., blood pressure ≥
180 mmHg [systolic] or ≥ 110 mmHg [diastolic])
- Symptomatic hypotension < 90/60 mmHg
- Acute infection or fever, or feeling unwell (including, but not limited to, acute
myocarditis or pericarditis)
- Resting tachycardia or arrhythmias
- Diabetes with poor blood glucose control (e.g., blood glucose level < 6 mmol/L or
> 15 mmol/L

Exercise safety

Advice to participants on exercise safety is given in Appendix 1 and is included in the

information provided for participants.

Guidelines for physiotherapists to enhance safety in exercise prescription are given in

Appendix 3.

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General principles of exercise prescription for improving co-ordination,
strength and endurance.
Co-ordination exercise
Background
• The ability to maintain “balance” during standing and other tasks requires the
individual to be aware of where s/he is in space and be able to pre-empt and
adjust body position for any potential challenges (i.e. from breathing, moving
one’s own body or reaction to an external push or unstable surface).
• Muscle co-ordination (ie dexterity) is thus required to prevent falls by making
the appropriate adjustments at the appropriate times during performance of a
range of tasks (e.g. standing, reaching, stepping, walking, stair climbing).
• This program aims to train this muscle co-ordination by practicing activities
relevant to a range of functional tasks. Research suggests that to improve
functional task performance, a large volume of practice relevant to these tasks
is required [52].

General prescription principles

• Aim for a large number of repetitions (initially 30, progressing to 100).
• Simplify exercise conditions initially (if required) by minimising distractions
and providing hand support.
• Provide instructions and feedback for exercise to be successfully completed
(eg, keep hips forward when reaching forwards).
• Structure environment to enhance performance and provide feedback, (e.g., use
of markers on floor to constrain base of support, or to indicate direction and
magnitude of steps).
• Progress by increasing the physical challenge (e.g., remove hand support,
increase speed, practice on different surfaces, add concurrent manipulative
and/or cognitive tasks to promote automaticity).
• Suggestions for systematically progressing movements of centre of mass, base
of support and amount of arm support are given below.

Grading components from easiest to hardest

Centre of mass Base of support Arm support

Aim to increase number of Aim to reduce size of base Aim to reduce support
body segments involved provided by feet
Reaching within arm’s Feet more than shoulder Grasping support
length- unilateral width apart, externally bilaterally
rotated
Reaching within arm’s Feet together shoulder Grasping support
length- bilateral width apart unilaterally
Reaching beyond arm’s Feet together Resting hand on support
length- unilateral bilaterally
Reaching beyond arm’s Step stance ( 1 foot in Resting hand on support
length- bilateral front) unilaterally

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Reaching above shoulder Standing on one leg Resting two fingers on
height-unilateral support bilaterally
Reaching above shoulder Pivoting on 1 leg Resting two fingers on
height-bilateral support unilaterally
Reach beyond arm’s Resting one finger on
length above shoulder support bilaterally
height unilaterally by
rising onto toes
Reach beyond arm’s Resting one finger on
length above shoulder support unilaterally
height bilaterally by rising
onto toes
Reaching down to floor- Hovering hand/fingers
unilateral above support
Reaching down to floor-
bilateral

Strength exercise
Background
• It is clear that muscle strength can be enhanced by resistance training but carry-
over to improved functional abilities is less consistent [53].
• Traditionally, strength training has been conducted in seated positions yet in
recent years, several authors have been able to add resistance to more
functional weight-bearing tasks by using weighted waist belts [54, 55],
weighted vests [56-58], hand weights [59] or elastic tubing [60]. For this
program we suggest the use of weighted belts or vests.
• High intensity progressive resistance training appears to be the best way to
enhance strength in older people [53] yet may have a high injury rate in a home
setting [61]. For this program we suggest the use of high intensity training in a
supervised setting in the absence of contra-indications outlined above and
moderate intensity training in the home setting.
• Intensity of strength training has traditionally been prescribed by 60-80% of
one repetition maximum (i.e. the maximum weight that can only be lifted once
through range with good form) or 10-15RM (the weight that can be lifted 10-15
times but no more)[49].
• For this program we suggest the use of the 10-15 RM method ie the person
should aim to complete each exercise with sufficient weight that no more than
10-15 repetitions can be completed, in good form. By following the guidelines
below, similar intensities should be achieved. In recent years, the Borg Scale
for Rating Perceived Exertion (15-category scale where 6 = no exertion at all
and 20 = maximal exertion) has been used to assist in prescription of resistance
training (see Appendix 5 for scale) [62, 63]. For this program we suggest the
use of the Borg Scale to supplement the 10-15 RM method; the participant
should aim to perform strengthening exercises at a perceived exertion rating of
15 on the Borg Scale.

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General prescription principles

Initial session
• Apply vest or belt with no weight or up to 2% of body weight added before
commencing strength exercises.
• Do 2 sets of 10 reps of three exercises in the following order: (i) sit-to-stand or
squats, (ii) Lateral step-up (or forward step-up if lateral not being done well)
(iii) heel raises (L and R)

Subsequent sessions
• Gradually increase the amount of resistance so that the person is working at a
level of 10-15 RM (also aim to achieve a perceived exertion rating of 15 on the
Borg RPE scale).
• Every 2-4 weeks, reassess and, if indicated, progress intensity of exercise to
maintain intensity at 10-15 RM.
• To focus on power production, participants should perform the concentric
component (rising) as quickly as possible, while maintaining good form,
followed by a one second pause and lowering of the body over two seconds
[57].
• If possible, the same weight should be used for all exercises. If there are
marked differences between exercises or sides, weights should only be changed
once within a session.
• Intensity can also be adjusted by changing the height of the block or chair or by
changing performance from bilateral to unilateral for some exercises (e.g. heel
raises).
• Gradually increase the number of exercises as tolerated.

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Endurance exercise

Background
• Several of the successful falls prevention exercise programs had an endurance
component. We suggest that increased endurance may assist in falls prevention by
increasing the time the person can safely undertake mobility tasks.
• Endurance training may also contribute to a better sense of well-being and play a
role in the prevention and management of heart disease.

General prescription principles

• The addition of endurance training to the program should only be undertaken if the
person is deemed safe to undertake this, and if an appropriate mode is available
and acceptable to the person.
• Aim to achieve, over time, 30 mins of moderate intensity exercise on 2-3 days
when the participant is not doing a strength/co-ordination exercise session.
• Moderate intensity physical activity elicits a moderate, noticeable increase in depth
and rate of breathing, while still allowing comfortable talking.
• Initially, the amount of activity can be achieved in shorter bouts (e.g., three 10 min
sessions) and at lower intensity.

Strategies to enhance adherence (from Gill et al)

• Explanation of relationship between impairments (eg poor balance) and on

functional ability
• Agreement from participant to address these via exercise
• Explanation of why exercises are expected to enhance function
• Discuss participant preferences of exercise eg individual versus group
• Set goals for frequency of exercise
• Provide instruction and logbook for recording exercise and effects of exercise
• Identify and address barriers to participation
• Consider use of behaviour modification principles such as contracts, rewards
• Monitor adherence to recommended exercise schedule and re-negotiate as required

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Exercises

Warm-up

1. High stepping on the spot

Aims: warm-up, enhance co-ordination, endurance

Suggestions for progression and variety:

Making it harder:
• Step higher
• Step for longer

Making it easier:
• place a table beside the person for hand support

To enhance co-ordination and endurance

• Minimise hand support
• Aim to increase time without using hand support

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Co-ordination exercises

2. Standing with a decreased base

Aims: enhance co-ordination

Suggestions for progression and variety:

Making it harder:
• Feet together and level
• Semi-tandem stance
• Tandem stance
• Stand on one leg
• Maintain position for longer
• Close eyes
• Stand on different surfaces eg foam rubber mat

Making it easier:
• place a table beside the person for hand support

To enhance co-ordination
• Minimise hand support
• Aim to increase time without hand support

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3. Graded reaching in standing
Aims: enhance co-ordination

Suggestions for progression and variety:

Making it harder:
• Foot placement- narrower, step standing
• Reaching further
• Reaching in different directions
• Reaching down to a stool or the floor
• Reaching for heavier objects
• Reaching for a full cup of water
• Standing on a softer surface eg foam rubber mat
• Stepping while reaching

Making it easier:
• place a table beside the person for hand support
• give feedback to enable the task to be successfully completed (eg, keep your
hips forward)
• structure the environment to enhance performance eg markers on floor to show
foot position, an object to move hips towards

Tip. If you have a sway-meter, people may enjoy tracing different size “race track”
paths with this.

To enhance co-ordination
• Minimise hand support
• Aim for as long as possible with out hand support

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4. Stepping in different directions
Aims: enhance co-ordination

Suggestions for progression and variety:

Making it harder:
• Narrow foot position
• Longer steps
• Faster steps
• Step over objects
• Choice component eg step forward with left foot
• Incorporate pivoting on the non-stepping foot
• Use different colours, numbers of letters or a clock face or coins as targets for
variety

Making it easier:
• place a table beside the person for hand support

To enhance co-ordination
• Minimise hand support
• Aim for as long as possible without hand support

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5. Walking practice
Aims: enhance co-ordination and endurance

Suggestions for progression and variety:

Making it harder:
• Decrease base of support i.e. progress to tandem walk
• Increased step size
• Increase speed
• Change direction
• Walk on different surfaces
• Walk sideways, backwards
• Obstacles to step over and walk around

Making it easier:
• Use a bar, wall or walking aid for hand support

To enhance co-ordination and endurance

• Minimise hand support
• Aim for as long as possible with out hand support

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Strength and co-ordination exercises

6. Sit-to-stand
Aims: enhance co-ordination, strength and endurance

Suggestions for progression and variety:

Making it harder:
• lowering the height
• don’t use hands to push off, cross arms across chest
• changing the nature of the surface (eg softer chair)
• ask the person to stand up with most weight on one leg- the other leg can be
placed in front or on a stool to ensure this
• adding weight (either vest or belt)

Making it easier:
• place a table in front of or beside the person for hand support
• give feedback to enable the task to be successfully completed (eg feet back
behind your knees, move your shoulders forward)
• structure the environment to assist performance eg markers on floor to show
foot position

Tip. Height can be adjusted by using an electric plinth, using different chairs or stools
and by placing large stable block/s under the feet.

To enhance co-ordination and endurance

• Aim for as many repetitions as possible, the height should be such that it is
easy for the subject to complete multiple repetitions
• Minimise hand support
• Increase speed eg count repetitions done in one minute

To enhance strength
• Aim for a chair height and amount of added weight for which the person can
just do 2 sets of 10-15 repetitions (ie 10-15 RM).

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7. Heel raises
Aims: enhance co-ordination and muscle strength and endurance

Suggestions for progression and variety:

Making it harder:
• decrease hand support
• hold the raise for longer
• one leg at a time
• adding weight (either vest or belt)
• use a wedge to increase the range of motion

Making it easier:
• place a table on one or both sides of the person for hand support or use their
walking aid

To enhance co-ordination and endurance

• Minimise hand support
• Do as many repetitions as possible

To enhance muscle strength

• Aim for an amount of added weight for which the person can just do 2 sets of
10-15 repetitions (ie 10-15 RM).

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8. Lateral step-up
Aims: enhance co-ordination and strength

Suggestions for progression and variety:

Making it harder:
• increasing block height
• adding weight (either vest or belt)

Making it easier:
• place a table on one or both sides of the person for hand support or use their
walking aid

Tip. Make sure the person doesn’t push off by plantar flexing ankle of foot on floor
instead of extending leg on block

To enhance co-ordination
• Aim for as many repetitions as possible, the height should be such that it is
easy for the subject to complete multiple repetitions
• Minimise hand support

To enhance strength
• Aim for a block height and amount of added weight for which the person can
just do 2 sets of 10-15 repetitions (ie 10-15 RM).

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9. Forward step-up
Aims: enhance co-ordination and strength

Suggestions for progression and variety:

Making it harder:
• increasing step height
• adding weight (either vest or belt)
• decrease hand support
• step up and over block

Making it easier:
• place a table on one or both sides of the person for hand support or use their
walking aid

Tip. Make sure the person lowers the leg in a controlled manner when stepping over
the block

To enhance co-ordination
• Aim for as many repetitions as possible, the height should be such that it is
easy for the subject to complete multiple repetitions
• Minimise hand support

To enhance strength
• Aim for a block height and amount of added weight for which the person can
just do 2 sets of 10-15 repetitions (ie 10-15 RM).

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10. Half- squats sliding down a wall
Aims: enhance co-ordination and muscle endurance

Suggestions for progression and variety:

Making it harder:
• decrease hand support
• hold the squat for longer
• move a short distance away from the wall
• adding weight (either vest or belt)
• one leg at a time

Making it easier:
• place a table on one or both sides of the person for hand support or use their
walking aid

To enhance co-ordination
• Minimise hand support

To enhance muscle endurance

• Aim to hold the position for as long as possible

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Endurance exercise

11. Bike, treadmill walk, overground walk or sit-to-stand

• Chose an activity which the person can perform safely according to the
prescription principles outlined earlier.
• Examples of activities include: exercise bike (a recumbent bike may be
safer), treadmill walk (ensure available treadmill can go slowly enough),
overground walk (up and down an indoor area or outdoors if safe), sit-to-
stand (from a height that is easy for the person).

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Other exercises

12.Getting off the floor training

Aim. Enhance ability to get off the floor and enhance confidence
Procedure: Follow backward chaining method described in Adams and Tyson [64].
- Begin by practicing Move 1 and 2, then return to starting position
- Systematically increase the number of moves practiced before returning to the
starting position, until the person can practice the whole task of standing up from
supine lying on the floor.

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Figure reproduced from Adams and Tyson [64].

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DRAFT 19, 1 September 2008
13.. Additional interventions for some individuals
Appendix 4 outlines commonly observed gait problems and possible causes and
intervention strategies for these. This may assist in identification of additional areas that
require intervention for an individual. Examples of other interventions are shown below.
For further information on rehabilitation for people with movement problems please see
recent text books [52, 65].

Additional strength training may be needed for individuals with specific strength
impairments. Additional co-ordination training may be needed for individuals with
difficulty coordinating muscles. Some exercises which can be undertaken are illustrated
below.

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DRAFT 19, 1 September 2008
Prolonged calf muscle stretches may be indicated if a person is unable to stand on a 10
degree wedge comfortably. (i.e. aim for 10 mins on the wedge and build up to 30 mins).

Additional task training may also be required if an individual has a problem with a
particular task e.g. getting from supine to sitting, sitting balance.

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DRAFT 19, 1 September 2008
Appendix 1. Safety advice for exercise participants

General advice

- Wear walking shoes or joggers. Do not wear open shoes of any kind, such as
thongs and sandals, high-heeled shoes, slippers or ill-fitting shoes
- Clothing should be comfortable and cool. Do not wear flowing clothing, such as
ties, scarves, flowing trousers or sleeves
- Please ask the other people in your household not to distract you when you are
concentrating on your exercises
- Make sure you replenish your fluids by having a drink of water after your exercise
session

Warnings

Do not perform your exercise session if:

- You are feeling unwell, due to a temporary illness such as a cold or flu
- You have not taken your regular medications as scheduled

Indications to terminate an exercise session and seek medical advice:

These indications to terminate exercise and seek medical advice apply to all participants
(regardless of whether you have recognised cardiovascular disease or not)
- Squeezing, discomfort or typical pain in the centre of the chest or behind the
breastbone ± spreading to the shoulders, neck, jaw and/or arms; or symptoms
reminiscent of previous myocardial ischaemia
- Dizziness, light headedness or feeling faint
- Difficulty breathing
- Nausea
- Uncharacteristic excessive sweating
- Palpitations associated with feeling unwell
- Undue fatigue
- Leg ache that curtails function
- Physical inability to continue
- For people with diabetes: shakiness, tingling lips, hunger, weakness, palpitations

Indications to stop a particular exercise and rest for a couple of minutes before
proceeding:

- Severe local muscle fatigue (mild fatigue is expected).

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DRAFT 19, 1 September 2008
Appendix 2. Doctor’s approval for commencement of exercise program

MEDICAL CLEARANCE FOR EXERCISE

Date: ___________
Dear Doctor

Your patient ____________________ has expressed an interest in commencing an

exercise program to be established and monitored by a physiotherapist in a home or group
setting.

This program aims to enhance the balance and strength of older people and to increase
their current level of physical activity. Participants are encouraged to work at a moderate
intensity depending on their individual capabilities. Rest intervals will be incorporated into
the program at appropriate intervals, and as necessary for each individual.

We have adopted the American College of Sports Medicine statement which states that the
following conditions require permanent exclusion from vigorous exercise: inoperable
enlarging aortic aneurysm, malignant ventricular arrhythmia related to exertion, severe
aortic stenosis, end stage congestive heart failure, other rapidly terminal illness, severe
behavioral agitation in response to exercise.

Specifically we have been advised that individuals with the following conditions and/or
symptoms should not undertake the program:
- Unstable angina
- Uncontrolled cardiac failure
- Severe aortic stenosis
- Uncontrolled hypertension or grade 3 (severe) hypertension (e.g., blood pressure ≥
180 mmHg [systolic] or ≥ 110 mmHg [diastolic])
- Symptomatic hypotension < 90/60 mmHg
- Acute infection or fever, or feeling unwell (including, but not limited to, acute
myocarditis or pericarditis)
- Resting tachycardia or arrhythmias
- Diabetes with poor blood glucose control (e.g., blood glucose level < 6 mmol/L or
> 15 mmol/L

Please sign the attached sheet if the participant’s medical condition is adequate to
commence this program. If you have any questions, please do not hesitate to contact

Thank you for your assistance.

Yours sincerely,

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DRAFT 19, 1 September 2008
MEDICAL CLEARANCE FOR EXERCISE

Dear __________________________

The medical condition of __________________________ is adequate to commence an exercise

program of the type you describe in your letter of _______________________.

Dr’s name: __________________________

Signature: __________________________

Date: __________________________

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DRAFT 19, 1 September 2008
Appendix 3. Safe practice guidelines for physiotherapists (Prepared by Dr Connie
Vogler, Geriatrician, Royal North Shore Hospital).

1) ANYONE who develops chest pain, collapse, faintness, or severe breathlessness

during exercise should go directly to hospital (via ambulance). In the case of chest
pain, lie the patient down and administer 1 sublingual anginine (if the patient has
them), and call an ambulance. In the case of cardiac arrest, commence CPR and
call an ambulance.

2) Always carry details of patients’ medical background, and have information to be

able to contact their local doctor if necessary.

3) Take extra care when individuals are on warfarin – they are more likely to bruise
and bleed.

4) Anyone with a known heart murmur who develops a cut or graze will need
antibiotics – inform their local doctor if a cut/graze occurs. Apply antiseptic
immediately.

5) Some exercise participants will have osteoarthritis/rheumatoid arthritis – only

exercise in the pain free range of motion.

6) Check and adhere to any special precautions for individuals who have had a total
hip replacement.

7) Individuals with respiratory disease should have their puffers/nebulisers nearby,

and may need to take the exercises slowly.

8) Individuals who report dizziness or fainting should see their local doctor.

9) Individuals with diabetes should be encouraged to test their blood sugar level after
exercise.

10) Individuals on diuretics, or with bladder irritability should be encouraged to void

prior to the commencement of exercise.

11) Ensure appropriate breathing with resistance training – inhale before a lift, exhale
during the lift and inhale as weight is lowered to the starting position.

12) Never force a patient to perform an exercise they are not keen to do.

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Appendix 4. Commonly observed gait problems and their possible causes. For more details
see [66, 67]
Decreased hip extension in late stance phase Knee hyperextension (decreased knee
flexion)
Hip - possible causes
• Weak/paralysed hip Knee/ankle – possible
extensor muscles early causes
in stance • Weak knee extensor
• Weak/paralysed hip muscles
flexor muscles in • Weak knee flexor
mid/late stance phase muscles in early
• Shortening of hip stance
flexor muscles/loss of • Excessive active
range of hip extension tension in knee
extensors
Knee – possible causes
• Excessive active tension in the ankle
• Weak knee extensor muscles throughout
plantarflexor muscles in early or
stance (excessive flexion)
mid-stance
• Knee flexion contracture
• Contracture of ankle plantarflexor
• Weak gastrocnemius
muscles
Ankle/Knee – possible causes
Increased knee flexion in stance phase
• Excessive tension/poor eccentric control
of ankle plantarflexor muscles Knee/ankle - possible
• Weak/paralysed ankle plantarflexor causes
muscles • Weak knee extensor
• Contracture of ankle plantarflexor muscles in shortened
muscles and/or soft tissues around the range
ankle joint • Contracture of knee
• Excessive tension in knee extensor flexor muscles or
muscles (hyperextension) other tissues on the
• Weak/paralysed knee extensor muscles flexor aspect of the
knee
Increased lateral pelvic displacement

Hip – possible causes • Weak/paralysed plantarflexor

muscles
• Weak hip abductor
muscles in mid to Decreased ankle plantarflexion at toe off
late stance Ankle - possible causes
• Poor eccentric → • Weak/paralysed
concentric control ankle plantarflexor
of hip abductors muscles
Appendix 5. Borg Rating of Perceived Exertion Scale

Instructions for Borg Rating of Perceived Exertion (RPE) Scale

While doing physical activity, we want you to rate your perception of exertion. This feeling should
reflect how heavy and strenuous the exercise feels to you, combining all sensations and feelings of
physical stress, effort, and fatigue. Do not concern yourself with any one factor such as leg pain or
shortness of breath, but try to focus on your total feeling of exertion.
Look at the rating scale below while you are engaging in an activity; it ranges from 6 to 20, where 6
means "no exertion at all" and 20 means "maximal exertion." Choose the number from below that best
describes your level of exertion. This will give you a good idea of the intensity level of your activity,
and you can use this information to speed up or slow down your movements to reach your desired
range.
Try to appraise your feeling of exertion as honestly as possible, without thinking about what the
actual physical load is. Your own feeling of effort and exertion is important, not how it compares to
other people's. Look at the scales and the expressions and then give a number.
********************************************************************************
6 No exertion at all
7
Extremely light (7.5)
8
9 Very light
10
11 Light
12
13 Somewhat hard
14
15 Hard (heavy)
16
17 Very hard
18
19 Extremely hard
20 Maximal exertion

**********************************************************************************
9 corresponds to "very light" exercise. For a healthy person, it is like walking slowly at his or her own
pace for some minutes
13 on the scale is "somewhat hard" exercise, but it still feels OK to continue.
17 "very hard" is very strenuous. A healthy person can still go on, but he or she really has to push
him- or herself. It feels very heavy, and the person is very tired.
19 on the scale is an extremely strenuous exercise level. For most people this is the most strenuous
exercise they have ever experienced.
Borg RPE scale
© Gunnar Borg, 1970, 1985, 1994, 1998
DRAFT 19, 1 September 2008

Note from The US Department of Health and Human Services Center for Disease
Control and Prevention home page (Accessed 20 March 2006)
http://www.cdc.gov/nccdphp/dnpa/physical/measuring/perceived_exertion.htm
A high correlation exists between a person's perceived exertion rating times 10 and
the actual heart rate during physical activity; so a person's exertion rating may
provide a fairly good estimate of the actual heart rate during activity (Borg, 1998)
[68]. For example, if a person's rating of perceived exertion (RPE) is 12, then 12 x 10
= 120; so the heart rate should be approximately 120 beats per minute. Note that this
calculation is only an approximation of heart rate, and the actual heart rate can vary
quite a bit depending on age and physical condition. The Borg Rating of Perceived
Exertion is also the preferred method to assess intensity among those individuals who
take medications that affect heart rate or pulse. (Borg, 1998) [68].

Additional references of the use of the Borg to prescribe exercise [69-71]

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DRAFT 19, 1 September 2008

Appendix 6. List of Equipment required for the program

Weight belt or vest and weights

Block, preferable adjustable in height such as an “aerobics” step
Wedge, approx 10 degrees
Tape (to place markers on the floor)
Non-slip mat
Object for stepping over eg high density foam
Borg Scale
Pillows
Tables
Chairs
Objects to reach for

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DRAFT 19, 1 September 2008

Appendix 7. Tips for running the program in a group setting

Some group activities can be introduced to help participants get to know each other
and to enhance variety and enjoyment. For example, throwing or kicking a large ball
or balloon (can use rice in it to make it heavier) to each other in sitting or standing,
walking relays.

A circuit class design can facilitate individual prescription if participants have

different levels of ability.

To enhance variety the exercises and/or stations chosen can be varied each class of
after several weeks

It is useful to have a social aspects to the class too, eg, meeting for morning tea prior
to or after the class.

Home exercises can be individually prescribed by asking several participants to come

early or stay later each class.

Laminated numbered station cards are a useful way to ensure participants move form
one exercise station to the next in the correct order.

When a program first starts 2-2.5 minutes per station my be all that participants can
manage but this an be progressed to 4 minutes.

Games can be incorporated into exercise stations to enhance interest eg finding pairs
in playing cards which can be temporarily fixed to a wall for standing tasks, magnetic
darts or quoits, mini-golf.

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DRAFT 19, 1 September 2008

Appendix 8. Managing freezing in people with Parkinson’s Disease

“Freezing” is the word used to describe a sudden difficulty in starting or continuing a

movement experienced by some people with Parkinson’s disease. People report feeling as
though they are frozen, or that their feet are stuck to the ground.

Using cues is thought to help prevent freezing and to end a freezing episode. Cues are
prompts that help people to move. They usually provide information about the
• timing (eg stepping to metronome beat, counting) or
• size (eg strip of tape on the floor to step over)
of the next movement.
Common times for freezing and some suggested strategies to overcome it are given
below.

Taking the first step to start walking

• Shift your weight from side to side so you are rocking between your right and left
leg.
• Count to yourself as you rock, and start walking on a particular number you have
chosen.
• Use a metronome beat to rock with and then start walking on the beat.
• Step over a stripe or other object on the floor (if you regularly freeze in the same
place, you could put a strip of tape on the floor there).
• Try to step into an uncrowded space.
• If shifting from side to side is not successful, try taking a step back or to the side,
then step forwards.

Walking in a confined space (eg doorway, between 2 chairs)

• Start counting to yourself a few steps before hand and keep stepping with your
counting rhythm.
• If you feel you are beginning to freeze, then STOP. Use the strategies above to
get started again.
• Take steps in time to a metronome to help you keep your rhythm.
• Step very deliberately or stamp your feet
• Place strips of tape on the floor, step width apart, in places where you regularly
freeze. Step over each strip of tape as you walk.
• Place a single strip of tape in doorways and focus on stepping over the tape.

Turning from a stationary start (eg, from kitchen bench) or in confined spaces
• Stepping and turning on the spot
• Step around with high steps, keep feet apart, do not swivel
• Count to yourself as you begin stepping on the spot, and maintain the stepping
rhythm throughout the turn
• Take steps in time with a metronome to help you keep your rhythm

Turning when walking

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DRAFT 19, 1 September 2008

• Turn in an arc using big steps.

• Start counting to yourself a few steps before the turn and keep stepping with your
counting rhythm.
• Take steps in time to a metronome to help you keep your rhythm.
• Step very deliberately or stamp your feet as you turn.
• Place strips of tape on the floor, step width apart, in places where you regularly
freeze when turning. Step over each strip of tape as you turn.

For evidence and further information, see:

1. Nieuwboer A, Kwakkel G, Rochester L, Jones D, van Wegen E, Willems AM, et

al. Cueing training in the home improves gait-related mobility in Parkinson’s
disease: the RESCUE trial. J Neurol Neurosurg Psychiatry 2007;78:134-40
http://www.rescueproject.org/

2. Royal Dutch Society for Physiotherapy (2004) KNGF guidelines for physical
therapy in patients with Parkinson’s disease. Supplement to the Dutch Journal
of Physiotherapy, Vol 114, Issue 3.
http://www.appde.eu/EN/pdfs/Dutch%20Parkinson's%20Physiotherapy%20Guide
lines.pdf

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DRAFT 19, 1 September 2008

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