Upgraded SNF restorative program reduces falls

Falls among residents of skilled nursing facilities (SNFs) are the leading cause of injury, hospital admissions and lawsuits for nursing home operators. The vast majority of these falls are caused by sarcopenia, the aging process that explains how the skeletal muscles of an elderly person steadily become smaller and weaker over time if not subjected to proper exercise.

Starting at birth, all humans naturally add muscle mass without exercise, but at a steadily slowing rate. At approximately 35 years of age this natural growth of muscle fiber ceases and thereafter, without proper exercise, muscle size and muscle tissue quality decrease at a steadily increasing rate. In 2013, there were 2.4 million fall-related hospital visits in the United States, which cost Medicare more than $30 billion per year. 

PRE reduces falls in AL

Progressive Resistant Exercise (PRE) is the technique of using progressively heavier weights in exercise as strength increases. In 2011, I conducted a 12-month falls prevention study at an assisted living (AL) community in Illinois. In a group format using ankle weights and five strength-rebuilding routines (first tested in New Zealand), we achieved a 54 percent reduction in both falls and fall-related hospital visits.

A 23-person test group, which consisted of residents who had previously fallen, participated in PRE three days a week. We compared falls and fall-related hospital visits of this group to a 24-person control group that did not exercise. This study, which was described in an online article in 2014, also produced a strength measurement process and computer-generated reports that made the program very easy and inexpensive to implement. Aides or activity directors have been trained to lead these sessions. This group exercise program is now in 20 independent living and AL communities in Illinois, and one in Washington. 

Testing the PRE process in a SNF

In May 2012, I began working with a Chicago-area SNF to integrate PRE into the AROM (active range of motion) portion of the restorative program. The AROM routines were left unchanged on Sundays, Tuesdays and Thursdays but PRE was used on Mondays, Wednesdays and Fridays, starting out with one-pound weights and progressing in weight as measured strength improved.

Regulations for a SNF restorative program were closely followed, which includes a 4:1 ratio of residents to aides. A certified nursing assistant, under the supervision of nursing, led the program. All participants signed HIPAA consent forms or had their legal representatives sign them. The project followed all National Institutes of Health rules on human research and was overseen by an Institutional Review Board.

From May 2012 through October 2013, 38 different SNF residents, all over 80 years of age, participated in this study.  Of these 38, only 19 could be motivated to attend at least one session per week with ankle weights. Therefore, only data on these 19 is included in this article.

Of these 19 participants, 12 were transported in wheelchairs by an aide, while seven ambulated to the sessions on their own using walkers.

The total number of sessions attended by each of these 19 participants varied significantly due to factors such as illness, injury, conflicts with physical therapy, refusals, lack of staff for transport and death. After 21 months, three residents attended over 200 sessions with weights, one attended 150 sessions with weights, seven attended 50 to 99 sessions and eight attended 19 to 49 sessions. 

As with the 2011 AL study, ankle weights provided the exercise resistance. We measured the strength of five different muscle groups, with the first set of measurements being the baseline against which all future measurements were compared.

After each set of measurements, strength data was entered into a spreadsheet that tracked personal best performance for each muscle group and also computed the percentage change in strength for each muscle group. The size of the ankle weights was increased as the measured strength increased following a set of rules developed in the previous study. These rules successfully avoided injuries by not advancing the weights too quickly.

The five key muscle groups and how they resist falling are as follows:

• The hamstrings are used to resist a backward fall. 
• The abductors are used to resist a sideways fall. 
• The front and rear ankle flexors are used to push back with the ball of the foot as well as flex the ankles and all the bones in the foot. 
• The quads are used for sit-to-stand movement and to resist a frontward fall. 

By December 2013, 16 of the 19 participants who had used ankle weights at least once a week showed strength gains in three of the five key muscle groups and five participants showed strength gains in all five muscle groups. In fact, five residents with high attendance, who previously were unable to sit to stand from wheelchairs without maximum assistance, could now safely do so. 

All five high-attendance participants could now safely transfer from their wheelchair to a standing position by independently and then be handed a walker to safely ambulate to meals.

The chart below shows the average percentage strength gain by muscle group for these 19 residents. 

Falls among residents of skilled nursing facilities (SNFs) are the leading cause of injury, hospital admissions and lawsuits for nursing home operators. The vast majority of these falls are caused by sarcopenia, the aging process that explains how the skeletal muscles of an elderly person steadily become smaller and weaker over time if not subjected to proper exercise.

Starting at birth, all humans naturally add muscle mass without exercise, but at a steadily slowing rate. At approximately 35 years of age this natural growth of muscle fiber ceases and thereafter, without proper exercise, muscle size and muscle tissue quality decrease at a steadily increasing rate. In 2013, there were 2.4 million fall-related hospital visits in the United States, which cost Medicare more than $30 billion per year. 

PRE reduces falls in AL

Progressive Resistant Exercise (PRE) is the technique of using progressively heavier weights in exercise as strength increases. In 2011, I conducted a 12-month falls prevention study at an assisted living (AL) community in Illinois. In a group format using ankle weights and five strength-rebuilding routines (first tested in New Zealand), we achieved a 54 percent reduction in both falls and fall-related hospital visits.

A 23-person test group, which consisted of residents who had previously fallen, participated in PRE three days a week. We compared falls and fall-related hospital visits of this group to a 24-person control group that did not exercise. This study, which was described in an online article in 2014, also produced a strength measurement process and computer-generated reports that made the program very easy and inexpensive to implement. Aides or activity directors have been trained to lead these sessions. This group exercise program is now in 20 independent living and AL communities in Illinois, and one in Washington.    

Testing the PRE process in a SNF

In May 2012, I began working with a Chicago-area SNF to integrate PRE into the AROM (active range of motion) portion of the restorative program. The AROM routines were left unchanged on Sundays, Tuesdays and Thursdays but PRE was used on Mondays, Wednesdays and Fridays, starting out with one-pound weights and progressing in weight as measured strength improved.

Regulations for a SNF restorative program were closely followed, which includes a 4:1 ratio of residents to aides. A certified nursing assistant, under the supervision of nursing, led the program. All participants signed HIPAA consent forms or had their legal representatives sign them. The project followed all National Institutes of Health rules on human research and was overseen by an Institutional Review Board.

From May 2012 through October 2013, 38 different SNF residents, all over 80 years of age, participated in this study.  Of these 38, only 19 could be motivated to attend at least one session per week with ankle weights. Therefore, only data on these 19 is included in this article.

Of these 19 participants, 12 were transported in wheelchairs by an aide, while seven ambulated to the sessions on their own using walkers.

The total number of sessions attended by each of these 19 participants varied significantly due to factors such as illness, injury, conflicts with physical therapy, refusals, lack of staff for transport and death. After 21 months, three residents attended over 200 sessions with weights, one attended 150 sessions with weights, seven attended 50 to 99 sessions and eight attended 19 to 49 sessions. 

As with the 2011 AL study, ankle weights provided the  resistance therapy. We measured the strength of five different muscle groups, with the first set of measurements being the baseline against which all future measurements were compared.

After each set of measurements, strength data was entered into a spreadsheet that tracked personal best performance for each muscle group and also computed the percentage change in strength for each muscle groups. The size of the ankle weights was increased as the measured strength increased following a set of rules developed in the previous study. These rules successfully avoided injuries by not advancing the weights too quickly.

The five key muscle groups and how they resist falling are as follows:

• The hamstrings are used to resist a backward fall. 
• The abductors are used to resist a sideways fall. 
• The front and rear ankle flexors are used to push back with the ball of the foot as well as flex the ankles and all the bones in the foot. 
• The quads are used for sit-to-stand movement and to resist a frontward fall. 

By December 2013, 16 of the 19 participants who had used ankle weights at least once a week showed strength gains in three of the five key muscle groups and five participants showed strength gains in all five muscle groups. In fact, five residents with high attendance, who previously were unable to sit to stand from wheelchairs without maximum assistance, could now safely do so. 

All five high-attendance participants could now safely transfer from their wheelchair to a standing position by independently and then be handed a walker to safely ambulate to meals.

The chart below shows the average percentage strength gain by muscle group for these 19 residents. 

Case study

This 81-year-old resident who participated in the study was retired and living independently in Palm Beach, Fla. In 2002, she experienced a fall-related hip fracture. Prior to her injury she led an active life as a community volunteer, housewife, mother and grandmother who enjoyed reciting poetry, parody writing and singing. As a result of this fall, her children decided to move her to a suburban Chicago SNF, where she used a walker to ambulate. In 2009 she fell again and broke the other hip. She was confined to her to a wheelchair and needed assistance to safely sit to stand.

In May 2012 she joined the original group of residents that began participating in this modified AROM program. She was quite motivated and rarely missed a session. By the end of December, she and another highly motivated resident had attended more than 130 sessions. This particular resident’s change in performance versus the baseline by muscle group over seven months is shown in the following graph.

As you can see, in the first seven months there was a 210 percent improvement in her ability to do the standing heel raises and she had a 100 percent improvement with the sitting quad strengthening routines. Her performance with the standing abductor (hip) routines initially went negative, but finally returned to baseline after five months and went positive thereafter.

Conclusion

The use of PRE as part of the AROM program significantly improved lower body strength when tested at this skilled nursing facility. It proved that motivated SNF residents over 80 years of age can regain lower body strength by participating in a series of exercise routines in which the resistance is increased gradually as strength returns. It also proved that the scientific process developed in 2011 by this author that measures strength and also guides the advancement of weights was successful in avoiding injuries to these frail participants while also improving strength.

Robert Kunio is the president of Simply Home Health, an Illinois home health agency with Joint Commission accreditation. Before that, he was the COO of SimplyRehab, a company that provides therapy services for SNFs.