Virtual physical therapy for falls patients during the pandemic

Falls and mobility impairment are regarded as one of the earliest signs of frailty.¹ The physical capacity of older adults can decline due to loss of muscular power, which progresses with age especially in sedentary individuals.²

Older patients are at further risk of deconditioning due to hospitalisation³ and chronic diseases.⁴In addition, reduced physical activity for one year is associated with a rapid decline in gait stability, balance and loss of independence in daily activities.⁵

Falls prevention programmes in many centres, therefore, rely on the promotion of physical activity to prevent falls incidences using various approaches.

In response to social distancing and the closure of non-essential clinics during the Covid-19 pandemic, we have developed virtual exercise sessions as an alternative to routine face-to-face physical therapy.

This article discusses the role of virtual customised physical rehabilitation and how we built a digital library of physical exercises for our patients with gait imbalance who are at high risk of falls

Importance of regular exercise in older adults

A healthy diet, appropriate physical activities, and avoidance of harmful habits such as smoking are necessary to maintain a healthy status in the ageing population.⁶

There are a range of exercises to consider in older adults. Regular resistance exercises can help to maintain muscular strength and aerobic exercise can improve endurance.⁷Tai chi also has a good impact on balance and falls risk reduction. However, it has to be performed under the supervision of an instructor, at least for beginners. Alternatively, Otago provides better lower extremities strength and falls risk reduction⁸ and it targets frailty.

Prevention of falls with physical activity plans

At our centre, the recommendations of the Prevention of Falls Network Europe⁹ are followed and the primary aim is to reduce falls and improve physical activity. All participants with mobility impairment are assessed regardless of their age, gender, ethnic background and whether they have a previous history of falls.

Patients with various chronic diseases are included regardless of the number of medications. Patients are excluded if they have terminal illness, are participating in any similar interventions in different organisation, have psychiatric illness prohibiting participation, contraindication to treatment, are unable or unwilling to complete the baseline assessments or not ambulatory with or without an assistive device.

The virtual falls therapist clinic includes video consultation and sending links of customised physical therapy by email or WhatsApp to patients. A designated Comprehensive Geriatric Assessment form is used for medical assessment and to identify the predominant cause of the falls. Therapists then decide what specific exercises to follow.

To customise the rehabilitation programme, the causes of falls and gait impairment are classified based on the main anatomical weakness that causes imbalance. This could be due to different medical conditions, physiological deterioration (frailty), syncope or postural hypotension.

Video clips are produced by the geriatric team within the hospital and are supported with narrations for further clarification. All the exercises are approved by the department of physiotherapy. These exercises are mixed isometric, resistance and aerobic.

Types of exercise for falls and gait imbalance

Breathing exercises for general population

Deep breathing
Deep breathing with stretches

Otago exercise for hoist and chair bound participants

Neck rotation left and right
Neck movement up and down
Trunk movement both sides
Ankle rom

Otago exercise for ambulant person with walking assistance

Front knee strengthening
Back knee strengthening
Hip abduction with weight in standing
Hip abduction/extension in standing without weight
Back extension in standing
Mini squat
Sit to stand

Postural hypotension

Postural hypotension lifestyle modification tips
Bending forward in sitting
Bending over to tie shoe lace
Leg crossing in sitting
Lying down with raised leg
Marching in sitting

Peripheral vertigo

Semont manoeuvre
Brandt Daroff manoeuvre
Gaze stabilisation, head movements
Romberg standing
Standing on toe and heel
Swaying side to side
Standing on cushion
Walking bare foot on stand – slide
Sit to stand progression
Single leg stance

Balance exercises

Sit to stand progression
Hip abduction/extension in standing without weight
Heel raise and toe raise
Single leg stance
Tandem stance
Forward lunges

Initial physical assessments are based on the Short Physical Performance Battery¹⁰ that includes balance assessment, three-metre walking assessment and a get-up and sit test. Follow up assessment is in subsequent virtual physical therapy sessions. The target is to follow up the participants for six months to assess the effectiveness of the short videos of physical therapy and community rehabilitation initiative.

Developing a falls prevention programme in the community requires creative methods with a positive message.¹¹ For example, the clips included a brief explanation of why these exercises are needed and how to eliminate pain and exhaustion. All participants were asked to document their daily activity and progress.¹²

The exercises are broken down into very short video clips, so the participants performed one exercise a day in a repeated manner before moving to another exercise.

Conclusion

Physical activities in older adults are necessary to prevent frailty,¹³ osteoporosis¹⁴ and better control some chronic diseases such as diabetes. This is in addition to its effect on promotion of independence in individual’s activity of daily livings.

This customised virtual programme is particularly beneficial for the pre-frail stage [Edmonton <5; Rockwood <4]. Although falls incidences in patients can be due to multiple factors, in most cases a predominant single factor (either medical or physical) is the cause.

Most of the patients regarded this as best alternative way to continue with physical activities. This has enabled them to initiate or continue their physical rehabilitations sessions. Further evaluation in a prospective research is necessary to assess its effectiveness.

Dr Kawa Amin, Consultant Geriatrician

Mr Syed Buhari, Physiotherapist

Mrs Sweety David, Physiotherapist

Dr Hanadi Al Hamad, Consultant Geriatrician

Mr Ayman Mahmoud, Head of Geriatric Physiotherapy Department

Geriatric Department, Hamad Medical Corporation

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