April Falls: Sunbeam trial shines a light on falls prevention exercise
The very first day that physiotherapist Jennifer Hewitt began working in an aged care facility she fell in love with the older population—and she has never looked back. However, frustration at the funding model for physiotherapy in the aged care setting led her to conduct some ground-breaking research.
Taking her physiotherapy rehabilitation skills and applying it to clients in the aged care setting, Jennifer Hewitt, APAM, realised that she could take someone with 20 or 30 per cent function and double or even triple it. The ability to be able to change people’s lives for the better so drastically continues to drive Jennifer’s work with the older population to this day.
‘But one of the things that really frustrated me about working in the residential care setting is that the physiotherapy interventions are dictated by the funding model, and the funding model only supports outdated modalities. We’re talking electrical agents or massage,’ Jennifer says. ‘I had to make a choice to either leave that sector or to try and demonstrate evidence to lobby for change.
‘I started by having a look at what evidence was available for other physiotherapy methods in that setting, and I found that it was really under-researched. People seemed to shy away from the residential aged care setting when performing research at that time, which was about 2011. So, I had to make a choice—either leave the cohort and go back to look for something different, or try and make a change,’ she says.
Jennifer chose to advocate for change. Initially, Jennifer approached the University of Sydney, where she had completed her undergraduate degree and Master of Health Science, and she spoke with Professor Kathryn Refshauge, APAM, the then-deputy dean of the Faculty of Health Sciences.
‘Kathy had done a lot of work in exercise-based treatment, and she was mortified to hear how physiotherapy was utilised in the aged care setting. So she just jumped on the bandwagon with me and pulled together an amazing group of co-supervisors including an occupational therapist (Professor Lindy Clemson), a health economist (Professor Stephen Goodall) because I wanted to be able to attach a cost benefit analysis to my project ... and then I had met Dr Tim Henwood, an exercise physiologist from the University of Queensland.
‘I had a great multidisciplinary team and they kept me on the straight and narrow, academically, in the early years when I had my ‘L’ plates on. So I pulled my sleeves up and got out there and recruited aged care facilities which had similar beliefs about the system needing to change.’
The result was a multicentre cluster randomised controlled trial that examined the effects of physiotherapy-prescribed, individualised strength and balance exercise on falls prevention in Australian residential aged care called ‘The Sunbeam Trial’ (tinyurl.com/qozmfqr). Sixteen facilities and 221 residents joined the trial, half the facilities were randomised to receive the intervention and the others were the usual care group. The study was published in 2018 and the Physiotherapy Research Foundation (PRF) funded an animation video that has helped spread the key messages contained in the trial about falls prevention and exercise in the older population. The name ‘Sunbeam’ was chosen as the most popular among the participants of the trial, Jennifer says.
If I’d have done what I thought I was going to do initially, in terms of the intervention, it probably wouldn’t have worked because I was thinking three months of strength and balance training.'
‘I wanted to focus on strength because I truly believe that because the older population spend so much time sitting in residential aged care, so deconditioning was part of the problem.
‘But just before I was about to put my ethics in, Professor Cathie Sherrington and Anne Tiedemann published a paper that listed the key components of successful falls prevention programs. Strength and balance training, two hours a week for six months, was what they published at the time, as best practice. So I had to change the intervention because it was going to be too short and it wasn’t going to have enough balance in it. I changed it to match what was then known as best practice.’
Jennifer implemented the evidence-based Sunbeam strength and balance program, prescribed by a physiotherapist, for six months at two hours a week. They measured falls as the primary outcome. The program included progressive resistance training, high-level balance work, with all exercises individually upgraded and progressed by a physiotherapist and performed under close supervision. Residents exercised in groups of up to 10 with five using seated pneumatic resistance training equipment while others performed closely supervised highchallenge balance exercises.
There was a maintenance program that continued after the initial conditioning phase, led by facility staff. These exercises included standing bicep curls and shoulder retraction using resistance bands, heel raises and dynamic and static balance exercises as well as resisted knee flexion and extension, leg press and hip extension, abduction and adduction.
We measured physical performance and a number of other outcomes at the end of the six months, and then we measured it again six months later and we found that by the 12-month mark, there was a 55 per cent reduction in falls rate in the groups that performed the exercises.'
‘It showed that the application of the best practice guidelines in that setting did work. Prior to this study, there were nine or 10 other studies that had looked at exercise but none of them had implemented those key exercise components in combination. The trick was to make sure that you were applying resistance and balance exercise at the right dose.’
Knowing that some of the exercise programs implemented in other studies had actually led to an increase in the incidence of falls in the older population, Jennifer admits to feeling nervous when the results of her trail first began to filter through.
‘I was really nervous that I might do all this hard work and prove that it [exercise] wasn’t effective. And I was still learning about statistical analysis so I didn’t really know what was going to happen when we ran the results through stringent statistical testing,’ Jennifer says. ‘I could see the raw data coming in but we had to correct for age and previous falls and a whole lot of other factors, so I didn’t know what the outcome was going to be until it was run. The data was run by somebody who was blind to group allocation and when the results came in, I nearly fell on the floor myself.’
The results showed the Sunbeam participants experienced a 55 per cent fewer falls and they also gained a significant boost to their physical performance, improving their opportunity to remain independent and participate in life, Jennifer says. Her research also showed that if the Sunbeam strength and balance program was scaled nationally, the short- and long-term benefits would save the Australian healthcare economy an estimated $120 million.
The same year that the trial was released, Jennifer was invited to speak at the Australia and New Zealand Falls Prevention conference in Hobart, Tasmania, and her team won an award from the Journal of the American Medical Director’s Association for the paper most likely to influence policy and practice for that year. Jennifer flew to Atlanta, in the US, to accept the award—something she still counts as a career highlight to this day.
© Copyright 2018 by Australian Physiotherapy Association. All rights reserved.