Otago Home Otago Home Exercise Exercise

Programme (OEP)Programme (OEP)to prevent fallsto prevent falls

LEADERSHIP LEADERSHIP TRAININGTRAINING

Otago Exercise Otago Exercise Programme Programme PartnershipsPartnerships

Prof John Campbell, Dr Clare Robertson Prof John Campbell, Dr Clare Robertson Julie WhitneyJulie Whitney Developing a “How to Teach Manual”Developing a “How to Teach Manual” Pilot 4 day course Dudley May 2006Pilot 4 day course Dudley May 2006

– Including social care workers / Rehab. assistants / NursesIncluding social care workers / Rehab. assistants / Nurses

Evaluating Programme Evaluating Programme TBC – Leadership NVQ units:TBC – Leadership NVQ units:

– Level 2 in Care, Level 2 in Care,

– Level 2 in Exercise & FitnessLevel 2 in Exercise & Fitness

– Level 3 in Promoting IndependenceLevel 3 in Promoting Independence

Course AimsCourse Aims

To provide the OEP student leaders with: To provide the OEP student leaders with:

the underpinning knowledge to understand the rationale behind the underpinning knowledge to understand the rationale behind the design of the OEP programme and the principles of the design of the OEP programme and the principles of programming and leading/instructing exercise for frailer older programming and leading/instructing exercise for frailer older people. people.

information about the health benefits of exercise for older information about the health benefits of exercise for older people and the impact of falls on frailer older people and people and the impact of falls on frailer older people and society society

the opportunity to put the leading/instructing theory into the opportunity to put the leading/instructing theory into practice by developing the leading/instructing skills necessary practice by developing the leading/instructing skills necessary to deliver the OEP safely and effectively to frailer older people to deliver the OEP safely and effectively to frailer older people with a high risk or history of falls with a high risk or history of falls

the opportunity for their OEP leadership skills to be evaluated the opportunity for their OEP leadership skills to be evaluated by tutors and peers and to develop self evaluation skills by tutors and peers and to develop self evaluation skills through the drawing up of a personal action plan in consultation through the drawing up of a personal action plan in consultation with the OEP tutor with the OEP tutor

Course ObjectivesCourse Objectives

On completion of the course the OEP leader will be able to: On completion of the course the OEP leader will be able to:

identify the aims, components, progressions and support identify the aims, components, progressions and support strategies of the OEP and the principles of programming and strategies of the OEP and the principles of programming and leading exercise for frailer older people leading exercise for frailer older people

identify the incidence, location and consequences of falls in identify the incidence, location and consequences of falls in older people older people

demonstrate competency in the necessary skills to deliver demonstrate competency in the necessary skills to deliver the OEP to individual and groups of frailer older people the OEP to individual and groups of frailer older people

identify, through tutor, peer and self evaluation, the identify, through tutor, peer and self evaluation, the practical leading skills and competencies he/she has practical leading skills and competencies he/she has achieved and those that still need to be improved; draw up achieved and those that still need to be improved; draw up an action plan to address these in consultation with the OEP an action plan to address these in consultation with the OEP tutor tutor

CertificationCertification

Timetable Timetable Day 1Day 1

9.00 - 9.30 Intro, Welcome and Registration

9.30 - 10.30 The Health Benefits of Exercise for Frailer Older People

10.30 - 10.45 Break

10.45 - 12.15 Practical Otago Exercise Programme

12.15 - 1.00 Warm Up Theory and Leading Practice

1.00 - 1.45 Lunch

1.45 - 2.00 Principles of Safe and Effective Exercise

2.00 - 3.00 The Otago Workout Part 1

3.00 - 3.15 Break

3.15 - 4.30 Leading Workout Practice

4.30 - 5.00 Candidate Guidance & Support and Allocation of Homework Task

Purpose of ManualsPurpose of Manuals

Why two manuals?Why two manuals?

– Otago Home Exercise Programme Otago Home Exercise Programme (OEP) Manual(OEP) Manual

– Later Life Training (LLT) ‘How to Later Life Training (LLT) ‘How to Instruct’ HandbookInstruct’ Handbook

Home based exercise programme

OTAGO

Chair Based Exercise Class

(Community based)

Exercise Referral Scheme

12 weeks

Balance and Safety Group/OTAO

(PSI/Rehab based)12 weeks

Community based classes for older people

OTAGO exercise classes

(Community based)

October 2007

Falls AssessmentIdentification of a falls problem and screening to determine risk factors

Cambridgeshire Falls Prevention EXERCISE PATHWAY

Motivation Pathway

How much exercise do How much exercise do you do?you do?

How much physical activity did you do How much physical activity did you do - over the last 2 daysover the last 2 days- over the last weekover the last week

How do you feel about your level ofHow do you feel about your level of

physical activity?physical activity?

Increasing the fracture Increasing the fracture risk?risk?

No standing activity leads No standing activity leads to active loss of bone and to active loss of bone and musclemuscle

1 wk bed rest 1 wk bed rest strength by ~ 20% strength by ~ 20%

1 wk bed rest 1 wk bed rest spine BMD by ~1% spine BMD by ~1%

Nursing home residents spend Nursing home residents spend 80-90% of their time seated 80-90% of their time seated or lying downor lying down

Too frail to benefit? Too frail to benefit? Dose response curveDose response curve The lower the baseline The lower the baseline

level of physical activity, level of physical activity,

the greater the health the greater the health

benefit associated with benefit associated with

an increase in physical an increase in physical

activity. Exercise can be activity. Exercise can be

adapted for any medical adapted for any medical

conditioncondition

(Haskell 1994)(Haskell 1994)

The evidence for the The evidence for the Otago Home Exercise Otago Home Exercise Programme to reduce Programme to reduce

falls falls

Don’t mention the Don’t mention the F**** word!F**** word!

Falls – a major problem Falls – a major problem in the UKin the UK

11 million people aged > 65 yrs11 million people aged > 65 yrs 28,000 women aged > 90 yrs28,000 women aged > 90 yrs

Fractures costs £1.6 billion paFractures costs £1.6 billion pa 1 Hip Fracture every 10 mins1 Hip Fracture every 10 mins

– Cost £12-15 k Cost £12-15 k 1 Wrist Fracture every 9 mins1 Wrist Fracture every 9 mins

– Cost £480Cost £480 1 Spine Fracture every 3 mins1 Spine Fracture every 3 mins

500 admitted to Hospital every day500 admitted to Hospital every day 3333 never go home never go home Annual European Home and Leisure

Accident Surveillance Survey (EHLASS) Report UK 2000

How common are falls?How common are falls?

In In > 75s> 75s, falls are the leading cause of , falls are the leading cause of

deathdeath resulting from injury resulting from injury

75-80%75-80% of falls are not reported of falls are not reported

1 in 3 >65’s and 1 in 2 >80’s fall each 1 in 3 >65’s and 1 in 2 >80’s fall each

yearyear

10%10% of all call-outs for of all call-outs for UK Ambulance UK Ambulance

ServiceService are for people aged 65+ who are for people aged 65+ who

have ‘fallen’ but nearly have ‘fallen’ but nearly half half are not taken are not taken

to Hospital.to Hospital.

Incidence of Fractures Incidence of Fractures Compared with Other Compared with Other DiseasesDiseases

1. National Osteoporosis Foundation, 2002. Available at: http://www.nof.org.2. American Heart Association. Heart & Stroke Facts: 1999 Statistical Supplement.3. American Cancer Society. Breast Cancer Facts & Figures 1999-2000.

1,200,000

513,000

228,000 184,000

0

500,000

1,000,000

1,500,000

2,000,000

OsteoporoticFractures

Heart Attack Stroke BreastCancer

An

nu

al I

nci

den

ce 1

2

2 3

1-14

Hip FractureHip Fracture

96% of all hip # follow a fall96% of all hip # follow a fall 6 months after surgery for hip # 50% 6 months after surgery for hip # 50%

are dead, in care or back in hospitalare dead, in care or back in hospital(Only 20% regain full pre-fracture (Only 20% regain full pre-fracture

mobility)mobility)Risk of a fall increases by 10X for those Risk of a fall increases by 10X for those

in residential care compared with in residential care compared with those still living in their own homethose still living in their own home

Nursing home residence spend 80-90% Nursing home residence spend 80-90% of their time sitting or in bedof their time sitting or in bed

IMPACT - Costs to the IMPACT - Costs to the NHSNHS

Hospital spending > £10 billion. Hospital spending > £10 billion.

Local authority, residential care > £3 billionLocal authority, residential care > £3 billion

– Non-residential care > £2 billion. Non-residential care > £2 billion.

– Half of L.A. social services spent on services for older Half of L.A. social services spent on services for older

peoplepeople

Formal and informal ‘care’Formal and informal ‘care’

Emergency call-outsEmergency call-outs

IMPACT- HospitalisationIMPACT- Hospitalisation

0

500

1000

1500

2000

2500

3000

3500

65-69 70-74 75-79 80-84 85+

MaleFemale

Age group- years

Rate / 100,00

Age-specific hospital admission rates for falls

[SE Thames

1991-2]

Cryer et al

OTAGOOTAGO

Map of NZMap of NZ

New Zealand RCTs - OTAGONew Zealand RCTs - OTAGOIndividually tailored programme: Campbell, BMJ 1997

-80+ years, n=233, home-based, physiotherapist -1 year, falls 32%, injuries 39%

Nurse delivered programme at home: Robertson, BMJ 2001-75+ years, n= 240, home-based, district nurse

-1 year, falls 46%, serious injuries and hospital costs

Nurse programme at GP centres: Robertson, BMJ 2001-80+ years, n=450, home-based, general practice nurse-1 year, falls 30%, injuries 28%

Visually Impaired Older People: Campbell, BMJ 2005-1 year, home-based. Only effective with full compliance, falls 28%

6 month programme: Liu-Ambrose, JAGS 2008

-70+ years, home-based, cognitive function improvements after 6 months and after 1 year falls 47%

OTAGO Exercise OTAGO Exercise ProgrammeProgrammeSummarySummary Designed to ↓ falls by ↑ strength and Designed to ↓ falls by ↑ strength and

balancebalance Effective in ↓ falls in community dwelling Effective in ↓ falls in community dwelling

OPOP Effective when delivered by physiotherapist Effective when delivered by physiotherapist

and trained, supervised nursesand trained, supervised nurses Most effective for 80+ years with previous Most effective for 80+ years with previous

falls historyfalls history Only effective with good compliance in OP Only effective with good compliance in OP

with visual impairmentwith visual impairment

What is the Otago What is the Otago Exercise Programme?Exercise Programme?

Components of the OEPComponents of the OEP How to deliver the OEPHow to deliver the OEP

Programme EssentialsProgramme Essentials Delivered at home or in groups by a Delivered at home or in groups by a

trained OEP leadertrained OEP leader Lower limb muscle strength and balance Lower limb muscle strength and balance

exercises individually tailored from a set exercises individually tailored from a set programmeprogramme

Frequency - 3 x p/wFrequency - 3 x p/w Intensity - ModerateIntensity - Moderate Duration - 30 minsDuration - 30 mins ProgressiveProgressive + Walking (30 mins x 2 p/w)+ Walking (30 mins x 2 p/w)

OEP ScheduleOEP Schedule

X 4 home visits in first 2 monthsX 4 home visits in first 2 months Booster visit at 6 monthsBooster visit at 6 months 1 hour first visit, 30 mins subsequent 1 hour first visit, 30 mins subsequent

visitsvisits Telephone call x 1 p/m between visitsTelephone call x 1 p/m between visits Exercises (Exercises (warm up, strength, balance, flexibility, cool warm up, strength, balance, flexibility, cool

downdown)) Walking Walking

OEP ScheduleOEP Schedule

MonthMonth 11 22 33 44 55 66 …………

1212

WeekWeek 11 22 44 88Home Home Exercise Exercise VisitsVisits

TelephoTelephone ne follow follow upup

OEP Exercise OEP Exercise ComponentsComponents

Warm Up – 5 exercisesWarm Up – 5 exercises Strength training – 5 exercisesStrength training – 5 exercises Balance training (dynamic & static) – 12 Balance training (dynamic & static) – 12

exercisesexercises (Cool down)(Cool down) Walking programmeWalking programme

Warm Up ExercisesWarm Up Exercises

5 exercises5 exercises

Strength Training Strength Training ExercisesExercises

5 exercises5 exercises

Balance Training Balance Training ExercisesExercises 12 exercises12 exercises

Walking PlanWalking Plan

Encourage person to include Encourage person to include walking for health benefitswalking for health benefits

Walk at usual pace with usual Walk at usual pace with usual walking aidwalking aid

Progress duration before intensityProgress duration before intensity Start with 10 minutes “walk-Start with 10 minutes “walk-

snacks”snacks” Progress to 30 mins 2 x p/wProgress to 30 mins 2 x p/w

OEP EquipmentOEP Equipment

For OEP LeaderFor OEP Leader– OEP Manual and LLT Teaching Supplement OEP Manual and LLT Teaching Supplement

For OEP ParticipantFor OEP Participant– Stable chair / furnitureStable chair / furniture– Ankle cuff weights (1, 2, 3 kg)Ankle cuff weights (1, 2, 3 kg)– Activity BookletActivity Booklet– Calendar / DiaryCalendar / Diary

Exercise DiaryExercise DiaryTo help monitor your progress try using the calendar.To help monitor your progress try using the calendar.

When you have completed your exercises put an When you have completed your exercises put an “E”(for exercise) or “W” (for walk) for that day.“E”(for exercise) or “W” (for walk) for that day.

DateDate MondayMonday TuesdayTuesday WednesdaWednesdayy

ThursdayThursday FridayFriday SaturdaySaturday SundaySunday

E W E W E F W

E EW

F

W E E

WW EE EE WW EE WW WW

EE EE EWEW EE

Principles of Principles of

Progressing Safe and Progressing Safe and

Effective ExerciseEffective Exercise

FITTAFITTA

FFrequency = how requency = how often?often?

IIntensity = how hard?ntensity = how hard?

TTime = how long?ime = how long?

TType = what type?ype = what type?

AAdherence/dherence/AApproach pproach

IIntensityntensity

5 R’s:5 R’s:Reps/SetsReps/SetsRateRateResistanceResistanceRangeRangeRestRest

TerminologyTerminology

SpecificitySpecificityReversibilityReversibilityProgressive overloadProgressive overload

Progression of Otago Progression of Otago Strength ExercieseStrength Exerciese 5 Reps no weight5 Reps no weight Add weight 5 – 10 repsAdd weight 5 – 10 reps 10 reps + add weight10 reps + add weight 5 – 10 reps5 – 10 reps 10 reps + add weight10 reps + add weightRateRate2 count concentric (up) 2 count concentric (up) 3 count ecentric (down)3 count ecentric (down)Page 19 Otago ManualPage 19 Otago Manual

Progression of Otago Progression of Otago Balance ExercisesBalance Exercises 5 – 10 second hold/reps with support5 – 10 second hold/reps with support Add second setAdd second set 5 – 10 sec/reps reduced support5 – 10 sec/reps reduced support Add second setAdd second set 5 – 10 sec/reps with no support5 – 10 sec/reps with no support Add second/third setAdd second/third set

Page 19 Otago manualPage 19 Otago manual

ImplementationImplementation

Remember the overall Remember the overall goals!goals!Strength & Balance Strength & Balance

exercises:exercises:3 x week 3 x week (rest days between),(rest days between), 30 30 mins mins

PLUS PLUS

Walking:Walking:If safe, 2 x week, 30 mins If safe, 2 x week, 30 mins (or “snacks”) (or “snacks”)

AssessmentAssessment

HealthHealthANDANDFunction:Function:1. chair stand test 1. chair stand test 2. four-test balance scale2. four-test balance scale(original Otago assessments)(original Otago assessments) p.25p.25

WHY?WHY?

Cambridgeshire Falls Cambridgeshire Falls Prevention Service Prevention Service ASSESSMENTSASSESSMENTS

Tinetti – Gait & BalanceTinetti – Gait & Balance Confidence in maintaining Confidence in maintaining

balance scale (ConfBal)balance scale (ConfBal) Visual analogueVisual analogue Timed up & Go (3 meter) (TuG)Timed up & Go (3 meter) (TuG)

Selection criteriaSelection criteria

– Inclusion:Inclusion: Living at homeLiving at home 65+65+ (most effective - (most effective - >80, previous fall in >80, previous fall in

past year)past year)– Exclusion:Exclusion:

Unable to walk around own homeUnable to walk around own home Unable to understandUnable to understand Currently receiving physioCurrently receiving physio

Outcome measure(s)Outcome measure(s)

Falls:Falls:– Stamped, addressed, Stamped, addressed,

monthly calendars filled in monthly calendars filled in dailydaily

Compliance:Compliance:– Diary/calendarDiary/calendar

Home visitsHome visits

Weeks 1,2,4,8 Month 6,12Weeks 1,2,4,8 Month 6,12 30mins each 30mins each

except week 1 = 1 hourexcept week 1 = 1 hour What happens at each?What happens at each?

Progression Progression

Strength:Strength:– How?How? Increase ankle weight resistance Increase ankle weight resistance– When?When? 2 sets of 10 reps (with sound 2 sets of 10 reps (with sound

technique) before progressing to next technique) before progressing to next weightweight

Balance:Balance:– How?How? Reduce support (recommended Reduce support (recommended

steps?)steps?)– When?When? Client can recover with legs not Client can recover with legs not

grab with armsgrab with arms

EquipmentEquipment

Instructor:Instructor:– StopwatchStopwatch– Table 4 (p.19) Reps/ProgressionsTable 4 (p.19) Reps/Progressions– Copies of exercise booklet (fill in reps)Copies of exercise booklet (fill in reps)– Chart to record exercise prescriptionChart to record exercise prescription

Client:Client:– Exercise bookletExercise booklet– Ankle cuff weights (1/2kg to start?)Ankle cuff weights (1/2kg to start?)– Falls/Exercise calendar(s)Falls/Exercise calendar(s)– Sturdy, armless chair Sturdy, armless chair

Health & SafetyHealth & Safety

Venue Venue

(home and/or community (home and/or community venue)venue)

EquipmentEquipment

Telephone supportTelephone support

Between home visitsBetween home visits– months 3,4,5,7,8,9,10,11 months 3,4,5,7,8,9,10,11

Did the leader Did the leader LEADING – The candidate:LEADING – The candidate:8. Demonstrated exercises with correct techniques 8. Demonstrated exercises with correct techniques (prior to and (prior to and during activity).during activity).

9. Named the exercises correctly.9. Named the exercises correctly.10. Selected an appropriate start position for performing 10. Selected an appropriate start position for performing exercises.exercises.11. Explained the purpose of the exercises and related to 11. Explained the purpose of the exercises and related to everyday life.everyday life.12. Ensured exercises were of appropriate duration 12. Ensured exercises were of appropriate duration (repetition and (repetition and timing).timing).

13. Gave postural checks and key teaching points at regular 13. Gave postural checks and key teaching points at regular intervals.intervals.14. Adopted an appropriate position to lead exercises effectively.14. Adopted an appropriate position to lead exercises effectively.15. Give clear and effective instructions.15. Give clear and effective instructions.16. Spoke clearly and audibly.16. Spoke clearly and audibly.17. Observed participant and corrected performance.17. Observed participant and corrected performance.18. Changed teaching position to improve observation18. Changed teaching position to improve observation19. Encouraged and motivated the participant.19. Encouraged and motivated the participant.20. Offered alternatives when appropriate.20. Offered alternatives when appropriate.

OEP SESSION PLANName: Course: Date:

EXERCISEEXERCISENo.No.

EXERCISE EXERCISE NAMENAME

REPETITIONREPETITIONSSAND/OR AND/OR TIMETIME

KEY SAFETY POINTSKEY SAFETY POINTS PURPOSE E.G.PURPOSE E.G.ACTIVITIES OF ACTIVITIES OF DAILYDAILY LIVING LIVING (ADL)(ADL)

ExamplExamplee

Front Knee Front Knee StrengtheneStrengthenerr

10 reps10 reps Sit back in chair so that back Sit back in chair so that back is supportedis supported*Posture (See above) – *Posture (See above) – Reinforce sit tallReinforce sit tallHands on ChairHands on ChairSlow & Controlled moveSlow & Controlled moveBreathingBreathingFull ROM but don’t lock kneeFull ROM but don’t lock knee

Strengthen Strengthen muscles at muscles at front of thigh front of thigh and helps to and helps to improve improve balance.balance.HelpsHelps: : walking, walking, getting up getting up from a chair, from a chair, stepping up or stepping up or down, down, dressing.dressing.

Campbell et al, 1997Campbell et al, 1997

Robertson et al, 2001Robertson et al, 2001

Effective Home Effective Home ExerciseExercise

Randomised Controlled Trial - GP

Practices - >80 year old women

20-30% reduction in risk of falls

1 Year duration - Physiotherapist support

home-based tailored progressive strength,

balance and gait training (3x p/w)

Campbell, BMJ, 1997

Then - Physiotherapist led nurse training

–For over 65’s – cost effective

–For over 80’s – saves money

Robertson, BMJ. 2001

Daily walking Daily walking

Plus 3 x per week home exercise Plus 3 x per week home exercise programmeprogramme

Exercises did not have to be done Exercises did not have to be done in any set order or all at the same in any set order or all at the same time time

Head Head

MovementsMovements

(Repeat 5 (Repeat 5

times)times)

Neck Neck

MovementsMovements

(Repeat 5 (Repeat 5

times)times)

Back ExtensionBack Extension

(Repeat 5 (Repeat 5

times)times)

Trunk Trunk

MovementsMovements

(Repeat 5 (Repeat 5

times)times)

Ankle Ankle

MovementsMovements

(Sit or stand(Sit or stand

Repeat 10 Repeat 10

times)times)

WARM UPWARM UP

Dynamic endurance and dynamic Dynamic endurance and dynamic balancebalance

StrengthStrength

Front Knee Front Knee

Strengthening Strengthening

ExerciseExercise

(Repeat X (Repeat X

times)times)

Back Knee Back Knee

Strengthening Strengthening

ExerciseExercise

(Repeat X (Repeat X

times)times)

Side Hip Side Hip

Strengthening Strengthening

ExerciseExercise

(Repeat X (Repeat X

times)times)

Calf (Heel) Calf (Heel)

Raises Raises

(with support)(with support)

(Lift x 20)(Lift x 20)

Calf Raises Calf Raises

(no support)(no support)

(Lift x 20)(Lift x 20)

Toe Raises Toe Raises

(with support)(with support)

(Lift x 20)(Lift x 20)

Toe Raises Toe Raises

(no support)(no support)

(Lift x 20)(Lift x 20)

BalanceBalance

Knee Bends Knee Bends

(with support)(with support)

(Repeat X (Repeat X

times)times)

Knee Bends Knee Bends

(no support)(no support)

(Repeat X (Repeat X

times)times)

Backwards Backwards

Walking Walking

(with support)(with support)

(10 steps x 2)(10 steps x 2)

Preparation – Preparation –

Forwards walking Forwards walking

with and without with and without

supportsupport

Backwards Backwards

Walking Walking

(no support)(no support)

(10 steps x 2)(10 steps x 2)

Walking and Walking and

Turning AroundTurning Around

(figure of 8 x 2)(figure of 8 x 2)

Preparation – with Preparation – with

chair supportchair support

Heel Toe Heel Toe

Standing (with Standing (with

support)support)

(10 secs)(10 secs)

Heel Toe Heel Toe

Standing (no Standing (no

support)support)

(10 secs)(10 secs)

Heel Toe Heel Toe

Walking (with Walking (with

support)support)

(10 steps x 2)(10 steps x 2)

Heel Toe Heel Toe

Walking (no Walking (no

support)support)

(10 steps x 2)(10 steps x 2)

One Legged One Legged

StandStand

(with support)(with support)

(10 secs)(10 secs)

One Legged One Legged

StandStand

(no support)(no support)

(10 secs)(10 secs)

One Legged One Legged

StandStand

(no support)(no support)

(30 secs)(30 secs)

Heel walkingHeel walking

(with support)(with support)

(10 steps x 2)(10 steps x 2)

? Order ? Order

Preparation – toe Preparation – toe

walkingwalking

Heel walkingHeel walking

(no support)(no support)

(10 steps x 2)(10 steps x 2)

Toe walkingToe walking

(with support)(with support)

(10 steps x 2)(10 steps x 2)

Toe walkingToe walking

(no support)(no support)

(10 steps x 2)(10 steps x 2)

Heel Toe Heel Toe

Backward Backward

WalkingWalking

(no support)(no support)

(10 steps x 2)(10 steps x 2)

Preparation – heel Preparation – heel

toe forward toe forward

walking with and walking with and

without support without support

and heel toe and heel toe

backward walking backward walking

with supportwith support

Sit to standSit to stand

(two hands)(two hands)

(Repeat X (Repeat X

times)times)

Sit to standSit to stand

(one hand)(one hand)

(Repeat X (Repeat X

times)times)

Sit to standSit to stand

(no hands)(no hands)

(Repeat X (Repeat X

times)times)

Preparation – Preparation –

hands on kneeshands on knees

Stair walkingStair walking

(Up and down X (Up and down X

steps)steps)