Otago Home Exercise Programme (OEP) to prevent falls LEADERSHIP TRAINING.
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Transcript of Otago Home Exercise Programme (OEP) to prevent falls LEADERSHIP TRAINING.
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)