Better Functioning in various environments Eeva Helminen Licentiate

Better Functioning in various environments Eeva Helminen Licentiate in Health Sciences Senior Lecturer of Physiotherapy JAMK University of Applied Sciences

International Classification of Functioning, Disability and Health (ICF) Health Body structures Activities Environment Participation: Individual factors

Presentation and main content Old person, physical capasity Acessibi lity Availability Usability Functions functioning Various Environments

Environment How do you describe it? • What is environment? - when we talk about old peoples environment •

Various environments • Physical environment -> the view in this presentation - tecnological / virtual environment • • • Perceived environment Social environment Institutional environment Temporal environment Cultural/ political environment

Various environments • Physical environment - the view in this presentation • home; alteration work inside • outside; walking routes, buildings, boundaries, hills etc • Services; shops, medical centres, pharmacy ets • - tecnology/ virtual environment • Machines, equipments, warning signs, • Information- transfer, data protection • • Perceived environment • meaningful- varies • all things what we have in home • identity

Various environments… • • Social environment Family, friends, neighbours Hobbies Society- where we live • Institutional environment • Organisations in and outside, rules, rights, the way how they works • Temporal environment • The rhytm of the nature (in Finland; four different seasons), city- countryside, services, trafic, talk etc

Various environments • Cultural/ political environment • - the way how the society works in Finland, in Netherland, in UK etc • Methods, services, the quality of the services • Different professionals etc

Important termsenvironment • Accessibility; usually accessibility of the physical environment • Availability; availability of the service/s • Usability of the physical environment, • -> assistive technology

CASE EDITH (79 year)

BACKGROUND of the Case Edith • • Edith, 79 years old woman, widow, open minded Retired ( working as a cleaner 40 years) Dg: blood pressure, osteoarthritis in her hips and knees, problems of hearing and seeing , good memory She lives in the city of Keuruu, in an aparment (2 rooms+ kitchen) in 2. th floor ADL: morning stiffness ->little bit hard to sit down and get up from the chairs and cutting nails of the feet, household ok outside: In the summer time: ok, in the winter time: she is a little bit afraid of slippery and ice, shopping (needs help), she meets friends etc- seldom

International Classification of Functioning, Disability and Health (ICF) Health: blood pressure, osteoarthritis etc Body structures: Joint, muscle etc Activities: walking, sitting Environmental factors: home, outside, in public places Participation: Taking part of social life Individual factors: Motivation, open mind,

Analysis of the risks of the functioning • What do you think? • Edith is afraid of walking outside (especially in the winter time )– why? • Edith needs help – when she goes to do shoppingwhy? • Edith meets seldom friends - why?

Edith is afraid of walking outside (in the winter time –why? ) • OBS. In Finland it is snow on the ground in winter time and it can be slippery. • Fear of falling • Some loss of balance and coordination • Some loss of muscle power and endurance • Some loss of sight and hearing (difficulties to see and hear ”trafficnoice” and signs) • Lonelyness (Renfors, THL 2013)

Edith needs help – when she goes to do shoppings- why? • • • Loss of sight and hearing Joint problems (osteoarthritis in her hips and knees) -> difficulties to find right things in the shop -> difficulties to carry heavy bags -> traffic; signs, cars, peoples->temporal (environment)

Edith meets friends seldom. Why? • Some difficulties of walking (in the morning etc) – because of osteoarthritis in her leg joints (pain and stiffness) • Severe loss of sight- seeing • Loss of hearing • Some loss of balance – when she is moving faster What can be done? ? How can we help Edith´s situation and functioning in various environments?

What are the strenghts? • Edith is open minded person • She has good memory • She is active; likes to walk etc •

What can be done? Evaluation of the Edith`s Situation • multiprofessional team (pt, ot, rehab. councelor, cesar therapist, social worker, public nurse etc) • Most important thing is to evaluate the home and surroundings outside the home • In physiotherapist view: assessment of the functional capasity; joints, muscle power, balance, coordination, endurance - Making together with Edith a Rehabilitation plan What is the Edith`s readiness of rehabilitation?

Physiotherapy Guideline in Finland: 2011 • Physiotherapy Guidelines for preventing Falls and Fall related injuries (evidence based) • Risk factors: over 75 years old, woman, general health, • restricted functional capacity. • Also living environment, safetyness, (poor lightning, pure shoes, aids, risk factors – to fall down (carpenters etc), • evaluation methods /prevent falling: functional scales, self – evaluations , movement tests, the fear of falling-questionaires functional tests; balance, coordination (TOIMIA- links/THL)

Guideline…. • Exercise plan including: aerobic exercise (walking ect 2. 5 h/ week and 30 min in time, hard exercise 15 min/week), • gym exercise 2 times/week and also balance exercise/ week) guiding, environment evaluation and changes, other spesific ptmethods • Also posture and movement exercises • Walking in different surfaces, walking with crutches (Nordic Walking ), walking with good shoes (in the winter time special …) • Dance etc… • -> regularly, continuing , progressively

Some research • 1/3 of old peoples hip fractures can be prevented if they should be active and walk and move about 3 -4 hour/ week. • It is possible to prevent the loss of functional capasity • ( Karinkanta S, Piirtola M, Sievänen H, Uusi-Rasi, Kannas P. 2010)

Some research (body structure- level) • 6 months resistance – type training (three times/ week); elderly woman (n 24) and men (n 29): muscle mass, strenght, functional capasity and metabolic profile were assessed. =>Type II muscle fibers increased, glycemic control profiles improved. A generic resistance- type exercise training is applied for both men and women to effective counteract the loss of muscle mass and strenght (Leenders M, Verdijk LB. 2011).

Some research (body structure - level) • In systematic review: (59 controlled trials, 7 metaanalyses and 8 reviews): Multicomponent programmes of strenght, aerobic, high impact and/ or weight –bearing training may help to increase or prevent decline of bony mass in menopausal women (Go`mes-Gabello A, Ara I. et al. 2012).

Some research (body structurelevel) • Systematic review: • The whole body vibration programs seems to improve significantly knee muscles isometric power , muscle strenght and balance control (Sitja- Rabert M & Ricau D. 2012.

Some research (activity- level) • It`s seems easily implemented; rocking- chair exercises at homebased environment. It improves physical performance and motivation (Niemelä K, Väänänen I et al. 2011). • Resistance exercise with dumbbells as well as elastic tubing showed increasing EMG amplitude and perceived loading with increasing resistance. • Therapist can choose the type in clinical practise • (Andersen LL, Andersen C et al. 2010).

Some research (activity- level) • In Systematic Review (20 studies of 582): • There were found correlations between Trunk muscle strenght, balance functional performance and falls. Core training and Pilates- type exercises can be used adjust or even alternative in a group resistance training programmes for old adults. (Granacher U, Gollhofer A et al. 2013)

Some research (activity- level) • Systematic review: • Physical exercise in the treatment and prevention of elderly with osteoporosis. • Physical exercise is important prevention treatment: isometric exercise, coordination and balance exercises, highimpact and aerobic exercises- those exercises are safe- more researh about vibration plates, walking etc (Howe TE, Rochester L et al. 2010). • In every home (371 people, aged 67 -70 old) environment had environmental barries ( entrances, indoors, irreguar walking surfaces, narrow parking places) • (Kyle`n M, Ekström, H, Haak M, Elmstål S, Iwarsson S. 2014) •

Evaluation of home and various environments • Method for living and accessibility is • Housing Enabler (www. enabler. hu, Iwarsson S, Ståhl A. 2001, 2003)

Housing Enabler • Method has been established in USA (1990 -1992) by Edward Steinfeld- in Europe the method has developed Susanne Iwarsson and Björn Slaug. • It is an evaluation equipment /method for aging people • It is a good equipment expecially for occupation and physiotherapists also for other professionals to evaluate aging peoples environments

Basics • The method can be used in clinical work, education, reseach and development work. • Important basics are in every country: Instructions for building houses (Finlands Constructer foundation). • Before you can use this method; it is good to have an education for that.

Basics • Evaluation documents: • persons back ground- an interview, functional restrictions, walking aids, other aids in use, evaluation inside and outside of the house (general, parking, sitting places, gaites etc) • You can give points (1 -4); different restrictions of the functioning; hearing- seeing-problems, movement and balance restrictions. • For instance: 1 point- no problems in balance, 4 point a lot of problems in balance

Environmental analysis Inside the house (lobby): 1 -4 Elevator/ lift: is there any? Is the door easy to open? The doors; are they ok ( width more than 85 cm, heavy, automatic/not) • Stairs: not < 30 cm? • •

Outside the house • • Outside the house: Are the walking gaites ok? (< 1. 5 m) 1 -4 Is the walkind surface ok? 1 -4 Is the angle of the surface more than ? 1: 20. 1 -4 Are there stairs in the gaites? 1 -4 What about the signs (warning)? 1 -4 Are the stairs more than 30 cm high ? 1 -4 Is there any sitting places? 1 -4

Outside the house • Are the lights ok? 1 -4 • Are the lights ok in walking surfaces? • Is there clear routes from house to outside and to the street? 1 -4 • Parking: is there good and safety route to the parking places? • Are the parking places wide enough? More than 3. 6 m (one site) • Where is the parking place? Is it too far away from the house ? (more than 25 m)

Outside the house • What about the doors in and out? Is the width of the door at least 85 cm? • Is it easy to open the door (heavy, no space)? • What about the stairs? Are they more than 30 cm high?

Examples of the use of HE • In Jyväskylä and JAMK • Sammonkoti- Sheltered home for older people has been evaluated with HE- method in construction phase • http: //home. coronaria. fi/hoivapalvelut/palveluyksikot/a sumispalvelut/jyvaskyla-sammonkodin-palvelutalo/

One example of the HE- method in use • One of my student; development study of 12 weeks practise in Health Centre City of Keuruu (10 400 inhabitants); in the middle of the Finland ( where Case Edith`s lives) • • 60 kilometers from Jyväskylä The goal was: to develop better client centered conditions and in accessibility view in the Health Centre … when Edith goes to see the doctor or public health Nurse

Health Centre of Keuruu city

Info- signs

Parking places

The way to out-patient policlinic

The way to adult policlinic inside the house

FINDINGS- RESULTS • • INFO- signs: The quality placement of the signs Parking Places Lights (out and inside) The ways to the main Entrance The doors (opening) Stairs, railings Elevators (usability)

Edith in action

Resources Andersen LL, Andersen C et al. 2010. Muscle Activation and Perceived Loading During rehabilitation Exercises: Comparison of Dumbbells and Elastic Resistance. Physical Therapy, vol 90, no 4. • Clemson L, Fiatore S MA. 2012. Integration of balance and strenght training into daily life activity to reduce rate of falls in older people (the LIFE- study); randomised parallel trial. BMJ; 245: e 4547. • Era. P, Saisio P, Koskinen S et al. Postural balance in random sample of 7979 subjects aged 30 years and over. Gerontology 2006: 52: 204 -213. • Gerontologia 2010. Heikkinen E, Rantanen T (toim). Duodecim. Otavan kirjapaino. Keuruu. 2 -3. painos.

Resources • Howe TE, Rochester L et al. 2011. Exercise for improving balance in old people. Cochrane database of Systematic Reviews. • Go`mes-Gabello A, Ara I. et al. 2012. Effects of Training on bone Mass in Oldder Adults. Systematic Review. Sports Medicine, 2012; 42 (4): 301 -325. • Granacher U, Gollhofer A. 2013. The Importance of Trunk Muscle Strength for balance, Functional Performance and falla Prevention. Systematic Review. Sports Medicine, 2013; 43 (7): 627 -41 • Karinkanta S, Piirtola M, Sievänen H, Uusi-Rasi, Kannas P. 2010. Physical Therapy Approaches to reduce fall and fracture risk among older adults. Nature Rev. Endocrinol. 6; 396 -407. • Leeanders M, Verdijk LB et al. Elderly men and women benefit equally from prolonged resistance –type execise training. Journals oj gerontology Series A: Biological & medical Sciences; Lul; 68 (7): 76979

Resources • Kyle`n M, Ekström, H, Haak M, ElmstÅl S, Iwarsson S. 2014. Home and Health in the Third Age- Methodological Background and Descriptive Findings. International Journal of Environmental Research and Public Health. 11, 7060 -7080. • Mikkola TM, Portegijs E, Rantakokko M, Gagné J-P, Rantanen T, Viljanen A. Association of self-reported hearing difficulty to objective and perceived participation outside the home in older community-dwelling adults. Journal of Aging and Health. In Press. • Niemelä K, Väänänen I. 2011. benefits of home- based rocking - chair exercise for physical performance in community dwelling randomised controlled trial. Aging Clinical & Experimental Research, 2011. Aug; 23, • Pikkarainen A, 2013. Gerontologisen kuntoutuksen käsikirja. Osa 1. JAMK julkaisuja – sarja. Suomen yliopistopaino.

• Sihvonen S. 2004. Postural balance and aging. Cross - sectional comparative studies and balance training intervention. Jyväskylän yliopisto. Terveystieteen laitos. Väitöskirja. • Sinkai S, Watanabe et al. 2000. Walking speed as a good predictor for the onset of functional dependence in a Japanese rural community population. Age and aging, 29, 441 -116. • Sitja- Rabert, Merc, Rigau David. 2012. Efficacy of whole body vibration exercise in older people: a systematic review. Disability and rehabilitaion 2012 Jun, 34 (11): • Suominen, H. Teoksessa Ikääntyminen ja liikunta. Liikunnan ja kansanterveyden julkaisuja 108. Toim. Pertti Era. Kopijyvä Oy Jyväskylä 1997 • World Health Organization (WHO). 2001. International Classification of Functioning, Disability and Health. WHO Library Catalogue in Publication Data • http: //www. terveysportti. fi/dtk/sfs/avaa? p_artikkeli=sfs 00003

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