Hi, I’m Jennie Hewitt, physiotherapist, Member of the Australian Physiotherapy Association and one of the authors of the Sunbeam Program – a successful exercise program that resulted in increased physical performance and reduced falls in residents of aged care.
I’m thrilled to be able to share our findings on best practice exercise for residents. We will be working through the implementation of the Sunbeam Program together, with the aim of giving you the knowledge, skills, and confidence to be able to put this into practice.
The Sunbeam randomised controlled trial was performed initially as there was a mismatch between what I was seeing as a clinician in residential care and what was reported in the literature.
As a clinician I saw residents making life changing functional gains with the right type of exercise but there was no convincing or consistent evidence of that in the research.
The key message here what is the right type of exercise to make a meaningful change to physical performance?
As allied health professionals we know that exercise should be viewed like medicine – it needs to be the right type, the right dose, and the right frequency to have a therapeutic effect.
To apply these principles in residential aged care where people are generally of advanced age, often with chronic conditions and multi-morbidities, takes expertise and confidence. In the beginning I needed to dispel some of my own concerns or insecurities about this.
Some of the myths that I was inclined to believe back then were that “any type of exercise is better than none” but when I looked into the research, I found that this wasn’t true. For example, introducing a walking program for previously sedentary residents without addressing their balance or strength deficits increased their risk of falls. I found that seated exercises alone would not improve balance to reduce falls, and light exercise may increase range of motion but not strength.
SO, what is the right type of exercise?
Best practice guidelines recommend at least 50 hours of exercise over a 6-month period, including high challenge balance exercise, progressive resistance training for those who are deconditioned, and all exercises need to be individually prescribed and upgraded with a maintenance program at the conclusion of the conditioning phase.
So together with an amazing multidisciplinary team including Professor Kathryn Refshauge – Physiotherapist; Professor Lindy Clemson – OT; Dr Tim Henwood – Exercise Physiologist and Professor Stephen Goodall – Health Economist, we conducted the Sunbeam Trial in 16 residential aged care facilities (RACF) with 221 residents who volunteered to be part of the trial. 8 villages continued with usual care and 8 implemented these best practice recommendations.
We found a 55% reduction in falls rate and a statistically significant improvement in physical performance in the group that performed the exercise program1. This was the first time such a positive result had been found with residents of aged care.
Today I am thrilled to share the implementation of this program with you so you can translate this into practice with your own residents too.
This video will be delivered in chapters to enable you to skip ahead in the future to the section you’d like to review.
The first chapter is on Initial Individualised Assessment and How to perform a standardised Physical Performance Outcome Measure
Next is how to implement the resistance training component if you are fortunate enough to have a gymnasium at your village (which is the protocol we used in the Sunbeam trial). We recognise that not all villages have these facilities, so Chapter 3 demonstrates how to adapt the program and include training for the same muscle groups using more easily accessible equipment such as bands or free weights.
Next, we will cover the safe prescription and progression of high challenge balance exercise – which is absolutely paramount in falls prevention.
Chapter 5 will be tips and tricks – I’ll cover practical ways to adapt for common conditions and ideas to spice up the program if it becomes repetitive. We will then wrap up with information on where to find resources to support you along the way. SO – let’s get started.
Initial individualised assessment
Allied Health Professionals are accustomed to taking detailed initial assessments. For this program, each resident is assessed individually. This includes a comprehensive investigation into all current and past conditions, medications, past medical and surgical history, current areas of pain, injury and weakness, as well as any other clinically relevant details.
Each allied health professional will need to use their own clinical reasoning skills to determine the suitability of the program for each person. You will also need to customise the exercise program we teach today to suit the abilities, relevant medical conditions, and preferences of each resident.
That is why the program is prescribed and progressed by a registered allied health professional with assumed knowledge on conducting assessments.
We have developed a standardised assessment form though, that may support you to carry out this process. This resource, along with any other support materials I mention today, will be publicly available on the web address found at the end of this video.
Now we will show you how to use the Short Physical Performance Battery.2 This includes three tests of physical performance; first a gait speed test, then a 5 times chair stand and then a balance test.
The gait speed test involves two attempts with the resident walking 3m at their usual pace with their usual walking aid. We record the fasted time.
The chair stand test involves asking the resident to stand up and sit down 5 times from a chair, unaided and without using the arms of the chair.
Dr Hewitt talking to Resident “1, 2, 3 good, 4, and 5 and sit down and have a rest. Good, great job, so that was really good, well done, not everyone can do 5 times in a row so good on you! What we’re going to do is measure that again every 4 weeks and just track how you are improving and the exercise program we’re doing should make it so you will be a bit stronger and you’ll be able to do it a bit faster and that’s how we will know how you are going.”
Resident: “Oh that’ll be good”
Dr Hewitt: “Yeah – good on you”
Once again, we record how long this takes and score accordingly.
Dr Hewitt with a different resident:
Dr Hewitt: “Ok, so one more go, let’s try and stand up without using your hands. 1,2,3 – too hard? ”
Resident: “yeah not going”
Dr Hewitt: “Well that’s alright, this test is a hard one but what this tells us is that the muscles in your thighs and hips are a bit weak and that’s what this exercise program is all about”
Resident: “I can’t push up without my hands”
Dr Hewitt: “No, well that’s the thing, in normal life you’d use your arms but this test, you don’t use your arms. So, we’re going to work on the muscles in your legs and your hips and we’ll test it again in a month and see how you go then, then we’ll test it every month because we’re doing this for 6 months and I’m pretty sure that at the end of 6 months you’ll be able to do that”
Resident: “I hope so”
Dr Hewitt: “I hope so too!”
The balance test involves the resident attempting to stand in 3 challenging balance exercise positions. First of all, with feet together, we see if they can hold that for 10 seconds. If this is successful, we progress to the next level, asking them to stand in a semi-tandem position. Once again, we ask them to hold this for 10 seconds. If that is successful, we progress to tandem standing where we ask them to hold that position for 10 seconds.
The Short Physical Performance Battery2 is recorded at the beginning of every 4-week period and, of course, at the end of the last visit at 6 months so we can track and see what kind of improvements our residents have made.
How to implement and record the Sunbeam Protocol.
We used 5 pieces of equipment during the Sunbeam Trial including hip abduction/adduction, leg press, triceps dip, leg extension/leg curl and abdomen/back.
Each resident’s program was individually prescribed and upgraded by a physiotherapist during the 6-month protocol. We ensured that each exercise was performed at a level where the resident reported a “moderate to somewhat hard” intensity using the Borg Scale3 of perceived exertion after 10 -15 reps.
Mostly, we stuck to 10 -12 reps so if someone felt an exercise was now “somewhat easy” after 12 reps we would increase the weight.
This dose is really important. Prescribing a generic 3 sets of 10 repetitions of a light exercise where everyone in the group is using the same weight will not get the same result.
We recognise that not everyone is fortunate enough to have access to this type of equipment so I have developed a resource to list each of the exercises needed to carry out a program as close as we can to replicating the Sunbeam Protocol.
The first page describes the key principles of exercise dosage and prescription including tips on how to perform each exercise and how to record the exercises performed each time.
Remember it is really important for resistance exercise to conduct 2-3 sets of 10 -15 repetitions at a resistance that the resident reports as “moderate or somewhat hard” on the Borg Scale of Perceived Exertion.3 This is determined during the individualised assessment.
Dr Hewitt: “Blue means it was easy, green means it was a little bit hard and red means it was terribly hard. So, what would you say those exercises felt like?”
Resident points to 12 on the scale (green section)
Dr Hewitt: “About there, we’re actually aiming for 12-15 on the Borg Scale of Perceived Exertion and around this early green part of the scale is where we are aiming so that’s the right weight for you”
Dr Hewitt with a different resident.
Dr Hewitt: “Now what I’m going to get you to do is sit up nice and tall, tummy in, shoulders back, and start to straighten your leg out. It’s quite difficult, can you get any straighter than that?”
Resident: “Not really”
Dr Hewitt; “ Ok so that’s actually too hard, alright so let’s take it back one level. So even though that’s only blue, I think that you’re going to find that quite a challenge. Do you want to give that a go?”
Dr Hewitt “1, can you get it any straighter? 2, 3,4 5, keep going. We’re aiming for 10, do think you’ll be able to get to 10?”
Resident: “I’ll try – laughs”
Dr Hewitt: “Keep going, 8,9,and 10. Well done, so would you say that was easy, moderate or a bit hard?”
Resident: “It was a little hard”
Dr Hewitt: “Ok so that’s a good level for you”
This is a resistance training component of the Sunbeam Program and it needs to be progressive. This means that we’d expect the sets, reps or dosage of each exercise to be increasing over time – at least every 2 weeks but sooner if needed. The allied health professional asks the residents each session whether the exercise is still “moderate” or if it has become a bit easy now.
Now if we wanted to make it harder, obviously we can change the band to a higher resistance, but the other things we can do are: make it shorter – so tighten the loop so it’s a little bit shorter or slow the movement down so it’s 1,2,3 hold 2,3, down 2,3. All of those will result in a higher resistance and a harder exercise without even having to go to the black band.
So, sit to stand is a really important functional activity that a lot of our residents really have trouble with and that’s why the Sunbeam Program really focussed on knee extension, leg curls, leg press, sit to stand, that kind of activity. You’ll find when you are doing the Short Physical Performance Battery2 that people will have trouble getting up out of the chair for that repeated chair stand measure so we need to make sure that we are really impacting that functional activity and that’s why we are including leg press, sit to stand, knee extension in the Sunbeam II as well. When it comes to prescribing leg press, some people will find that it is really difficult, and some will find that it is too easy. So, as for machine- based leg press, the action is going to be to push out then control it on the way in. We are not looking for knee extension here, we are looking for leg press, like this. So, I have gone for the hardest band for myself, but I can actually make it quite hard, even for myself, just by shortening it – so if you wrap the bands around your hands like this (you might need to do this anyway if someone had poor grip strength or arthritic fingers) so if you make it quite firm and short then even for me that’s a bit of a challenge. Once again you can slow the movement down, hold it in an isometric position half way and control it on the way in, and after you’ve done 2-3 sets of 10 -15 reps, even I will be feeling that one. If you happen to have someone who finds that too easy as well, you can start doubling up your resistance bands. So, you can, for example, just add two bands together and perform the same exercises. Just remember that over time resistance bands will perish, so you might need to replace them after a few months so that you are still getting the resistance that you think you are.
This process is repeated for each of the exercises on the protocol;
Knee extensors; Knee flexors; Hip abduction; Hip adduction; Seated Triceps; Standing calf raise.
Safe prescription and progression of high challenge balance exercise
The Sunbeam Program included resistance and balance exercise. It is also essential that the balance exercises are prescribed at the right dose also to achieve best outcomes for residents.
Dr Hewitt: “Ok, what we are going to do now is see how your balance is because in our classes we are going to do both strengthening exercises and balance exercise, ok? So, the first thing I’m going to ask you to do is to stand up – and you can use your hands this time, oh that made a difference! Just pop 2 hands on here. What we going to do here is put your feet apart but straight under your hips, standing up nice and tall and take your hands off. And see you’re not really wobbling at all so that’s telling me it’s not really challenging enough. So, let’s try with your feet together, and your toes together too. Sometimes the feet can’t get together because your knees knock”
Resident: “Yeah they do”
Dr Hewitt: “So, if that’s as close as you can get then that’s good, Right so standing up nice and tall, hands off, there’s a little bit of a sway there”
Resident: “Yeah, I can feel it”
Dr Hewitt: “Let’s try the next level just to see how you go, so the next level is called a semi-tandem. So, you take one foot in front of the other like mine are, doesn’t matter which foot, you just choose whichever you feel strongest with. Probably a bit further forward I’d say, that’s it. Now stand up nice and tall again, take one hand off. Do you feel like you can take the other hand off?”
Resident: “I’ll try”
Dr Hewitt: ”Yeah, this is about the right challenge because you’re actually having to concentrate a bit there aren’t you? So, I’ll record this as semi-tandem, right foot forward, no hands. Stand up tall, that’s it, nice job.”
Dr Hewitt with another resident.
Dr Hewitt: “When you do an exercise program like this you want both strength and balance work because you need to do both strength if you want to stay on your feet! Some of the balance work involves reaching from one side to the other and seeing if you can keep your balance because a lot of people fall when they try to reach and then they topple.”
Dr Hewitt: “So we’re going to practice that what we’re going to do is reach from one side to the other and rock like we’re on a boat. So we’ll start of with our hand on there and rock from side from to side, and then we’ll try with just one hand and then we’ll see if you can go with no hands and I’ll stand here to keep you safe, is that alright?” So we’ll rock from one leg to the other so come towards me and lift your other heel up – yes that’s perfect. Side to side – now you’re doing a good job of that so what I’ll get you to try is one hand off and see how you balance. Good now try both hands off – good.
So, this time when you tip to the side we are going to lift one foot off – see that’s what happens when your too good – we make it harder! So do it with both hands up then rock side to side, Good now try one hand, that’s a bit harder isn’t it. Now try no hands”
Resident: “I’m getting my feet a bit wider”
Dr Hewitt: “Yes you’re exactly right, that’s how you make it harder, in time this will be too easy and that’s how we’ll make it harder – by bringing your feet closer together but for now it’s right having your feet wide if you’re not holding on”
Resident: “Yes – not yet!”
Dr Hewitt: “Exactly we’ll get the feet closer together as you get better at it”
Dr Hewitt: So, the next exercise is probably the hardest exercise and it’s designed so that if you start to fall you can catch yourself. It’s no good having strong muscles if you can’t move your foot quickly and it’s no good having quick feet if your leg is weak and buckles under you when you try to catch yourself. You need both! So, what we’re going to do is start to tip and then catch yourself – it’s a bit like falling, falling, catch. It’s a little bit scary but that’s why I’m standing right here beside you. So, are you happy to give it a go?
Dr Hewitt: “Ok so let’s get you standing up, hanging on here with 2 hands. Now we’re going to go away from me and what you do is tip to the side, like you are actually going to tip over and then you quickly move that foot out to catch yourself, yes, that’s it! Have another go – falling, falling, catch – good on you – lovely, another one. Good – it’s the catch that’s the important part – not the falling, falling bit! Right let’s take one hand off and try the same thing again. Good and again. Alright – for our grand finale we’re going to try it with no hands. I’m right here – you won’t go. Ok have another go. That’s it, one more – good, have a rest!”
The group therapy program is to be run with an allied health professional and 4 residents each performing the exercises at their own individually prescribed therapeutic dose.
The aim is to make the sessions both specific and challenging enough to help the residents regain physical performance, but also enjoyable to address isolation and loneliness. It is up to the allied health professionals to develop an environment where residents want to be, that they look forward to and embrace.
Infection control is paramount, so we use snap lock bags and individualised bands. Each band is cut to about 120cm length (so we get around 20 bands per 25m box). Every resident has a bag labelled for their own use containing their own bands. Other equipment is cleaned using appropriate strength alcohol as per each village’s standard protocols. Other infection control directives given by each facility are also adhered to.
Tips and tricks. Practical ways to adapt for common conditions and avoid repetitiveness.
Some common scenarios that may need different attention include: Protection of fragile skin: a variation for Triceps; inclusion of weights if the bands are not strong enough; and wheelchair variations.
This resource has been provided on the website to list exercises to help guide you on the program delivery but also minimise record keeping time. Each sheet records 4 weeks of training and we ask that you repeat the Short Physical Performance Battery at the beginning of each 4 weeks. This will let you and the residents know if they are improving and also, help us to see how the program affects residents.
It is important to document cancellations as well as progressions.
The Australian Government is funding an evaluation that will include factors such as how many sessions people attended, whether they were able to adhere to the program and how their physical performance changed over time.
Over the years of implementing the Sunbeam Program, it has become very clear to me that it is not just the exercise that is important but also the sense of enjoyment, pride and belonging that really helps residents.
It is up to us as Allied Health Professionals leading the program to foster this in our sessions. We can group people with similar abilities together but sometimes it is better to group people with similar interests together. Perhaps bring someone shy in with another who will take them under their wing. Having a resident who enjoys motivating the group might help with others who are not so motivated! It is up to you to figure out the best combinations that will make the program something that everyone (including you) will look forward to. This program can then have benefits that extend far beyond just addressing physical performance
We’ve tried different ways of making the balance exercises fun – you can see here photographs of residents working with nerf guns, fussball, playing games, doing circus acts – it just helps to spice it up a little.
If you find that you are getting more efficient over time and the exercises are finishing earlier – feel free to add other exercises or activities to your program too – as long as you keep the foundation exercises that have proven benefit. Variations not included on the Record Keeping Sheet can be recorded by you using standard record keeping for your facilities.
We often use music and ask the residents to request songs or genres to build a playlist. Creating a space for socialisation before and or after the exercises also helps build momentum and excitement for the sessions.
Resident talking: “Well I’ve been coming to the gym 3 times a week for about a year now and I can honestly say the gym is the best thing since sliced bread, with the honey on it. I think the strength in my muscles, I wasn’t so weak, I can straighten up and walk tall, a bit more confidence, my quality of life is definitely better since I’ve been doing these exercises.”
Another resident: “A world of difference, I can walk taller, I’m just so much more able to get about, it’s wonderful, as I said, I was a couch potato and I didn’t move and one day was just like the other, and now I look forward to the exercises very much”
Another resident: “Leg wise, the strength in your legs, being able to push up from the floor without using your hands, and get up from the chair easier, just the overall strength in the body”
I hope that this video has helped you to feel inspired to implement the Sunbeam II program at your villages. I am super excited that we have an opportunity as allied health professional to implement an evidence- based program and demonstrate one of the many benefits that allied health can deliver residents if we are given an opportunity implement best practice.
By carrying out the program and recording your residents’ progress we will be able to evaluate and report on how this type of approach benefits residents.
I hope that this is the start of a new chapter for residential aged care where allied health is empowered to do our best work.
- Hewitt J, et al. Progressive Resistance and Balance Training for Falls Prevention in Long-Term Residential Aged Care: A Cluster Randomized Trial of the Sunbeam Program. JAMDA 2018: 19 (4): 361-369. ISSN 1525-8610, https://doi.org/10.1016/j.jamda.2017.12.014.
- Guralnik J et all. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994;49:M85eM94
- Borg G. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982: 14:377-381.